We provided mental health professionals (N = 546, Table 1) with case vignettes of different paraphilic behaviors and a control vignette, and randomly changed the gender and sexual orientation of the described subject. We also randomly changed the severity of the described symptoms to include a condition that should affect the evaluation based on the diagnostic criteria. Thus, MHP were randomly assigned to one cell of a 2 “gender” (male/female) × 2 “sexual orientation” (homosexual/heterosexual) × 2 “diagnostic criteria” (fulfilled/ambiguous) factorial design. They were asked to evaluate the cases, and to estimate whether or not a mental disorder is present, indicate its biological or psychological underpinnings, and provide various measures of stigma. Sixty-four % women and 35% men participated in the present study. Most participants were psychologists (59%) or psychiatrists (36%) who had, on average, 11 years of clinical experience (further details see Table 1).

Table 1 Sociodemographic variables of participating mental health professionals. Full size table

The first vignette described an individual with psychotic symptoms followed by five vignettes describing subjects with paraphilic sexual interests or behaviors (exhibitionistic, frotteuristic, sexual sadistic, pedophilic, sexual masochistic) (for detailed descriptions of the vignettes see Supplementary File 1).

Estimation of psychopathology was lower (p < 0.001) in all of the paraphilic vignettes compared to the psychosis vignette (Fig. 1) with regard to the question as to whether or not the subject is mentally disordered (F 5,3222 = 162.95, p < 0.001) and fulfills the criteria for a mental disorder (F 5,3182 = 93.21, p < 0.001). On average, the mean scores of all the vignettes were >3.5 (on a rating between strongly disagree “1” and strongly agree “6”) and thus leaning toward the pathological end of the scale. The pedophilic vignette was significantly more pathologized compared to the other paraphilic vignettes (p < 0.001). When participants had to indicate “the cause” of the symptoms, it was also found that a significant difference existed between vignettes (F 5,3270 = 61.91, p < 0.001). While psychotic symptoms were comparably attributed to both biological and psychological factors (49.5% vs. 50.5%), the paraphilic vignettes were significantly more often ascribed to psychological factors (~70%, p < 0.001). The pedophilic vignette (62 ± 1% psychological factors) was again somewhat between the psychotic vignette and the other paraphilias. Pedophilia was thus estimated of being remarkably more “biological” and “mentally disordered” than the other paraphilias (p < 0.001), especially in terms of the full criteria condition (Suppl. Figure 1). Overall, the behaviors presented also differed in the degree to which they were stigmatized (F 5,3183 = 202.09, p < 0.001). A Bonferroni post-hoc analysis indicated that the overall stigmatization scores were lowest in the psychosis condition, followed by masochism, exhibitionism, and frotteurism, and highest in the pedophilia and sexual sadism condition (Fig. 1C).

Figure 1 Mental health professionals responded differently to the six vignettes. While psychotic behavior were rated highest regarding psychopathology (A) they were also the least stigmatized (C) and the presumed psychological component was lowest (B). Pedophilic behavior were rated to be significantly more biologically-based and mentally-disordered compared to all other paraphilic behavior. Pedophilic and sexual sadistic behavior had the highest stigma index. Sexual masochism was significantly less stigmatized compared to all other paraphilias. ***Indicates a significant difference in post-hoc analysis compared to all other vignettes. Full size image

Both questions addressing how participants evaluate the mental health of the subject correlated highly (Fig. 1; for example, R = 0.77, p < 0.001 for the psychosis vignette and R = 0.81, p < 0.001 for the exhibitionism vignette). We calculated a “psychopathology factor” as the mean of both values for further analysis in order to include both a subjective and an objective estimation of mental disorder. This psychopathology factor was included in a 2 × 2 × 2 ANOVA. In this 3-factorial ANOVA, the ambiguous condition was estimated as less pathological in all of the vignettes (psychosis: F 1,513 = 9.78, p = 0.002, exhibitionism: F 1,510 = 56.14, p < 0.001, frotteurism: F 1,516 = 20.85, p < 0.001, sexual sadism: F 1,513 = 14.79, p < 0.001, pedophilia: F 1,538 = 105.53, p < 0.001, and sexual masochism: F 1,519 = 8.85, p = 0.003). Thus, we confirmed that the manipulation of the vignettes affected the participants’ estimation of psychopathology.

Interestingly, MHP also gave lower psychopathology factors to female subjects in most of the paraphilic vignettes (exhibitionism: F 1,510 = 35.95, p < 0.001, frotteurism: F 1,516 = 7.34, p = 0.007, sexual sadism: F 1,513 = 17.46, p < 0.001, and pedophilia: F 1,523 = 26.50, p < 0.001, Fig. 2A). In contrast, with regard to the control and sexual masochism vignettes, gender did not influence the participants’ estimation of psychopathology (psychosis: F 1,513 = 0.01, p = 0.917, sexual masochism: F 1,519 = 0.02, p = 0.964). The percentage of MHP who rated the symptoms described as a mental disorder (psychopathology factor >3.5) also differed profoundly from vignette to vignette (Fig. 2B). Almost 100% of the participants judged the psychotic symptoms as indicating a mental disorder, independent of gender or criteria (χ²(3) = 3.43, p = 0.329, Fig. 2B). In contrast, in the exhibitionistic (χ²(3) = 62.20, p < 0.001), frotteuristic (χ²(3) = 34.14, p < 0.001), sexual sadistic (χ²(3) = 21.03, p < 0.001) and pedophilic (χ²(3) = 47.12, p < 0.001) vignettes, female subjects were less likely to be diagnosed as mentally disordered. This gender bias was particularly pronounced in the ambiguous condition (Fig. 2B). For example, while 65% of MHP pathologized an exhibitionistic man, only 36% pathologized the female subject in the ambiguous condition. Interestingly, we also found a gender effect for the sexual masochism vignette (χ²(3) = 10.23, p < 0.017). In the ambiguous condition, females were less likely to be pathologized. In contrast, when full diagnostic criteria were present, the percentage of MHP who diagnosed a mental disorder was almost 10% higher in the female condition.

Figure 2 Female subjects were less pathologized in the exhibitionistic, frotteuristic, sexual sadistic and pedophilic vignette (A). In line with this, the percentage of mental health professionals who rated the symptoms as a mental disorder (=psychopathology factor >3.5) was lower in the female condition in these vignettes (B). In contrast, the psychopathology factor was comparable between males and females in the masochistic vignette (A). Interestingly, while females were also less pathologized in the ambiguous condition with the number of females who received a mental disorder diagnosis increased in the full criteria condition (B). Neither the psychopathology factor, nor the percentage of mental health professionals that gave a diagnosis was affected by gender in the psychosis control condition. *,**,***Indicate a significant difference in post-hoc analysis compared to all other vignettes with p < 0.05, 0.01, 0.001, respectively. Full size image

In terms of different stigma dimensions, a gender difference occurred for all paraphilias – with the exception of masochism – on the dimensions desire for social distance and perceived dangerousness. Male subjects were perceived as being more dangerous and provoked more desire for social distance compared to female subjects. In addition, MHP blamed male subjects more than female subjects for frotteuristic behaviors (see Table 2).

Table 2 Stigmatization of different paraphilic behaviors by MHP. Full size table

Roughly 20–25% of all participants provided explanations concerning their diagnoses in the open-ended text boxes. These qualitative data were rated by two independent raters and sorted into different coding categories (displayed in Supplemental Table 1). In line with the quantitative results, under ambiguous conditions, MHP listed on average less pro and more contra arguments compared to the full criteria condition (Fig. 3A). In the female compared to the male condition, the percentage of MHP who listed at least one pro argument was lower in the exhibitionism, frotteurism, sexual sadism and pedophilia vignettes. This was more pronounced under ambiguous conditions (Fig. 3A). In contrast, in terms of sexual masochism in the full criteria condition, the percentage who listed at least one pro argument was 25% higher in the female condition (χ²(3) = 8.99, p = 0.029, Fig. 3B). Intriguingly, personality disorders were only listed as a reason for pathologizing atypical sexual behavior in the female/full criteria condition by 21% of the participants (χ²(3) = 17.98, p < 0.001, Fig. 3B). Moreover, less contra arguments (21%) were to be found in the female/full criteria condition, in contrast to 45–58% in the other three conditions (χ²(3) = 7.19, p = 0.066, Fig. 3B).

Figure 3 Percentage of mental health professionals listing at least one pro argument for a mental disorder in their opinions in the open text box (A). Especially in the ambiguous condition, the percentage of mental health professionals in the female condition was lower. Again, sexual masochism was differently evaluated in the ambiguous and full criteria condition (B). The percentage of mental health professionals listing at least one pro argument was increased in the full criteria condition and reduced in the ambiguous condition. Moreover, more than 20% of mental health professionals diagnosed a personality disorder for the female subject in the full criteria condition. *,***Indicate a significant difference in post-hoc analysis compared to all other vignettes with p < 0.05, 0.001, respectively. #Indicates a difference on trend level p < 0.1. Full size image