Hebephilia update: DSM-5 workgroup stubbornly clinging to pet diagnosis

Salvador Dali*: The Average Bureaucrat

A few weeks ago, I reported on an open letter to the American Psychiatric Association, calling for it to reject three controversial expansions of sexual paraphilia diagnoses that are being promoted by government evaluators in civil commitment cases.

A lot has happened since then. The only one of the three controversial diagnoses still in the running for official status has been altered for the umpteenth time. An esteemed journal is issuing a scathing critique. And the open letter is generating buzz in the blogosphere.

The open letter has garnered more than 100 signatures, many from prominent forensic psychologists and psychiatrists in the U.S. and internationally. If you intend to sign on but haven’t yet, act now because I understand it will be submitted very soon. (Click HERE to review the text; click HERE to email your name and professional title to co-author Richard Wollert.)

Hebephilia gets yet another makeover 

This week, the Sexual Disorders Workgroup for the upcoming fifth edition of the APA's diagnostic manual toned down its proposal to turn sexual attraction to young teens into a mental disorder. As psychiatrist Allen Frances explains at his DSM5 in Distress blog, hebephilia is still there -- you just have to read the small print to see it:

Dali: Enchanted Beach with Three Fluid Graces

Confronted by universal opposition from the rest of the field, the DSM 5 group has been forced progressively to whittle down their pet, but they so far have refused to just drop it altogether. 'Hebephilia' first lost its free-standing independence and was cloaked as Pedohebephilia. When this didn't fly, the term was dropped altogether in the title but the concept was slipped into the definition of Pedophilia -- which was expanded out of recognition by having a victim age cut-off of 14 years. No one accepted this outlandish suggestion and now finally the work group comes back with ‘early pubescent children' and tries to keep 'hebephilia' as a term in the subtype. The instability of the criteria sets associated with this concept is additional evidence that the fervor for its adoption stems from emotional loyalty rather than reasoned review of its weak conceptual and research base. How can the group vouch for the reliability of the diagnosis when the concept and criteria are changing every month? This is no way to develop a diagnostic system.

The staunch insistence on this transparent attempt to turn statutory rape into a mental disorder owes in large part to the makeup of the sexual disorders workgroup. As Frances notes, "the most wayward of all the DSM 5 work groups" is "lopsidedly dominated" by psychologists from a sex clinic up in Toronto, whose ambition is "to find a place in DSM 5 for their pet diagnosis."
Although the group's other outlandish proposals, Paraphilic Coercive Disorder and Hypersexuality, have been shelved for the time being, Frances worries that putting them in the appendix "for further study" is still risky:

Recognizing that the jig is up on the grand design, members of the DSM 5 sexual disorders work group have been heard saying they may have to settle for an Appendix placement for their three hothouse creations. This would create forensic dangers. We have learned from the abuse of "Paraphilia Not Otherwise Specified" in Sexually Violent Predator cases that any (even remote) legitimization by DSM 5 is certain to be misconstrued and misused in the courtroom. 

Come on guys. This is absolutely absurd just on the face of it…. So back to the drawing board, DSM 5 sexual disorders work group. The grand dream is lost -- now at least make sure you don't mess up on the fine print.

On the professional listservs today, some conspiracy theorists were speculating that the new wording signifies a plot to enhance the standing of physiological testing in sex offender assessment. The latest proposed criteria for "pedophilia, hebephilic type" require "equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons." How to determine that fuzzy standard? Enter the penile plethysmographer, a new niche career track, penis cuff at the ready to measure who is aroused by what.

"There is withering criticism already that the DSM is being expanded to sell more drugs," wrote one colleague. "Now it appears that psychiatry and psychology are conspiring to use the DSM to spur PPG tests -- tests which risk leaving patients with traumatic and indelible memory traces. Do most psychiatrists really want to open this door?!"

Orwellian thought police? 

The mere idea of allowing the American Psychiatric Association to dictate "normal" sexuality frightens English Professor Christopher Lane. Lane, whose book Shyness: How Normal Behavior Became a Sickness exposed the unscientific inner workings of the DSM-III committee, expressed shock over the first listed criterion for the shelved disorder of hypersexuality: "Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior." On his Side Effects blog, Lane mused:

Dali: Femme a Tete de Roses

"Excessive time"? What exactly does that mean, and according to whose standards? That's not a small or trivial matter to settle when the APA is talking in vague generalities about the nation’s libido -- how much sex it wants and how much sex the APA thinks it should think about wanting. The APA is talking about how much time Americans can devote to sexual fantasy before it suggests that we’re mentally ill if our preoccupations are stronger than those set by the relevant task force.

Does that initiative seem to overreach a bit, even to the point of sounding almost Orwellian? It does so to me. If we're to have criteria, are quotas next, including for fantasy? It’s as if the East Coast offices of the APA had morphed into those of the Thought Police in Orwell's 1984, warning citizens that they’d overstepped their "sexual thought quota" for the week and must be rationed -- or punished accordingly.

Lane analyzed hebephilia through his characteristic historical lens:

It's an archaism, a throwback literally to 19th-century psychiatry, but refers to practices that were as central to the Classical age -- and thus to Western democracy -- as were Socrates, Plato, and especially Plato’s Symposium, one of the foundational books in the West on eros and love.

The APA is already trying to determine how long normal grief should last before it’s thought pathological. Its brisk, jaw-dropping answer: two weeks. Do we really want the same organization dictating how often we can think about sex? These kinds of proposals can only end badly.

Leading journal tackles the controversy

The good news this week, which should have all of us jumping up and down with joy, is that the APA has caved in under massive public pressure and dropped its plan for a new psychosis risk disorder. This disorder would have put thousands if not millions of youngsters at risk of being dosed up with dangerous antipsychotic drugs based on a suspicion that they might go crazy in the future. Mixed Anxiety Depression has also bit the dust.

Dali: Daddy Longlegs of the Evening Hope

But, as featured in a special issue of the esteemed Journal of Nervous and Mental Diseases due out in June on the raging diagnostic controversies, there are still many battles ahead as the bloated DSM-5 enters the final stretch. The special issue will tackle diagnostic inflation, pharmacological conflicts of interest, controversies with the newly revamped personality disorders, and problems with diagnostic reliability in the recent field trials. Hebephilia, often neglected amidst controversies with wider impact such as psychosis risk syndrome and the pathologization of normal grief, merited an article in this special issue.

 In "Hebephilia and the Construction of a Fictitious Diagnosis," forensic psychologists Paul Good and the late Jules Burstein make a strong case for abandoning this faux disorder, which will only make the APA more of a laughingstock in the future.

Good and Burstein catalog an assortment of empirical problems. These range from the difficulty of reliably measuring "recurrent and intense" sexual arousal to problems determining the pubertal status of a young teenage victim. They also challenge the very idea that sexual attraction to pubescent minors is a mental illness, rather than merely illegal.

Although the Sexual Disorders Workgroup hides behind a fictive notion of a pure and ethereal "science," Good and Burstein clearly believe that hebephilia, if added to the DSM-5, will be mainly invoked in a partisan manner in forensic proceedings, in order to justify harsher punishment and involuntary civil detention. Because of its power to do harm, they say, its scientific grounding should be especially strong. If it does manage to worm its way into the DSM, they say, it should still be challenged in court:

We believe the admissibility of the proposed revision to DSM-5 that would include Hebephilia as a type of Pedophilia could be challenged in a court of law based on current legal standards. For example, since there is no professional consensus or general acceptance in the scientific community to support the notion of Hebephilia as a mental disorder, it would have difficulty passing the Frye test for admissibility. Similarly, without a widely established body of peer-reviewed, validation research and repeated studies showing inter-rater reliability in the laboratory and among clinicians in the field, Hebephilia would also have difficulty meeting the criteria specified in the Daubert standard.

Indeed, this is just what has been happening to hebephilia in federal court, where at least three civil detention petitions in a row have been thrown out due to the level of controversy in the field over this purported condition.

With all of this tumult, it seems that the DSM-5 excesses are producing a backlash against the American Psychiatric Association and, indeed, fueling disenchantment with the whole enterprise of psychiatric diagnosis.

As Frances writes, the turnaround on psychosis risk syndrome came about due to a combination of:

• extensive criticism from experts in the field
• public outrage
• uniformly negative press coverage
• abysmal results in DSM-5 field testing

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today's revisions should be just the first step in a systematic program of reform.… This is certainly no time for complacency. Much of the rest of DSM 5 is still a mess. The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise.

Who needs reliability? 

Frances calls for slowing down the process to allow for additional field testing and, more importantly, an independent scientific review of all the remaining controversial DSM-5 changes. But the DSM-5 folks are taking a different tack. Faced with field trial results showing very poor reliability -- not much better than chance -- for many of their proposed diagnoses, they want to change the definition of what counts as minimally adequate.

Dali: Autumn Cannibalism

It’s pretty ironic: The DSM-III went down in history for elevating the importance of reliability at the expense of validity. Remember, diagnostic reliability just means that similarly trained raters see a certain symptom presentation and call it by the same label. It says nothing about external validity, or whether the label is meaningful in explaining a real-world phenomenon. But reliability is basic. If a diagnostic label cannot be reliably applied, you can't even start talking about its validity. And now, the same psychiatric organization that reified the kappa reliability statistic as the be-all, end-all of science is trying to tell us that traditional kappa levels are unrealistically high for psychiatric research.

Historically, psychiatric reliability studies have adopted the Fleiss standard, in which kappas below 0.4 have been considered poor. In the January issue of the American Journal of Psychiatry, Helena Kraemer and colleagues complained that this standard is unrealistically high, and lobbied for kappas as low as 0.2 -- traditionally considered poor -- to be deemed "acceptable."

Former DSM-III guru Robert Spitzer and colleagues object to this proposal in a letter in the latest issue of the Journal. "Calling for psychiatry to accept kappa values that are characterized as unreliable in other fields of medicine is taking a step backward," they state. "One hopes that the DSM-5 reliability results are at least as good as the DSM-III results, if not better."

Alas, just wishing won't make it so. Despite its grandly stated ambitions, the DSM-5 will likely go down in history as a major gaffe by American psychiatry in its continuing struggle for world dominance.  

Remember to check out the open letter 

and send in your name, if you are in agreement with it.

Further reading:

• American Sex and American Psychiatry: The APA is trying to determine how much sex we can fantasize about by Chris Lane at Side Effects
• DSM 5 Rejects 'Hebephilia' Except for the Fine Print: Now the devil is in the details by Allen Frances at DSM5 in Distress
• Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat: Perhaps this will be the beginning of real reform by Allen Frances at DSM5 in Distress

*Salvador Dali: "One day it will have to be officially admitted that what we have christened reality is an even greater illusion than the world of dreams."