Psychiatrists vote no on controversial paraphilias

By an overwhelming majority, a group of seasoned forensic psychiatrists who work with sex offenders voted last night against three controversial new sexual disorders being proposed for the DSM-5.

The votes were 31-2, 31-2, and 29-2, respectively, against Paraphilic Coercive Disorder, Pedohebephilia, and Hypersexual Disorder. The votes came at the end of a debate at the annual meeting of the American Association of Psychiatry and Law (AAPL) in Tucson, Arizona.

The rejection is symbolic, but sends a strong message to the DSM-5 developers. One of the six debate panelists, Richard Krueger, is a member of the Paraphilias SubWorking Group. Two other panelists serve as advisors to the committee. In the audience were prominent forensic psychiatrists who took stances regarding similar proposals during previous revisions of the DSM.

The American Psychiatric Association, to which most forensic psychiatrists belong, publishes the influential Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition. But psychiatrists have not played a central a role in the 20-year-old sex offender civil commitment industry, which is lobbying for these new diagnoses. Much of the planned field testing will be done at civil commitment sites.

The debaters

Arguing for and against Hypersexual Disorder were two prominent psychiatrists with decades of experience in assessing sexual disorders. Richard Krueger, on the "pro" team, is a Columbia University professor and medical director of the Sexual Behavior Clinic at the New York State Psychiatric Institute. John Bradford, an advisor to the DSM-IV and past president of AAPL, is a Distinguished Fellow of the APA, last year earning its prestigious Isaac Ray Award. The University of Ottawa professor is founder and clinical director of the Sexual Behaviors Clinic in Ottawa. He expressed concern about how clinicians would determine how much sexual preoccupation is excessive, and voiced worry that homosexual men might be disproportionately given the label.

Two Wisconsin psychologists debated "Paraphilic Coercive Disorder," which would apply to rapists. Thomas Zander took the "con" position while David Thornton of the Sand Ridge Secure Detention Center for sexually violent predators was "pro." This is the third time that the American Psychiatric Association has considered such a diagnosis.

Tackling Pedohebephilia were two Northern Californians, forensic psychiatrist Douglas Tucker ("pro") and your faithful blogger ("con"). The controversial proposal would expand pedophilia from its current definition, in which the target of sexual attraction must be prepubescent, to young pubescents as old as 14.

The debate was organized by forensic psychiatrist Lynn Maskel, a clinical professor at the University of California-San Diego.

Clinical versus forensic utility?

The three-member "con" team focused on two main themes:

• All three proposed diagnoses lack a sufficient scientific basis.

• They are highly likely to be misused in the forensic context, the primary site for their application.

The "pro" debate team repeatedly insisted that these diagnoses are being proposed based on their scientific merit, not their utility to government evaluators in civil commitment cases. They said these new diagnoses are needed so people suffering with these conditions can get adequate treatment.

The clinical needs argument is a red herring. Clinicians are not turning away patients with problematic sexual behaviors because the proper billing code is missing from the Diagnostic and Statistical Manual of Mental Disorders. Rapists will not flock in for needed treatment when they hear that a Paraphilic Coercive Disorder label is now available for them.

The audience of forensic psychiatrists clearly did not buy the clinical justification. As more than one audience member asked the panel, If the rationale is strictly clinical, why are attorneys serving as advisors to the work group?

Back in 1986, the last time Paraphilic Coercive Disorder was proposed for the DSM, it was defeated in large part due to the opposition of forensic psychiatrists (not pesky feminists, as the historical revisionists would have it). Hopefully, history will repeat itself with respect to all three of these poorly conceptualized and dangerous proposals.

The debate was audiotaped, and will be available for purchase from AAPL. The texts of the proposed diagnoses can be viewed at the DSM-5 website. My resource page on Hebephilia is HERE. Thomas Zander’s article, Inventing Diagnosis for Civil Commitment of Rapists, is online HERE.

Photo: (L to R) John Bradford, Karen Franklin, Thomas Zander, David Thornton, Douglas Tucker, Richard Krueger. Photo credit: Luis Rosell.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.