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Report to American Psychiatric Association
Presented at a May 19, 2003, symposium sponsored by the American Psychiatric Association entitled "DSM-IV-TR and the Paraphilias: An Argument for Removal."
DSM-IV-TR and the Paraphilias: An Argument for Removal
Charles Moser, Institute for Advanced Study of Human Sexuality San Francisco, California
Peggy J. Kleinplatz, University of Ottawa Ottawa, Ontario, Canada
The DSM-IV-TR (2000) sets its own standards for inclusion of diagnoses and for changes in its text. The Paraphilia section is analyzed from the perspective of how well the DSM meets those standards. The concept of Paraphilias as psychopathology was analyzed and assessed critically to determine if it meets the definition of a mental disorder presented in the DSM; it does not.
The Paraphilia diagnostic category was critiqued for logic, consistency, clarity and whether it constitutes a distinct mental disorder. The DSM presents "facts" to substantiate various points made in the text. The veracity of these "facts" was scrutinized.
Little evidence was found in their support. Problems with the tradition of equating particular sexual interests with psychopathology were highlighted. It was concluded that the Paraphilia section is so severely flawed that its removal from the DSM is advocated.
DSM-IV-TR and the Paraphilias: Reevaluating an obsolete category
All societies attempt to control the sexual behavior of their members. One mechanism of exercising this control is to define a specific sexual interest as pathognomonic for a mental disorder. Historically and cross-culturally, even an accusation of interest in specific sexual practices could result in death, imprisonment, loss of civil rights and other social sanctions. Similarly, being classified as mentally ill could result in death, imprisonment, loss of civil rights and other social sanctions. Thus, the confounding of mental illness with unusual sexual desires is understandable.
Which sexual interests are proscribed often changes; masturbation, oral sex, anal sex and homosexuality were once considered mental disorders or symptoms of other mental disorders but are now typically accepted as part of the spectrum of healthy sexual expression. Similarly, there are conditions that were accepted as "normal" in the past but are now classified as mental disorders (e.g., hypoactive sexual desire, sexual aversion disorder and female orgasmic disorder). It is exceedingly difficult to eliminate historical and cultural factors from the assessment of unusual sexual interests. As such, empirically based, scientific definitions of healthy and pathological sexual behavior continue to elude us.
Cross-culturally, sexual activity considered "acceptable" in the United States is viewed as "stigmatized" in other cultures; similarly, sexual activity considered "acceptable" in the United States is "stigmatized" in other cultures. For example, non-marital coitus is accepted in the U.S. but is stigmatized harshly in many Moslem countries; topless sunbathing among women at public beaches is accepted in Western Europe but illegal and condemned in most of the United States. Violation of these cultural norms often results in strong negative reactions. Given the socio-cultural context in which such beliefs are embedded, it is not surprising that the lay public and even many sex experts cannot understand how unusual sexual interests can signify anything but mental disorders. Nevertheless, it is the assumption that unusual sexual interests constitute symptoms of or are mental disorders per se, that we are questioning.
The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual (DSM); it describes the diagnostic criteria and defining features of all formally recognized mental disorders. It serves as a definitive resource for mental health professionals. Although its primary influence is in the United States, its impact is global. A psychiatric diagnosis is more than shorthand to facilitate communication among professionals or to standardize research parameters.
Psychiatric diagnoses affect child custody decisions, self-esteem, whether individuals are hired or fired, receive security clearances or have other rights and privileges curtailed. Criminals may find that their sentences are either mitigated or enhanced as a direct result of their diagnoses. The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas. A review of this area is not only a scientific issue, but also a human rights issue. The power and impact of the DSM should not be underestimated.
The DSM is revised at regular intervals. Diagnoses can be added or eliminated and diagnostic criteria reformulated with each new edition. There have been six editions to date (APA, 1952, 1968, 1980, 1987, 1994, 2000). The current edition is designated DSM-IV-TR (APA, 2000) and will be the focus of this paper.
With the publication of DSM-III in 1980, the focus of the DSM changed from a theoretically based, psychoanalytic model of illness to an evidence-based and descriptive model. The DSM is currently intended "[...] to be neutral with respect to theories of etiology" (APA, 2000, p. xxvi), based on objective observation and able to support its statements with empirical research. With this transition, the nomenclature of these disorders changed from "Sexual deviation" to "Paraphilia," a supposedly atheoretical, non-pejorative descriptor.
In the text of the latest edition of the DSM, it is asserted that a "comprehensive and systematic" (APA, 2000, p. xxvi) review of the literature was conducted in preparation of the DSM.
The text indicates,
Our own, extensive review found no literature to support most of the assertions made in the Paraphilia section of the DSM, and several studies were found that contradict the text (discussed below). Objective data to support the classification of the Paraphilias as mental disorders is lacking.
When the APA removed homosexuality from the DSM approximately 30 years ago, some observers thought that the other Paraphilias would also be removed from subsequent editions. The argument for removal of homosexuality was bolstered by the lack of objective research supporting its inclusion and research that failed to support the theory that homosexuals fit specific psychiatric stereotypes.
Nevertheless, some observers believe the removal of homosexuality was primarily a political act (Bayer, 1981). The situation of the Paraphilias at present parallels that of homosexuality in the early 1970s. Without the support or political astuteness of those who fought for the removal of homosexuality, the Paraphilias continue to be listed in the DSM.
The term "paraphilia" will be employed here in keeping with its use in the literature, even though we have serious reservations about the validity of the diagnosis and the applicability of this term. The rationale for the inclusion of the Paraphilia diagnostic category as it is constituted in the DSM-IV-TR (APA, 2000) will be addressed and challenged. It will be suggested that the construct of the Paraphilias is ambiguous and does not describe a diagnosable, distinct mental disorder. A review of the scientific literature does not support the inclusion of this diagnostic category in the DSM.
Are the Paraphilias Mental Disorders?
The concept that unconventional sexual interests are mental illnesses or crimes (religious or societal) predates both the DSM and modern psychiatry. Sanctions against individuals who engage in proscribed sexual behavior have changed over time. At first, it was considered a sin to be governed by penitentials and religious courts. Over time, civil laws were used to "control" the unacceptable behavior. In the [past], the medical model was applied to transform these "sins" or "crimes" into "pathology"
The assumption that Paraphilias are a form of psychopathology has been questioned, and each subsequent edition has attempted to address some of the perceived weaknesses in this diagnostic category. Nevertheless, the bulk of serious criticism
has not been addressed fully.
In the DSM, it is indicated that it is difficult to define a mental disorder as well as mental health. Nonetheless, the text defines a mental disorder as being
Individuals who engage in many common activities (scuba divers, gun owners, mountain climbers, inhabitants of many large cities and criminals) also incur increased risks of death, pain, disability, or loss of freedom but are not diagnosed with mental disorders. This apparent contradiction demonstrates that social context can affect the application of this definition.
To clarify the definition, the DSM further states,
There is concern that psychiatric diagnoses can be used inappropriately to discredit dissenters; at least in some venues, criminals have more rights and credibility than psychiatric patients do. The above statement was added to protect the labeling of unpopular or illegal activities as mental illnesses, but the last clause allows the clinician to disregard this distinction.
The DSM does not define healthy sexuality, much less healthy mood, thoughts or personalities. Unfortunately, the range of "healthy" human sexual behavior is not known, thus creating potential pitfalls in the diagnostic process. The DSM is meant to be interpreted by an experienced and objective clinician. Without consensus from the scientific literature, however, clinicians are often forced to rely on their own subjective evaluations.
The problem here is that engaging in "Paraphilic" behavior qualifies the participant a priori as a candidate for diagnosis. In addition, when individuals have unusual sexual interests, there is often speculation that any presenting problems are related to their sexuality. When a behavior per se signifies a diagnosis, then by definition the behavior is symptomatic of the disorder. This confound obscures the possibility that for at least some individuals, their specific sexual behaviors are healthy expressions of sexuality and beneficial to them. The fact that specific sexual behaviors are socially unacceptable or illegal is, and should be, irrelevant to the diagnostic process.
Historically, this was the situation that confronted homosexuals. When homosexual patients presented to a psychotherapist with any problem, it was often assumed that the problem was caused or exacerbated by their homosexual interests.
The DSM has been organized with a “categorical”
approach to classification of mental
disorders since the third edition (APA, 1980). This
approach works best,
Although the text acknowledges problems with the categorical approach, these problems are particularly evident with the Paraphilias.
The Paraphilia disorders do not have clear boundaries (Laws & O’Donohue, 1997). Non-clinical studies of individuals with unusual sexual interests demonstrate that these individuals are indistinguishable from those with “normophilic” (i.e., conventional) sexual interests
The clinical studies do not identify a discernible group who have anything more in common than their shared sexual interest. The existing empirical research does not distinguish individuals with Paraphilias from those with other mental disorders. That is, there is no demonstrable and distinct class of “paraphiliacs”, except as created by defining specific sexual interests, a priori, as evidence of psychopathology.
The inability to define “healthy” sexuality or to distinguish the characteristics of individuals with a paraphilia from those without one, suggests that the distinction does not exist and the category is invalid.
Individuals can and do experience psychiatric problems related to their sexual interests and behavior. Problems related to normophilic sexual interests or behaviors, associated with distress or dysfunctions, are dealt with differently and given non-sexual diagnoses. We can find no logical or scientific reason why some sexual behaviors and interests have been designated as Paraphilias and others have not.
The DSM Definition of a Paraphilia
The definition of intense is the issue; otherwise this statement in isolation describes healthy, sexually active individuals. The DSM already defines terms such as compulsive, impulsive, and obsessive; so intense in this situation must have a different implication.
Even trained clinicians have difficulty distinguishing strong “unhealthy” sexual interests from strong “healthy” sexual interests, as demonstrated by previous, failed attempts to define
Conversely, individuals lacking intense sexual arousal may be subject to diagnosis with a Sexual Arousal Disorder or Hypoactive Sexual Desire Disorder. The editors further qualify their paraphilia definition by stating,
The implication is that the distinction between a mental disorder and a healthy sex interest is based in the nature of the specific sexual interest rather than in its intensity. The following statement found later in the text, reinforces that point:
Although a less intense interest in the "unhealthy" behavior or an intense interest in a “healthy” behavior does not qualify for a paraphilia diagnosis, the distinction appears to be based upon the focus of the sexual interest rather than its intensity.
An intense interest in conventional sexual behavior was once considered a criterion for a valid diagnosis. Nymphomania, satyriasias, and erotomania were not included in the current DSM for the same reasons that homosexuality was removed, i.e., the lack of data to support inclusion and the recognition that these diagnoses impose a cultural value judgment on the behavior, rather than comprising a diagnosable entity.
The tradition of identifying specific sexual behaviors as pathological predates the DSM-I (1952), possibly originating with Krafft-Ebing (1965/1886). It is a remnant of the reclassification of sexual sin to sexual pathology in the 19th century (Bullough & Bullough, 1977).
The specifying of behaviors creates problems for at least six reasons:
Changes to the Diagnostic Criteria
It has been asserted that,
This is patently false; the criteria for Exhibitionism, Frotteurism, Pedophilia, Sexual Sadism, and Voyeurism (i.e., “criminal” paraphilias) were changed and these changes were substantive.
Of note, the Paraphilia section appears to be the only section of the DSM-IV-TR (APA, 2000) to which changes to the diagnostic criteria were made. The impetus for these changes is not stated.
There are essentially two changes for each of the above diagnoses.
The inclusion of nonconsent is especially problematic in the case of Sexual Sadism. Although it is clearly possible for an individual with the diagnosis of Sexual Sadism to engage in nonconsensual acts, most “sadists” do not seek non-consenting partners
Just as it is inappropriate to confuse rapists with those individuals interested in consensual sexual activities, the lumping of individuals interested in consensual sexual sadism with those who engage in non-consensual activities is similarly inappropriate (McConaghy, 1999).
One can conclude the editors of the DSM appear to reject the possibility that anyone would engage willingly in these activities, despite a now sizeable professional and lay press which indicates just that. The application of the current DSM criteria may result in many rapists being diagnosed inappropriately with Sexual Sadism.
The data suggest that the majority of rapists are not motivated by sadism (Groth & Hobson, 1983; Hucker, 1997); correspondingly, there is no data to suggest that rape is more common among practitioners of Sexual Sadism. It is noteworthy that “rape” was removed from the DSM with the publication of the second edition (1968). It is not clear why the concept is being reintroduced into the DSM at this time.
The “B” Criterion: Distress and Dysfunction and the “Paraphilias”
An essential criterion for making the diagnosis of paraphilia is that the behavior, urges, or fantasies cause distress or dysfunction. These two symptoms will be analyzed separately.
It is acknowledged in the DSM that,
Possibly for emphasis, the DSM includes the statement:
One must conclude that distress is rarely a problem for those individuals diagnosed with a paraphilia.
Consider the minority of individuals diagnosed with a paraphilia who are distressed because of their sexual interests. Although one’s sexual interests, “tend to be chronic and lifelong” (APA, 2000, p. 568), there is no indication that the distress is chronic.
This distinction has been overlooked in the diagnostic criteria. If the distress can be mitigated, would these individuals cease to be diagnosable as having Paraphilias? Support groups can alleviate social stigma and isolation. Although they are helpful to mitigate this distress, they are rarely mentioned in the clinical literature in regard to the treatment of the Paraphilias (Moser, 1988; 1999).
A strict reading of the definition of a mental disorder suggests that the distress must be “present distress” (APA, 2000, p. xxxi), which implies that if the distress is mitigated, the individual no longer meets the criteria for the diagnosis.
Some individuals sincerely wish to change their sexual interests and have not found solace from or are unwilling to attend support groups. These individuals should be treated in a similar fashion to those who are uncomfortable with their sexual orientation.
One may question why an individual with a paraphilia does not give up the sexual interest that results in adverse consequences. This has been interpreted as further evidence of the compulsive nature of these “disorders.” Even if individuals exhibit compulsive fantasies, behaviors and urges, compulsivity is not included in the diagnostic criteria of the paraphilias, and should have no bearing on the diagnosis of a paraphilia.
Furthermore, how many “normal” heterosexuals would be able to eliminate their interests if the laws suddenly changed? We wonder why individuals who refuse to change unpopular political or religious beliefs are not similarly diagnosed. It is worth considering the possibility that unusual sexual interests might enhance one’s quality of life rather than diminishing it.
Proscribed fantasies, desires, and behaviors may not be pathological; healthy individuals resist giving up life-affirming and enhancing experiences, regardless of social mores.
Historically, social and psychiatric sanctions have done little to decrease the incidence of other forbidden sex acts
but have caused the participants significant distress and misery.
It is important to distinguish carefully between
The perseverance of gay rights activists in the face of the “diagnosis and treatment” of homosexuality provides an excellent example of this courage.
Discrimination can also lead to distress. It is difficult to argue that individuals suffer from mental disorders solely because they must deal with the consequences of discrimination. This would lead to diagnosing people for being homosexual, African-American, female, Communist, or Wiccan. When individuals in these “minority” groups present to therapists with problems related to the discrimination that they experience, “therapy” focuses on the development of coping strategies. Their minority status is not the diagnosis.
The “B” criterion allows for the diagnosis if there is,
The implication is that the dysfunction results from the paraphilia per se, rather than social reactions to the sexuality. Theoretically, the paraphilia diagnosis might be justified if the patient was fired for being habitually late as a result of engaging in the paraphilic behavior. However, if one is fired solely due to the discomfort of others, it does not signify dysfunction on the part of the employee.
Suppose an individual is functioning in society without difficulty and also has an interest in a Paraphilia, thereby satisfying the “A” but not the “B” criterion. Theoretically, that person would not be diagnosed with a Paraphilia.
Now assume that an employer, spouse, or parent discovers this interest. This revelation leads to termination of employment, discord in the couple or family, etc.
Whether the nature of the problem is a psychiatric dysfunction or practical difficulty is particularly murky. Social isolation may lead to depression; participating in support groups and in a subculture surrounding the specific sexual interest may lead to resolution of the alienation and associated depression without psychotherapy or anti-depressants.
It is indicated in the DSM (2000) that individuals with paraphilias may be sexually dysfunctional. Although it is true that an individual with a paraphilia may be sexually dysfunctional, the DSM emphasizes causality
this statement lacks the requisite supporting empirical data.
Our review of the literature did not uncover any references suggesting correlation between sexual dysfunction and a diagnosis of a paraphilia, much less causation. It is unclear if the incidence of sexual dysfunction is higher or lower among those with a paraphilia, but sexual dysfunctions are exceedingly common in the general population,
Brown et al. (1996) suggested that there is no difference between the sexual functioning of those diagnosed with a paraphilia compared to a “normal” sample. They reported that cross-dressers were indistinguishable from non-crossdressers on the Derogatis Sexual Functioning Inventory (DSFI).
In addition, Wise, Fagan, Schmidt, Ponticas & Costa (1991) found no significant difference in sexual functioning as measured by the DSFI between “transvestitic fetishists” and “other paraphilics.”
Could individuals with Paraphilias have impaired sexual responses to "normative" sexual interests and manifest sexual dysfunctions when presented with non-paraphilic stimuli? Although this is a common belief, it too, is not supported by the data. Individuals diagnosed with Paraphilias apparently have a wide range of interests, including normative sexual interests
Conversely, “unusual” sexual interests are commonly found in the general population
The DSM contains the statement,
The theme of reciprocal, affectionate sexual activity is repeated through several editions. In the DSM-III (1980), this phrase was used in conjunction with Ego-dystonic Homosexuality. Although this diagnosis was technically abandoned with the publication of DSM-III-R (1987), essentially the same wording remains in the description of Sex Disorder, Not Otherwise Specified in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000).
The judgment of what constitutes reciprocal, affectionate sexual activity is clearly value laden and suggests an underlying, implicit, theoretical orientation. There are no data to suggest that individuals diagnosed with a paraphilia have any more difficulty maintaining relationships than “normal” heterosexuals, who have staggering divorce rates.
When Do “Paraphilic” Sexual Behaviors Become Pathological?
The DSM is intended to help the clinician distinguish between healthy functioning and mental disorders. The DSM cautions,
The statement implies, but does not state explicitly that the stimuli can include the paraphilic “fantasies, behaviors, or objects.” Guidance on how the clinician is to make this distinction is not given in the text.
In keeping with the DSM definition of a mental disorder, any sexual behavior can signify pathology if it interferes with the individual’s functioning. However, the behavioral manifestations of a mental disorder should not be confused with the mental disorder or underlying problem itself.
An individual with alcoholism may abuse other drugs if access to alcohol is limited. An individual with auditory hallucinations emanating from the radio may hear voices from other objects if the radio is removed. Similarly, an individual who crossdresses to relieve anxiety after arguing with his wife may benefit from marital therapy rather than “treatment” targeting his transvestic fetishism.
Stopping the “problematic” sexual behavior does not imply any problem has been treated or that subsequent sexual expression will be “healthy.”
Statements of Fact?
The Paraphilia section contains a number of purportedly factual statements that do not appear to be supported by the research literature. For example,
No studies were found to support the 20 : 1 statement. Several studies were found that reported a significant number of women in the S/M subculture,
By combining the data of Breslow et al. (1985) and Levitt et al. (1994), a ratio of four male masochists to each female masochist was found. Even if clinical samples are overwhelmingly male, no study supports the naming of a specific ratio.
The DSM-IV-TR states,
One study (Wise et al., 1991) appears to support that statement. That study involved 50 men, comprised of 24 “transvestitic fetishists” and 26 “other paraphiliacs.” The "other" types of paraphilias were not specified. However, only by combining the divorced, separated, and married category could one conclude that one-half the individuals were married. It is not clear if the “finding” that half are married is higher or lower than expected.
Of interest, the Paraphilias were the only diagnostic section to include information about marital status. The rationale for inclusion of this poorly substantiated "fact" is not clear.
The purpose of many of the statements made in the Paraphilia section is nebulous. Some statements, while correct, are equally true for both those with a Paraphilia diagnosis as those judged to be normophilic. For example,
The implication is that those diagnosed with Paraphilias are more likely to have sexually transmitted diseases or difficulty engaging or refraining from their sexual interests than those with more conventional interests. Neither point is supported by data nor is the reason for their inclusion in the DSM apparent.
Another misleading statement is,
Although any sexual activity can lead to injury, there is no data to suggest that the practitioners of "sadistic or masochistic behaviors" frequent emergency departments more often than practitioners of other sexual behaviors. A review of the sports medicine and emergency medicine literature reveals numerous studies of specific injuries related to various sports and other activities. If unusual sexual acts resulted in a significant number of injuries, presumably they, too, would appear prominently in the medical literature.
Another erroneous statement is evident in the confusion of hypoxyphilia with sexual masochism. The DSM contains the following statement:
In fact there is no empirical data correlating hypoxyphilia to masochism. In their study of 117 fatal cases of autoerotic asphyxia, Blanchard and Hucker conclude,
Some statements confuse rather than clarify the diagnostic process. For example,
Analogously, heterosexual fantasies or stimuli are obligatory for some heterosexuals, but in other cases occur only episodically. Again, the purpose of the DSM statement is questionable.
The Special Case of Pedophilia
The politics and moral outage surrounding the diagnosis of pedophilia are so pervasive that specific comments about this sexual interest must be explicit.
Pedophiles occupy a particularly odious position in our society and suggestions that these individuals do not suffer from a mental disorder may be interpreted as support for their activities. We wish to clarify that our suggestion to remove the paraphilias, which includes pedophilia, from the DSM does not mean that sexual acts with children are not crimes.
We would argue that the removal of pedophilia from the DSM would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes. Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred. Any interpretation of our work as supporting adult-child sexual interactions is misguided and wrong.
The Paraphilia section of the DSM (APA, 2000) does not meet the goals set forth in its text
The premise of the DSM is that diagnoses should be based upon objective science and not on political or social motivations. Therefore, objective research is needed to substantiate statements that some forms of sexual expression are healthy and other forms constitute mental disorders.
Although it may be tempting to generalize from one's clinical experiences, it is contrary to the premise and stated goals of the APA in the DSM. Without data to suggest that a behavior pattern is dysfunctional, one should either suspend judgment or assume the behavior pattern signifies a healthy, normal variation. Although that statement also has political ramifications, it is correct from a scientific perspective.
The DSM criteria for diagnosis of unusual sexual interests as pathological rests on a series of unproven and more importantly, untested assumptions. Given the explicit intent to produce an empirically valid document, the DSM must provide supporting documentation. Even if future research should verify their current assumptions, they have been inserted into the DSM inappropriately at this time. In the interim, these untested assumptions can be and are being misused.
The text of the DSM states,
Although this goal is laudable, it can be interpreted as setting up an impossible burden for the removal of a diagnosis or category. If health cannot be defined, then it is impossible to prove that individuals currently subject to a specific diagnosis are actually “healthy” and not pathological. It is logically impossible to prove a negative. Diagnoses should be removed if they can not be shown to meet the definition of a mental disorder unambiguously and be substantiated by appropriate research. Failing that, the diagnosis in question should be either considered experimental or removed from the DSM completely.
The present critique did not explore every problem in the Paraphilia section. Many more were found than could be documented here. It is obvious that the present diagnostic category has not fulfilled the criteria for inclusion set out in its own text;
There are two possible solutions:
Alternatives to the current paraphilia category have been proposed (see Moser, 2001, for one example), but a discussion of these alternatives is beyond the scope of the present paper.
If the editors of the DSM choose to revise this section, they will need to
Although a radical solution, we now favor removal of the entire category from the DSM as the most appropriate remedy for the problems outlined.
There are individuals now diagnosed with a paraphilia who seek psychotherapy. We believe that other psychological characteristics describe these individuals and their concerns more accurately than their sexual interests do. It is not their sexual interests, but the manner in which they are manifest that can be problematic at times and is a more appropriate focus for therapy.
A guiding principle in medicine is the dictum “First, do no harm." The confusion of variant sexual interests with psychopathology has led to discrimination against all "paraphiliacs." Individuals have lost jobs, custody of their children, security clearances, become victims of assault, etc., at least partially due to the association of their sexual behavior with psychopathology.
This is not a new problem for psychiatry. Within the last 100 years, the labeling of other sexual behaviors as pathological (e.g., masturbation, “nymphomania,” homosexuality) has caused untold misery.
Judgments should be made on the basis of science, rather than the morality that is popular at the time of a given edition. It is time to reevaluate rigorously the Paraphilia section of the DSM.
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Correspondence concerning this article can be addressed to either Charles Moser, Ph.D., M.D., 45 Castro Street, #125, San Francisco, California 94114 (E-mail: firstname.lastname@example.org) or Peggy J. Kleinplatz, Ph.D., 161 Frank Street, Ottawa, Ontario K2P 0X4, Canada (E-mail: email@example.com).
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