PRODUCT BRIEF DEVELOPMENT TOOLS Quality Function Dep.docx

PRODUCT BRIEF
DEVELOPMENT
TOOLS
Quality Function Deployment
In a few words: The voice of the customer translated into the
voice of the engineer.
To design a product well, a design teams needs to know what it
is
they are designing, and what the end-users will expect from it.
Quality Function Deployment is a systematic approach to design
based on a close awareness of customer desires, coupled with
the
integration of corporate functional groups. It consists in
translating customer desires (for example, the ease of writing
for
a pen) into design characteristics (pen ink viscosity, pressure on
ball-point) for each stage of the product development
(Rosenthal,
1992).
Ultimately the goal of QFD is to translate
often subjective quality criteria into objective
ones that can be quantified and measured and
which can then be used to design and
manufacture the product. It is a complimentary
method for determining how and where
priorities are to be assigned in product
development. The intent is to employ
objective procedures in increasing detail

throughout the development of the product.
(Reilly, 1999)
Quality Function Deployment was developed
by Yoji Akao in Japan in 1966. By 1972 the
power of the approach had been well
demonstrated at the Mitsubishi Heavy
Industries Kobe Shipyard (Sullivan, 1986) and
in 1978 the first book on the subject was
published in Japanese and then later translated
into English in 1994 (Mizuno and Akao,
1994).
In Akao’s words, QFD "is a method for developing a design
quality aimed at satisfying the
consumer and then translating the consumer's demand into
design targets and major quality
assurance points to be used throughout the production phase. ...
[QFD] is a way to assure the
design quality while the product is still in the design stage." As
a very important side benefit he
points out that, when appropriately applied, QFD has
demonstrated the reduction of development
time by one-half to one-third. (Akao, 1990)
The 3 main goals in implementing QFD are:
1. Prioritize spoken and unspoken customer wants and needs.
2. Translate these needs into technical characteristics and
specifications.
3. Build and deliver a quality product or service by focusing
everybody toward customer
satisfaction.
Technique useful for:

Derivative First of a kind
Me too with
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Familiar New
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Product Concept
Since its introduction, Quality Function Deployment has helped
to transform the way many
companies:
• Plan new products

• Design product requirements
• Determine process characteristics
• Control the manufacturing process
• Document already existing product specifications
QFD uses some principles from Concurrent Engineering in that
cross-functional teams are
involved in all phases of product development. Each of the four
phases in a QFD process uses a
matrix to translate customer requirements from initial planning
stages through production control
(Becker Associates Inc, 2000).
Each phase, or matrix, represents a more specific aspect of the
product's requirements.
Relationships between elements are evaluated for each phase.
Only the most important aspects
from each phase are deployed into the next matrix.
Phase 1, Product Planning: Building the House of Quality. Led
by the marketing
department, Phase 1, or product planning, is also called The
House of Quality.
Many organizations only get through this phase of a QFD
process. Phase 1
documents customer requirements, warranty data, competitive
opportunities,
product measurements, competing product measures, and the
technical ability of
the organization to meet each customer requirement. Getting
good data from the
customer in Phase 1 is critical to the success of the entire QFD
process.

Phase 2, Product Design: This phase 2 is led by the engineering
department.
Product design requires creativity and innovative team ideas.
Product concepts are
created during this phase and part specifications are
documented. Parts that are
determined to be most important to meeting customer needs are
then deployed
into process planning, or Phase 3.
Phase 3, Process Planning: Process planning comes next and is
led by
manufacturing engineering. During process planning,
manufacturing processes
are flowcharted and process parameters (or target values) are
documented.
Phase 4, Process Control: And finally, in production planning,
performance
indicators are created to monitor the production process,
maintenance schedules,
and skills training for operators. Also, in this phase decisions
are made as to
which process poses the most risk and controls are put in place
to prevent
failures. The quality assurance department in concert with
manufacturing leads
Phase 4.
The House of Quality
The first phase in the implementation of the Quality Function
Deployment process involves
putting together a "House of Quality" (Hauser and Clausing,
1988) such as the one shown below,

which is for the development of a climbing harness (fig. from
Lowe & Ridgway, 2001).
Steps to the House of Quality (Becker and Associates, 2000)
Step 1: Customer Requirements - "Voice of the Customer"
The first step in a QFD project is to determine what market
segments will be analyzed
during the process and to identify who the customers are. The
team then gathers
information from customers on the requirements they have for
the product or service. In
order to organize and evaluate this data, the team uses simple
quality tools like Affinity
Diagrams or Tree Diagrams.
Step 2: Regulatory Requirements
Not all product or service requirements are known to the
customer, so the team must
document requirements that are dictated by management or
regulatory standards that the
product must adhere to.
Step 3: Customer Importance Ratings
On a scale from 1 - 5, customers then rate the importance of
each requirement. This
number will be used later in the relationship matrix.

Step 4: Customer Rating of the Competition
Understanding how customers rate the competition can be a
tremendous competitive
advantage. In this step of the QFD process, it is also a good
idea to ask customers how
your product or service rates in relation to the competition.
There is remodeling that can
take place in this part of the House of Quality. Additional
rooms that identify sales
opportunities, goals for continuous improvement, customer
complaints, etc., can be
added.
Step 5: Technical Descriptors - "Voice of the Engineer"
The technical descriptors are attributes about the product or
service that can be measured
and benchmarked against the competition. Technical descriptors
may exist that your
organization is already using to determine product specification,
however new
measurements can be created to ensure that your product is
meeting customer needs.
Step 6: Direction of Improvement
As the team defines the technical descriptors, a determination
must be made as to the
direction of movement for each descriptor.
Step 7: Relationship Matrix
The relationship matrix is where the team determines the

relationship between customer
needs and the company's ability to meet those needs. The team
asks the question, "what is
the strength of the relationship between the technical
descriptors and the customers
needs?" Relationships can either be weak, moderate, or strong
and carry a numeric value
of 1, 3 or 9.
Step 8: Organizational Difficulty
Rate the design attributes in terms of organizational difficulty.
It is very possible that
some attributes are in direct conflict. Increasing the number of
sizes may be in conflict
with the companies stock holding policies, for example.
Step 9: Technical Analysis of Competitor Products
To better understand the competition, engineering then conducts
a comparison of
competitor technical descriptors. This process involves reverse
engineering competitor
products to determine specific values for competitor technical
descriptors.

Step 10: Target Values for Technical Descriptors
At this stage in the process, the QFD team begins to establish
target values for each
technical descriptor. Target values represent "how much" for
the technical descriptors,
and can then act as a base-line to compare against.
Step 11: Correlation Matrix
This room in the matrix is where the term House of Quality
comes from because it makes
the matrix look like a house with a roof. The correlation matrix
is probably the least used
room in the House of Quality; however, this room is a big help
to the design engineers in
the next phase of a comprehensive QFD project. Team members
must examine how each
of the technical descriptors impact each other. The team should
document strong negative
relationships between technical descriptors and work to
eliminate physical contradictions.
Step 12: Absolute Importance
Finally, the team calculates the absolute importance for each

technical descriptor. This
numerical calculation is the product of the cell value and the
customer importance rating.
Numbers are then added up in their respective columns to
determine the importance for
each technical descriptor. Now you know which technical
aspects of your product matters
the most to your customer!
The Next stage
The above process is then repeated in a slightly simplified way
for the next three project phases.
A simplified matrix involving steps 1, 2, 3, 5, 6, 7, 9 & 11
above is developed.
The main difference with the subsequent phases however, is that
in Phase 2 the process becomes
a translation of the voice of the engineer in to the voice of the
part design specifications. Then, in
phase 3, the part design specifications get translated into the
voice of manufacturing planning.
And finally, in phase 4, the voice of manufacturing is translated
into the voice of production
planning.
QFD is a systematic means of ensuring that customer
requirements are accurately translated into
relevant technical descriptors throughout each stage of product
development. Therefore, meeting
or exceeding customer demands means more than just
maintaining or improving product

performance. It means designing and manufacturing products
that delight customers and fulfill
their unarticulated desires. Companies growing into the 21st
century will be enterprises that
foster the needed innovation to create new markets.
References
Akao, Y., ed. (1990). Quality Function Deployment,
Productivity Press, Cambridge MA.
Becker Associates Inc, http://www.becker-
associates.com/thehouse.HTM and
http://www.becker-associates.com/qfdwhatis.htm
Hauser, J. R. and D. Clausing (1988). "The House of Quality,"
The Harvard Business Review,
May-June, No. 3, pp. 63-73
Lowe, A.J. & Ridgway, K. Quality Function Deployment,
University of Sheffield,
http://www.shef.ac.uk/~ibberson/qfd.html , 2001
Mizuno, S. and Y. Akao, ed. (1994). QFD: The Customer-
Driven Approach to Quality Planning
and Development, Asian Productivity Organization, Tokyo,
Japan, available from Quality
Resources, One Water Street, White Plains NY.
Rosenthal, Stephen R, Effective product design and
development, How to cut lead time and
increase customer satisfaction, Business One Irwin, Homewood,
Illinois 60430, 1992
Reilly, Norman B, The Team based product development
guidebook, ASQ Quality Press,
Milwaukee Wisconsin, 1999
Sullivan, L.P., 1986, "Quality Function Deployment", Quality
Progress, June, pp 39-50.
Recommended further reading
Clausing, D. and S. Pugh (1991). "Enhanced Quality Function

Deployment", Design and
Productivity International Conference, Honolulu HI, 6-8 Feb.
Day, R. G. (1993). Quality Function Deployment: Linking a
Company with Its Customers,
ASQC Quality Press, Milwaukee WI.
Dean, E. B. (1992). Quality Function Deployment for Large
Systems", Proceedings of the 1992
International Engineering Management Conference, Eatontown,
NJ, 25-28 October.
King, B. (1989). Better Designs in Half the Time: Implementing
Quality Function Deployment in
America, GOAL/QPC, Methuen MA.
Page 1 of 4
Maladaptive Behavior and Psychopathology
© 2013 Argosy University
Psychological Evaluation
Confidential: For Professional Use Only
Name: Homer Brine
Date of Birth: 1-11-65
Date of Evaluation: 7-30-08
Clinician: A. Adler, PhD

Reason for Referral
Brine was referred by the Division of Family Services for a
psychological evaluation to assess his current
level of cognitive, behavioral, and emotional functioning and to
provide recommendations for outpatient
mental health services and family reunification.
Background History
The following background information was obtained from an
interview with Brine and a review of available
records.
Brine is a forty-three-year-old Caucasian male who was referred
for a psychological evaluation by the
Division of Family Services to assist with providing
recommendations for outpatient mental health services
and family reunification. He became involved with the Division
of Family Services after he was arrested for
sexually abusing his daughter. Brine was informed that the
results of the evaluation would be utilized to
develop opinions and conclusions regarding the likelihood that
he would revictimize his daughter. In
addition, he was told that the report or the examiner might
appear at his court proceedings to give evidence
regarding his past, present, or potential future mental state.
Brine chose to participate in the evaluation
recognizing the nature of the evaluation and its purpose.
Brine was born in York County, Pennsylvania, in a rural
farming community near the Maryland state line. He
was the older of two children raised in a ―traditional Christian
home.‖ When Brine was a young boy, his
family moved to Wheeling, West Virginia, due to his father’s

employment with a mining company. Brine’s
mother was a ―stay-at-home mom‖ who was actively involved
in her sons’ school-related activities. Brine
described his parents as hardworking people who always
supported him. He reported that he had begun
having school learning problems in middle school related to
comprehending and retaining learned
materials. Brine described himself as a ―quiet‖ child who
―always had difficulty in school.‖ He described
being involved with special educational services throughout his
secondary education (middle school and
high school). He received small group instruction and
individualized assistance with learning arithmetic
skills, developing memory skills, and improving his
comprehension. Brine was an impulsive, distractible,
and active boy who had difficulty completing school
assignments and interacting with peers in the
classroom. He obtained part-time employment after school and
during summer vacations and worked for
the Natural Services Department cleaning campgrounds.
Although Brine enjoyed working for the Natural
Services Department, he was unable to obtain full-time
employment after his high school graduation due to
his learning problems.
Brine continued to live with his parents after he graduated from
high school, moving back to York County,
Pennsylvania, with his family after his father lost his job (was
laid off). He reported having felt awkward in
social situations throughout his teenage years, choosing not to
date due to a fear of being rejected by his
female peers. Brine’s difficulty with social skills not only
affected his interactions with others but also
interfered with his ability to communicate with his coworkers
and supervisors in a work-related environment.
He has had difficulty maintaining employment as evidenced by

his history of losing jobs due to poor
attendance and insubordination. After many failed vocational
pursuits, Brine and his family began working
Page 2 of 4
2
with the Office of Vocational Rehabilitation (OVR) to assist
him with job training and social skills
development. He described having participated along with
several work crews doing janitorial work at local
schools, office buildings, and small businesses. Brine stated
that he enjoyed working independently due to
the difficulties he faced in relating to his coworkers. He often
needed assistance with handling interpersonal
conflicts and managing his anger (negative mood).
While at OVR, Brine met his wife, Kelda Brine, after an
introduction by mutual friends. Their relationship
progressed rapidly and within months, they began living
together. Brine described his wife as a ―mentally
retarded‖ and ―slow‖ woman who ―needs a lot of guidance.‖
She reportedly has difficulty with decision
making and lacks appropriate parenting skills. Brine and his
wife argue frequently due to her irresponsibility
and irritable mood. They have a history of verbal and physical
aggression toward one another, which has
included pushing, saying hurtful things, and threatening to kill

each other. Brine acknowledged having made
statements that he did not mean and feeling remorseful after
their arguments. Brine acknowledged that he
was unable to set appropriate boundaries or create a structured
environment at home. Although his parents
often attempted to help him with establishing limits in his
home, his wife would refuse. Brine’s mother and
wife have a strained relationship due to their inability to
communicate and their differences in parenting
styles. Consequently, his wife has refused to accept help from
her in-laws due to the fear that they ―would
take her daughter away.‖ After the Division of Family Services
became involved with his family, his wife’s
biggest fear came true—their daughter was removed from the
home and placed with his parents.
Brine stated that he was incarcerated because he sexually
molested his kid—he was in the closet naked
with her. He described having had a pornographic magazine that
he showed to his daughter and reportedly
touched her inappropriately. Brine stated that he did ―not
remember‖ touching his daughter at that time;
however, he admitted to having his daughter touch him in his
private area in the past. He spoke of their
sexual relationship beginning when his daughter was seven
years old. Brine had told his daughter ―not to
talk about it‖ to anyone. He reported that his wife had walked in
on them two years ago, saw what was
happening, and didn’t say anything. He stated that his wife
probably did not understand what was
happening or did not want to know about it. Brine described the
abuse as including both contact and
noncontact acts. The sexual abuse involved multiple incidents
over time as the activity progressed from
less invasive to more invasive (began with exposure and
fondling and had moved to digital and oral

penetration). Although Brine denied having engaged in sexual
intercourse with his daughter, he stated that
she ―would be able to describe what it is‖ due to having walked
into their (her parents’) bedroom without
their knowledge.
Brine and his wife have been referred counseling for marital
therapy and assistance with parenting. He
described having difficulty setting limits for his daughter and
struggling with decision making. He reported
that his daughter ―is in charge at home,‖ often ignoring her
parents when she is told that she cannot do
something. He has disciplined his daughter by taking something
away from her, making her sit in her room,
yelling at her, or thumping her on the head. The two household
rules that are enforced include not going out
of the yard without permission and going to bed at 8:00 p.m.
Brine denied recent alcohol or drug use, stating that he only
experimented with alcohol and marijuana as a
teenager. Legal history is significant for a previous charge of
Arson (1990) that resulted in a ten-day jail
sentence and a year of supervised probation and his current
charge of incest.
Behavioral Observations
Brine is a forty-three-year-old Caucasian male of average build
who appeared to be older than his stated
age. He has short-cropped dirty blonde hair and several missing
teeth and was dressed in an outfit issued
by the county jail (orange jumpsuit). He was pleasant and
cooperative during the evaluation, appearing
motivated to answer all questions posed to him in an honest and
forthright manner. Brine seemed alert and
well rested, exhibiting no unusual mannerisms and relating

quite appropriately to the examiner. He
maintained good eye contact, smiled appropriately, and made
spontaneous comments about various tasks
that were presented to him. Brine would refuse to complete
items that he described as difficult due to his
fear of making mistakes (arithmetic section on the Wide Range
Achievement Test—Third Edition [WRAT-
3]). He was asked to read the instructions for the 16PF
Questionnaire, and from his performance on that
Page 3 of 4
3
task, it was apparent that his reading ability was of a level
sufficient to enable him to complete the
instrument without assistance. He reported that he was not
taking any medication that could have hindered
his performance during any phase of this evaluation. From an
environmental perspective, the temperature
and lighting of the room where Brine completed the 16PF
Questionnaire and Parenting Stress Index (PSI)
conformed to room conditions used in the standardization of
that instrument. Therefore, given the
aforementioned behavioral and environmental observations, it is
believed that the results of this evaluation
provide an accurate estimate of Brine’s cognitive, behavioral,
and emotional functioning.

Review of Prior Assessments
Brine was previously evaluated in July 2005 to determine his
level of cognitive functioning and to determine
whether he was competent to stand trial. The results from this
previous evaluation suggest that Brine is
functioning within the Low Average range of cognitive
functioning (Full Scale IQ of 85) with a significant
difference evident between his verbal and nonverbal reasoning
abilities (Verbal IQ of 80 and Performance
IQ of 94). At this time, Brine demonstrated uneven cognitive
development with scores ranging from the
Borderline to Average range with relative strengths in his
perceptual organization and a relative weakness
in his processing speed.
Tests Administered
16PF Questionnaire: Fifth Edition
PSI
WRAT-3
Clinical Interview
Mental Status Examination Results
Brine came across as an anxious man who wanted to cooperate
with the evaluation despite feeling
uncomfortable at times. He spontaneously and candidly spoke of
the inappropriateness of his actions
toward his daughter and of the problems in his marriage. He
spoke of his difficulty in coping with stressful
situations and of not having adequate problem-solving or
parenting skills. He appeared genuine in his
request for assistance, often stating that he ―knows he needs
help.‖ He spoke of the difficulty he had in
comprehending information and of his wife’s cognitive

limitations. He described his wife as having difficulty
with making decisions and with being responsible. He described
his daughter as having been ―in charge‖ at
home, stating that she often told her mother what to do. His
responses were unrehearsed and no loose
associations in his cognitive processes were observed. Brine
was oriented to person, place, and time and
denied having experienced auditory or visual hallucinations. He
stated that he had had thoughts of suicide
since he had been incarcerated, however, he would never
attempt to hurt himself in any way. His affective
display was appropriate and within normal range. He reports
having had several mutual fulfilling
relationships and indicated that he got along quite well with a
variety of people. His medical history is
significant for acid reflux disease and a repaired hernia.
Assessment Results and Interpretations
Intellectual Functioning
Brine’s WRAT-3 performance showed high school–level
reading skills, seventh grade–level spelling skills,
and third grade–level arithmetic skills. He achieved an Average
range standard score on the reading
subtest, a Low Average range standard score on the spelling
subtest, and a Deficient range standard score
on the arithmetic subtest. Results suggest that his academic
functioning is below average and discrepant
from his intelligence test scores. A significant discrepancy
exists between Brine’s potential and
achievement as measured by standardized tests and supported by
interview and observation. This
suggests that Brine may have a specific learning disability.
Personality Assessment Results

The 16PF Questionnaire was administered to assess Brine’s
personal attitudes, beliefs, and experiences.
Page 4 of 4
4
Brine’s 16PF Questionnaire profile suggests that he is not
experiencing a level of psychological distress
that would warrant clinical attention. However, his profile
should be interpreted with caution due to his
responses, indicating that he may have been inattentive to item
content or may have answered randomly.
Brine’s responses indicated that he is interested in activities
that involve fewer interactions with people. It is
likely that he prefers to work independently as opposed to
working closely with others. He might be
described as a skeptical man who has difficulty trusting. Brine
has difficulty understanding the emotional
cues of others or relating to their feelings. He might experience
feelings of insecurity or feel uncomfortable
in social situations. When under stress, he may became reactive
and have difficulty considering another
person’s point of view.
Parenting Assessment Results
The PSI was administered to assess the degree of stress in his
parent–child relationship. Brine is currently

reporting that he is experiencing a great deal of life stress due
to being financially overwhelmed, having a
limited support system, and being recently involved with the
court system. He views his daughter as
hyperactive, demanding, and unable to adjust to changes in her
physical or social environments. Brine
describes his daughter as having qualities that make it difficult
for him to fulfill his parenting role. In addition,
he endorsed several items, which indicate that the source of his
stress and potential dysfunction of the
parent–child systems may be related to dimensions of his
child’s functioning. He does not experience his
child as a source of positive reinforcement due to the failure of
their interactions to produce good feelings in
himself. This may be caused by her inability to respond to
events in a predictable manner, which causes
Brine to misinterpret his daughter’s behaviors. Brine describes
himself as an incompetent parent who is
often depressed and feels unable to observe and understand his
child’s feelings or needs accurately.
Overall, he acknowledged having difficulty in managing his
daughter and balancing his own needs with
those of his family. The parent–child system is under stress and
is at risk for dysfunctional parenting
behaviors.
Paraphilic Disorders
Most relevant to the forensic mental health professional is the
category of paraphilic disorders. Previously, DSM-IV-

TR categorized all sexual deviancy and sexual dysfunctions in
the same category. However, DSM-5 presents them in two
separate categories to distinguish difficulties in normal sexual
activity (sexual dysfunctions) from hurtful, illegal sexual
behavior (paraphilic disorders).
The paraphilic disorders category includes disorders related to
sexual fantasies, urges, and behaviors involving (1) nonhuman
objects (fetishistic disorder and transvestic disorder), (2) the
suffering or humiliation of oneself or one’s partner (sexual
masochism and sexual sadism, respectively), and (3) the
suffering or humiliation of children or other nonconsenting
persons (pedophilia, exhibitionism, frotteurism, and voyeurism).
Paraphilias involving children or nonconsenting adults
constitute illegal behaviors. Perpetrators of these behaviors are
frequently involved with the criminal justice system. Although
not all paraphilias are illegal, the manner in which an individual
chooses to respond to them might be. For example, a man who
is sexually aroused by women’s feet (foot fetishistic disorder)
and goes to a shoe store to fondle himself while watching
women try on shoes is engaging in illegal behavior, even though
the fetishism in and of itself is not illegal. An individual can
also be diagnosed with a paraphilic disorder without actually
engaging in the behavior, because a paraphilic diagnosis is
warranted if the sexual urges or fantasies alone cause marked
distress or interpersonal difficulty for the individual. Some
women occasionally engage in these behaviors, but as many as
90%–95% of individuals with paraphilic disorders are male.
Sexual Dysfunctions
Sexual dysfunctions refer to disorders that impair the
performance of the sexual response cycle and are not at all
considered deviant or illegal. The sexual dysfunctions category
includes the following disorders:
· Delayed ejaculation

· Erectile disorder
· Female orgasmic disorder
· Female sexual interest/arousal disorder
· Genito-pelvis pain/penetration disorder
· Male hypoactive sexual desire disorder
· Premature (early) ejaculation
· Substance/medication-induced sexual dysfunction
It is important to note that many of these disorders can have
physiological as well as psychological causes. Individuals
suffering from sexual dysfunctions should first have a complete
physical evaluation to rule out any contributing physical
factors. For example, male erectile disorder can be caused by
diabetes.
Even when the cause of the sexual dysfunction is deemed
psychological, due to the complexity of human sexual behavior,
it is important to consider both the functioning of the
individual's relationship with the current partner and the context
of the relationship. When the erectile dysfunction is determined
to be nonmedical in nature, cognitive behavioral therapy can be
very effective in treating it. However, some states require
specific training in the treatment of sexual dysfunctions before
a mental health professional can engage in that practice. As
with any professional services provided, it is necessary to know
state laws regarding the profession.
Gender Dysphoria
Gender dysphoria (known as gender identity disorder in DSM-
IV-TR) is an overwhelming sense of being the wrong gender for
one’s body. In such cases, a female feels like a male on the
inside or a male feels like a female on the inside. These
individuals want their physical bodies (their exteriors) to match
how they feel on the inside, and many desire a full sex change
operation. Due to the high cost of such procedures, many
individuals with gender dysphoria take less expensive hormone

therapy to help alter some of their physical characteristics.
Gender dysphoria is not the same as homosexuality.
Homosexuality is an attraction to others of the same gender and
is not a discontentment with one’s own gender. In other words,
homosexual individuals do not want to be a physically different
gender, yet individuals with gender dysphoria do. In early
editions of DSM, homosexuality was listed as a deviant sexual
behavior but was removed in 1974. Gender dysphoria is listed
in DSM not as a deviant disorder but in its own category due to
the emotional distress of experiencing a mismatch between the
gender that one is and the gender that one feels.
The stage and screen performer Cher has an adult son Chaz
(formerly Chastity), who has been outspoken about his gender
dysphoria. With hormone medication and surgical
reconstruction, he has physically transformed himself from a
female into a male. However, gender dysphoria is relatively rare
both among the general population and even less common
among the offender population because it is unrelated to
criminal behavior. Nonetheless, consider the following case
example:
Clarence was an African American male in his mid to late
twenties who in his whole life never felt quite right in his body.
*** At 6’2” as an adult, he was built like a strong athlete, but
he felt different on the inside—like a female. He didn’t know it,
but he had gender dysphoria. When he turned eighteen years
old, he began secretly taking his mother’s hormone replacement
therapy, and he enjoyed how he began to look more like a
female since that was congruent with the femininity that he felt
within. In spite of his large build, he began to carry himself
with all the grace and gentleness of a delicate, petite ballerina.
Clarence felt better than he ever had.
However, in his early twenties, an unrelated set of symptoms
began to occur. He started to hear things sometimes, and he
began feeling untrusting of others. At times, he even thought
that other people wanted to hurt him. He grew increasingly
more withdrawn from his family and no longer showed up for

his part-time job at a record store. At age twenty-two, he was
arrested one night for creating a public disturbance in a park by
yelling angrily and continuously at no one. While he was in jail,
the psychiatrist determined that Clarence was experiencing the
onset of schizophrenia. He was released in a few days only to
return to jail a few months later on similar types of charges.
Thus, he began a cycle in his life of being arrested for minor
crimes, incarcerated for a short period, and released.
During one of Clarence’s longer periods of incarceration,
related to fighting with a police officer, he had been prescribed
both hormone medication and antipsychotic medication by the
jail psychiatrist, which he took regularly. Then he began
meeting weekly with one of the jail therapists. He felt
comfortable talking to her about his desire to be fully female
and his intense fear of others hurting him when his symptoms of
psychosis were strong. They formed a solid therapeutic
relationship that Clarence found quite helpful and supportive.
He was eventually released, and upon his return to jail six
months later, he requested to meet with the same therapist right
away.
When his therapist came to meet with him, he requested to talk
in a room rather than in his cell, which was a privilege reserved
for well-behaved inmates. The therapist, who was normally
quite cautious, agreed since Clarence was so cooperative and
easy to work with. The only room available was the one with
the emergency buzzer that did not always work properly. The
therapist dismissed any need for an emergency buzzer since she
knew Clarence well. She also was unconcerned when she forgot
protocol and walked in to the long, rectangle-shaped room first
to sit at the far end. As soon as she sat down and looked at
Clarence, with the door shut behind him, she heard a difference
in Clarence’s voice. It was much deeper and angrier as he
pointedly asked her if she was working for the police. She froze
because she realized that she was not talking to the Clarence
that she formerly knew. He continued to demand an answer on
whether she was working for the police.

The therapist knew that this had instantly become an unsafe
situation. Since the buzzer to alert corrections officers did not
work, her only way out of the room with this large, angry male
was to carefully, calmly, and repeatedly reassure him that she
was there to help him. Clarence began to believe her and
disclosed his belief (delusion) that all the police and corrections
officers wanted to kill him to get his important government
secrets. She realized that Clarence was more afraid than angry,
and she expressed understanding of his feelings, which further
helped to calm Clarence. Eventually, when Clarence was calm
enough, she pointed out to him that the sooner she left the
room, the sooner she could talk to her supervisor about how to
best help him. He stood up to leave, and his therapist was
relieved as the two of them exited the small room. She
immediately went to talk with her supervisor on how she could
avoid that type of situation in the future.
Let’s consider what had changed about Clarence.
Why had his behavior and demeanour become so different in
just six months?
Clarence was no longer taking either his antipsychotic
medication or his hormone medication (estrogen). It is quite
common for inmates to discontinue medication upon their return
to the community due to a lack of access to psychiatrists, a lack
of finances to pay for it, and a generally itinerant lifestyle.
When Clarence returned to jail, he had been off his
antipsychotic medication for six months and was floridly
psychotic, which means that his delusions and hallucinations
were in full bloom. Further, just as testosterone is associated
with aggression, estrogen is linked with a lack of aggression.
So, without his estrogen medication, all his feminine gentleness
was gone. While his gender dysphoria was not the cause of his
psychosis or his aggression, his estrogen medication had helped
to diminish some of his resulting anger from his psychotic
symptoms, specifically his delusions about the city’s police
force wanting to kill him. Hence, the compound effect of
Clarence being off both medications left him with active

delusions and plenty of aggression for responding to them.
It was a valuable lesson for the jail therapist about the need to
maintain personal safety at all times and on the adverse effects
of noncompliance with antipsychotic medications among
individuals with schizophrenia.
Other Conditions of Clinical Attention
This module addresses the other conditions that may be a focus
of clinical attention from DSM-5. Other conditions that may be
a focus of clinical attention were formerly listed in DSM-IV-
TR as v-codes. These conditions apply when the individual has
a clinically significant problem but does not meet criteria for a
specific psychological disorder. An example would be a partner
relational problem or the person could have a diagnosis, but the
additional problem (v-code) may not meet the full criteria for a
mental illness. Examples of other conditions that may be a focus
of clinical attention are problems related to abuse or neglect,
malingering, relationships problems, bereavement, and
occupation. Previously, in DSM-IV-TR, conditions of this
nature were listed on Axis IV, but since DSM-5 has moved to a
nonaxial format, they are now just listed after any primary and
secondary diagnoses.
This module also addresses cross-cultural issues in the
assessment and treatment of sexual disorders. You can refer to
the American Psychological Association (APA) website in
the Webliography to learn about cultural sensitivity for mental
health professionals. You are encouraged to use this website to
increase your cultural sensitivity as a forensic mental health
professional.
Conclusion
Sexual dysfunction is an undesirable physical or psychological

condition that occurs in both males and females and is unrelated
to criminal behavior. In contrast, the paraphilias are very much
intertwined with criminal offenses. Sex offenses are some of the
hardest disorders to treat due to the physical pleasure that the
offender experiences at the expense of his or her victims.
Sexual offenders, in particular pedophiles, are of great concern
because many of them begin offending at a very young age and
are able to elude detection for decades. The immense number of
child victims that a pedophile might have over his or her
lifetime can be staggering. Sexual offenders who prey on adults
can also be quite dangerous because, often, the degree of their
sexual offending as well as the level of violence associated with
it often increase over time.
Further, each time one of these types of offenders is not caught
after exploiting the victim, he or she is emboldened to engage in
additional and more severe offenses in the future. These
individuals are often able to evade detection for many years
because, on the surface, they appear to be just like everyone
else. They do not come with warning labels, and they rarely
look scary or mean. In fact, sexual offenders often use their
friendly disposition or attractive appearance to groom their
victims, which means gaining the trust of their victims so that
they can more easily violate them. It is not uncommon for both
child and adult victims of sexual offenses to hesitate to come
forward about the sexual assault because they fear that they will
not be believed due to the likability, attractiveness, or social
prominence of the offender.
Paraphilic Disorders
Pedophilic Disorder
Pedophilia involves prepubescent children, generally children

under the age of thirteen years. Pedophilia is
not diagnosed when the child has reached sexual maturity
(puberty). Sexual behavior with children who
have reached puberty but are under the age of consent is illegal,
but it is not classified as a DSM disorder.
In spite of a few highly sensationalized cases in the media,
approximately 99% of all pedophiles (adults
sexually attracted to children under the age of thirteen years)
are males.
Exhibitionistic Disorder
Exhibitionism is sexual arousal from exposing one’s genitals to
an unsuspecting stranger.
Frotteuristic Disorder
Frotteurism is touching or rubbing against a nonconsenting
person. This could be the act of rubbing genitals
against a stranger in an elevator or a subway.
Voyeuristic Disorder
Voyeurism is sexual arousal from observing an unsuspecting
person who is naked, getting undressed, or
engaged in sexual activity.
These four disorders (pedophilic disorder, exhibitionistic
disorder, frotteuristic disorder, and voyeuristic
disorder) involve illegal behaviors and are considered sex
offenses. Forensic mental health professionals
are playing an increasing role in the assessment, treatment, and
prerelease evaluation of sex offenders.
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