June 8, 2011

Leading psychiatrists critique proposed sexual disorders

  • Dangerous.
  • Unnecessary.
  • Sloppy.
  • Inaccurate.

These adjective express the sentiment of prominent forensic psychiatrists about a set of controversial new sexual disorders being proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Four critiques in the current issue of the flagship journal of the American Academy of Psychiatry and Law follow two well-attended meetings in which forensic psychiatrists were "decidedly negative" toward the proposed paraphilias, in the words of psychiatrist Howard Zonana.

Pandering to legal pressure 

A primary concern of forensic psychiatrists is that the proposals are being developed not based on clinical need or scientific discovery but, rather, to meet demands from the legal system. Specifically, broadening of paraphilias will make it easier to:
  • Increase prison terms for Internet pornography users 
  • Win civil detention for repeat sex offenders who have no genuine mental disorders
"The sexual disorders in the current and proposed DSM contain a potpourri of categories that increasingly intersect with the criminal justice system," notes Zonana, a psychiatry professor at Yale:
"Caveats saying the DSM is designed for clinical and not legal purposes notwithstanding, our classification system has difficulty distinguishing what we consider criminal behavior from culturally unacceptable behavior and mental disorder. Several current proposals continue this trend and seem more responsive to criminal justice concerns than mental illness considerations. They also lack sufficient specificity to warrant being called a disorder."

Loosening categories will reduce accuracy

J. Paul Fedoroff echoed Zonana's concern about legal influence, and also highlighted the reduction in accuracy that the diagnostic expansions will engender:
"The [proposals] raise more questions than answers. The proposed revisions to current DSM-IV-TR criteria will decrease the specificity of ascertained and diagnosed conditions by dramatically loosening the diagnostic categories. While the proposed changes may increase diagnostic reliability, they will certainly decrease diagnostic accuracy. Given the consequences of mistaken diagnosis, the proposed revisions are both unhelpful and dangerous."

Federoff, chair of  AAPL's Sexual Behaviors Committee, also directs both the Sexual Behaviors Clinic at Royal Ottawa Mental Health Care Centre and the forensic research program at the University of Ottawa Institute of Mental Health Research. 

Hypersexuality: Pathologizing young adults

Both Zonana and Federoff critiqued the conceptual and practical problems with the big three proposals that were resoundingly rejected in an audience poll after a debate at last year's AAPL meeting. These include hypersexuality, pedohebephilia and paraphilic coercive disorder (which the DSM revisers recently agreed to shelve). Wrote Zonana:
"The amount of time a person spends thinking about and engaging in sexual behavior varies enormously across the life cycle, with a sharp peak in adolescence and early adulthood. The most striking feature of the current criteria for hypersexuality is that, in my experience, it will be especially hard to find a young adult of college age who does not meet all of the criteria. The same will be true of many adults. The amount of time adolescents spend fantasizing and engaging in sex-related behavior is enormous.... To call this a mental disorder will include far too many false positives."

Pedohebephilia: Confusing illegality with disorder

Zonana, Federoff, and two other prominent forensic psychiatrists – Johns Hopkins University psychiatry professor Fred Berlin and Columbia University professor Michael First – all criticized the proposal to expand pedophilia to include adults with sexual interests in minors who have reached puberty.

"What is the great need to expand the definition to make more diagnoses?" asked Zonana. "Their rationale seems to conflate law enforcement with mental illness even more. There certainly are no new good treatments to justify a need to identify more cases."
“Our culture has initiated a 'war on sex offenders' and the legal system has geared up to wage it. Since we have made the diagnosis almost completely overlap with the crime, we have become overly enmeshed with legal goals.”
Federoff agreed:
"With the broadening of the age range of interest that will satisfy the diagnosis, more people will be labeled. By definition, expansion of the range of diagnostic criteria reduces sensitivity (true positives). Is this a good idea?"
Critical voices encouraged

Introducing the critiques, Richard B. Krueger, a psychiatry professor at Columbia University and medical director of the New York State Psychiatric Institute's Sexual Behavior Clinic, invited others to submit input – especially in published form:
"We hope that these articles will stimulate further discussion and submission of thoughtful criticism. Forensic psychiatrists are particularly well suited to offer commentary concerning the use or misuse of paraphilia diagnoses in legal proceedings, and observations on any aspect of the proposed criteria would be welcome. Indeed, editors of relevant journals have been generous in publishing commentary and articles. The Journal of the American Academy of Psychiatry and the Law, Sexual Abuse, the Archives of Sexual Behavior, the Journal of Sex Research, and The Journal of Sexual Medicine have published criticisms of DSM-5. There is still time to submit comments. Even if suggestions are not actually incorporated or reflected in the revised criteria, the published record would be valuable and relevant for the future."
While I would certainly echo Krueger's encouragement, I am skeptical that some members of the DSM-5 Sexual Disorders Work Group will willingly give up their pet diagnoses – especially the scientifically suspect pedohebephilia construct that is already being misused on a widespread basis in Sexually Violent Predator cases.

As psychiatrist John Sadler noted in his book dissecting the conflictual history of the DSM's, Values and Psychiatric Diagnosis, the DSM committees claim openness and seek input, “but how such input is to influence the actual decision-making process is not discussed.”

At any rate, Krueger makes the excellent point that having a formal record of the opposition will be important in the future. If any of these three proposals makes it into the DSM-5, vigorous Daubert challenges by increasingly sophisticated attorneys will be certain to follow. Indeed, use of any of the paraphilias in court only calls attention to the scientifically weak underpinnings of the entire category. As Zonana points out:
"The work group has a difficult set of disorders to contend with. The category lacks a principled basis for considering inclusions and exclusions, which makes it vulnerable to societal pressures rather than advances in science. The proposals discussed should not be accepted in their current form, as they create more problems than they solve."
Daubert challenges will be especially likely in that the American Psychiatric Association has decided not to conduct any formal field tests of the proposed paraphilias. This means that even their interrater reliability -- far easier to establish than actual scientific validity (accuracy) -- will remain in doubt. Unofficial field trials being conducted at the Sand Ridge Detention Center in Wisconsin and in California will not alleviate this concern, as the coordinators of these trials have a vested interest in a positive outcome. It's something like hiring the fox to guard the chicken coop.

I predict that the paradoxical consequences of this shaky endeavor are going to come back and bite organized psychiatry in the future. As I wrote in the conclusion to my historical review of hebephilia's sudden emergence:
Significant unintended consequences are likely if novel syndromes of primary benefit to the sex offender commitment industry are incorporated into the upcoming edition of the DSM. First, at a time of mounting controversy over partisan influence and lack of scientific rigor in the DSM diagnostic system, critics will seize on this as a glaring example of arbitrary and unscientific use of psychiatric diagnosis in the service of a pragmatic goal. This could have the paradoxical effect of reducing the scientific credibility of the DSM and the fields of psychiatry and psychology more broadly. In the forensic arena, where the diagnosis will most often be invoked, it may paradoxically invigorate defense challenges on the grounds that psychiatry is being deployed in a pretextual manner. In the end, hebephilia will come to haunt not only those who are civilly committed on pretextual grounds, but the entire mental health field, for years to come.
As always, the Journal of the American Academy of Psychiatry and Law is available online for free downloading. The current issue includes some other interesting articles, including a critique by forensic psychologist Brian Abbott of a current push in the sex offender industry to combine actuarial scores with clinical judgment. I encourage you to check it out (HERE). 


ACH said...

. The category lacks a principled basis for considering inclusions and exclusions, which makes it vulnerable to societal pressures rather than advances in science.
Of course it lacks a conceptual basis. The perversions arouse in 19th century forensic practice, and were rooted in the idea that procreation is the purpose of the human sexual instinct, such that any sexual instinct not directed at potentially procreative activities was perversion (different from perversity, which was immoral sexual behavior). Now that the perversion of perversions of old (homosexuality) has been (largely) normalized (at least in the mental health professions) and a potentially-procreative sexual ethic has itself become marginal, the whole concept of "paraphilia" is based on a foundation we no longer accept.

Thus, you have Federoff basically taking our "between consenting adults" ethical standard as though it were a scientific concept ("informed consent" is an ethicolegal concept, not a scientific one!) as his basis for paraphilia. (And then he ignored this for TF.)

Berlin is honest about his basis for regarding things as paraphilias--it's a value judgment through and through. But that leaves little room for distinguishing between mental disorder and crime (both of which are things we devalue).

First (in another article in JAAPL) basically embraced the idea that the core of the concept of "paraphilia" is that they are sexual interests that are "bizarre." Well..."bizarre" according to who?

Combine all this with the fact that of all the variations in human sexuality that exist that might be regarded as perversion, the only ones to become specific diagnoses are those that have a forensic history, the fact that the perversions are primarily studied by in forensic contexts, with data on their very high prevalence in the general population (so high that they really can't be judged deviant in any scientifically meaningful sense) basically ignored.

Unless you can tell me what sex is for, you have no foundation for a concept of "paraphilia."

Anonymous said...

Hey Karen,

Am I reading right on this? Crossdreamers.com seems to suggest in its April 1, 2011 entree on Paraphiliphilia that the APA has decided to include Hebephilia into the upcoming DSM-5. Or did I misread this? Do you know the status on this?


I can only say: Heaven help the world and the fields of psychology and psychiatry if this is true!


Karen Franklin, Ph.D. said...

You're not misreading. In the current proposal, Hebephilia is folded into Pedophilia as a brand-new disorder called "Pedohebephilia." The Sexual Disorders Work Group has backed off on another controversial proposal, to turn rape into a mental disorder (Paraphilic Coercive Disorder), but they are clinging tenaciously to this one despite the fact that it's making them look foolish to mainstream clinicians, researchers, etc. around the world. I've blogged about this a lot; you can do a search for the term on my blog site to find out more. The DSM-5 public comments period has been extended until mid-July, so you can write to the DSM-5 and share your thoughts.

Anonymous said...

Thanks Karen,

As you may know, I am aware of the construct and the notion to which it refers. I knew that the debate has been ongoing as well. Many of your blog entries on this were posted after the crossdreamers post, so I thought the decision wasn't yet determined. The Crossdreamers post seems to suggest that the construct will, in fact, be entered into the DSM-5, that the decision has been made. That was what caused my confusion.

By the way, is there still a chance that the pedohebephilia construct might not be approved for the DSM-5? So many in your field (and others) are dead set against it. How can the sub-group or APA approve it with so such a heavy opposition within it's ranks? Europe will likely laugh at it and then disregard it, as many AoCs in Europe are 14.

As for why they are clinging tenaciously to it, I can understand why. The reasons have absolutely NOTHING to do with science. At least the construct hasn't gone so overboard as to include adolescents up to 18 (i.e. ages 15, 16, 17), although the forces that be are likely pushing for that to eventually happen and ensure that pathology runs concordance with age, as if there is a difference. With the continuing rise of hysteria and creation of laws to fight SVP (sexually violent predation) in this country, said forces will go to any extent to stifle such behavior as adult-teen sexual interaction. I don't condone breaking the law, but the collective powers seem to think they can change evolutionary programming simply because it conflicts with social mores. They won't. They are persistent indeed.

By the way, why direction do you believe this will be heading? What do you believe will happen?


Anonymous said...

As for the DSM-5 site, I plan on it. I read somewhere that reviewers require an account in order to post. Sadly, I am not quite sure if my input would make that much of a difference.


Karen Franklin, Ph.D. said...

Nothing is set in stone. It hasn't been reviewed by the recently established scientific review task force. When that group sees the incredibly weak and irrelevant research underlying the construct, it should dump it in the scrap heap. If this does not happen, many eyebrows will rise.

Anonymous said...

I submitted my comment at the DSM-5 site and subsequently posted here, at a different blog entry, for others to read. Let's keep our fingers crossed.

By the way, do you think that Pedophilia, like homosexuality, will eventually be dropped from the DSM as well? Apparently, this construct also has weak underpinnings (if I recall, you and others have mentioned this). If the legal system and law enforcement agencies have their way it won't be.