Hebephilia hopes hidey-hole will help it slip into DSM-5

Jean Broc: The Death of Hyacinthos

Hebephilia, the controversial faux disorder proposed for the upcoming DSM-5, has been repackaged in the hopes that no one will notice its presence. Unfortunately for its survival, two newly published journal articles may make it harder to hide.

The proposed label of "pedohebephilia” has been quietly discarded. Instead, hebephilia – defined as sexual attraction to young pubescents – has been buried in the text of revamped criteria for pedophilia. Presumably hoping it will go unnoticed, the web page authors do not mention the change.

The questionable diagnosis is the brainchild of a Canadian sex offender clinic with inordinate influence on the Sexual Disorders Workgroup of the American Psychiatric Association’s DSM-5 revision committee.

It is the last of three quacky sexual paraphilia proposals still standing. Overwhelming opposition derailed paraphilic coercive disorder (which would have turned rape into a mental disorder) and hypersexuality.

These victories notwithstanding, the developers of the DSM-5, due out in 2013, have been remarkably deaf to an ever-increasing roar of concern from allied professions in the United States and internationally. The revision process steamrollers on despite a mushrooming petition by a coalition of psychology organizations, a scathing critique by the British Psychological Society and, most recently, public statements of concern by the 154,000-member American Psychological Association and the 120,000-strong American Counseling Association. 

More costly and ineffective civil detentions

Following on the heels of my historical review of hebephilia in Behavioral Sciences and the Law, the Journal of the American Academy of Psychiatry and Law has just published two new critiques.

In an article focusing on the legal ramifications, forensic psychologist and attorney John Fabian warns that the primary result of adding this scientifically unproven diagnosis to the DSM-5 will be an increase in civil commitments of sex offenders.

Fabian outlines the inconsistent federal case interpretations of hebephilia, including the only federal court of appeals ruling, by the U.S. Court of Appeals for the First District in the case of Todd Carta (the case I led off with in my review):

The court in Carta focused on the offender's behavior as causing him distress, impairment, and dysfunction in his life. However, the question of whether hebephilia is a type of paraphilia NOS, depends on whether it is considered deviant and abnormal to have a sexual attraction and to engage in subsequent sexual behaviors toward pubescent adolescents and postpubescent minors. To this date, neither the case law nor clinical research on sex offenders has clearly supported classifying hebephilia as an abnormal pathology.

As we can see through this psycholegal analysis, both clinicians and the courts disagree as to whether hebephilia is a pathological sexual deviance disorder. Given the fact that the U.S. Supreme Court recently denied certiorari in hearing McGee, Michael L. v. Bartow, Dir., WI Resource Center, addressing whether a rape paraphilia NOS, nonconsent, meets the constitutional threshold for legal mental abnormality for civil commitment, it is unlikely that the Court will hear such a case addressing hebephilia. More likely, the DSM-5 will provide guidance for clinicians, attorneys, and judges who evaluate and litigate this issue in civil commitment proceedings.

Focus on clinical impairment

In a commentary on Fabian's article, sex offender researchers Robert Prentky and Howard Barbaree try to take a middle road in the contentious debate. At the outset, they acknowledge the questionable nature of diagnosing a condition that is hard-wired in heterosexual men:

Brooke Shields was only 12 years old when she played a child prostitute in Pretty Baby, three years before she modeled Calvin Klein jeans, asking, "Want to know what gets between me and my Calvin's? Nothing." Klein's young teenage models were so provocative that the Justice Department investigated whether the ads violated federal child pornography and child exploitation laws. Penelope Cruz was only 13 years old when she played a child prostitute in the French soap opera Série Rose. Jodie Foster was 14 years old when she played a child prostitute in Taxi Driver. The model Maddison Gabriel, the official "face" of Australia's Gold Coast Fashion Week in 2007, was only 12 years old. Highly sexualized young girls would not be used in advertising, in movies, and on catwalks unless a great many adult males were paying close attention. It appears that heterosexual human males are hard wired to respond sexually to young females with secondary sexual characteristics.

But, they continue, men with an "exclusive sexual preference for young teenagers" (if such men can be found) may indeed be sufficiently impaired so as to meet the mental disorder requirement of "clinically significant deficits in social and interpersonal skills."

This was the approach taken by the appellate court in upholding the civil commitment of Todd Carta, and it is a tactic being used by government experts in sexually violent predator civil commitment proceedings. In a circular rationale, once the pseudo-diagnosis of “Paraphilia Not Otherwise Specified-Hebephilia” is assigned, clinically significant impairment can be inferred from the mere fact of an arrest and criminal prosecution.

To their credit, Prentky and Barbaree do admit that the research base for hebephilia is insufficient at the present time:

The bright line in the sand should be the clinical and empirical integrity of the proposed diagnosis…. Examined in isolation, there does not appear to be adequate empirical evidence that sexual arousal in response to young adolescents constitutes a paraphilia…. Clearly, this is an area that warrants further research.

Let's just hope the DSM-5 gods tune in to the controversy in time to pull the plug on yet another half-baked idea that will only bring further embarrassment to the profession.

Both articles are freely available online:

• John Fabian: Diagnosing and Litigating Hebephilia in Sexually Violent Predator Civil Commitment Proceedings

• Robert Prentky and Howard Barbaree: Commentary: Hebephilia—A Would-be Paraphilia Caught in the Twilight Zone Between Prepubescence and Adulthood

The DSM-5 petition, spearheaded by the Society for Humanistic Psychology, is HERE.

"Invasion of the Hebephile Hunters," my oldie but goodie from 2007 (before all this hoopla got started), is HERE.

Sexual violence prevention: Recommended journal issue

The current issue of the International Journal of Law and Psychiatry features an excellent collection of diverse scholarship on the prevention of sexual violence. Papers address the empirical and moral foundations of prevention from the perspectives of law, psychiatry, criminology, psychology, and public policy. Here's a preview of a couple of the articles I've read so far….
 

Paraphilia battle pivotal to future of U.S. civil liberties

Jerome Wakefield, a professor at New York University and an influential theorist of mental disorder, provides a searing analysis of the messy paraphilia debacle that the DSM-5 task force has waded into. After providing a brief history, he dissects the current proposals to show how their conceptual invalidity will open the door to widespread abuse in forensic practice:

 

Needless to say, prosecutors availing themselves of civil commitment processes and wishing to keep offenders from release find it in their interest to argue for the most expansive possible interpretation of the DSM criteria for paraphilic disorders -- lending enormous weight to the details of the diagnostic criteria…. The convenience of these criteria in forensic evaluations seems more than offset by the potential for prosecutorial abuse and the long-term undermining of the credibility of the distinction – sanctioned by the Supreme Court as a constitutionally crucial one – between mental disorder-driven behavior and other motives for criminal behavior.

Wakefield joins the ranks of other respected figures to recognize the high stakes involved in the battle over whether sex crimes equate to mental disorder. As he bluntly puts it, the struggle over how sexual paraphilias are defined is “tactically central to the future of civil liberties in our country.” If the government can indefinitely detain men who have served prison time for sex crimes based on bogus psychiatric labels that supposedly impair their volitional control, it's only a matter of time before other groups are rounded up, too. 

Of all of the controversial paraphilias, Wakefield asserts, the “most flawed and blatantly overpathologizing” is pedohebephilia, which would expand pedophilia to encompass attraction to pubescent minors. Arguments by its proponents are both weak and misleading, he writes:

The first argument for the expanded category is that hebephilia is similar to pedophilia in that both involve attraction to physically immature individuals. This is about as valid an argument as saying that both dyslexia and illiteracy involve difficulties reading, thus illiteracy should be considered a disorder. The kind of immaturity involved in pubescence is vastly different from the kind in prepubescence from the specific perspective of its ability to trigger normal sexual interest, so in fact the dissimilarity is more important than the similarity…. The other two arguments – that some prosecutors are currently using the diagnosis “Paraphilia Not Otherwise Specified (Hebephilia)” and that the ICD [the World Health Organization’s diagnostic system] allows sexual preference for early pubescence as a disorder – ignores the critical question of whether these uses are valid…. Hebephilia as a diagnosis violates the basic constraint that disorder judgments should not be determined by social disapproval. This is a case where crime and disorder are being hopelessly confused.

Although the sexual disorders work group has backed down on two of its three most controversial proposals, it is clinging tenaciously to pedohebephilia, the brainchild of the Canadian laboratory that employs two members of the work group. Hopefully, a newly established scientific review committee for the DSM-5 will heed the increasingly strong warnings emitting from mainstream social scientists and psychology-law practitioners such as Wakefield, and have the common sense to squelch this ridiculous proposal. Otherwise, as Wakefield puts it, “the forensic tail [will be] wagging the validity dog, and we are likely to get criteria that possess a misdirected pseudo-validity that will not serve us in the long run and set a dangerous precedent for future tensions between civil liberties and civil commitment for mental disorder.”

Inevitable recidivism: An urban legend

Tamara Rice Lave, a law professor at the University of Miami, tackles the essential premise underlying current social policy toward sex offending: that apprehended sex offenders (especially child molesters) will continue to re-offend. As Lave shows, the courts and the public accept this premise with an unquestioning and almost religious fervor, ignoring a growing body of empirical evidence to the contrary.

Inevitable recidivism has saturated the media, political and popular discourse, and thus it has become the dominant frame due to its availability…. This sets up a dialectical process in which the public believes that sex offenders inevitably recidivate; the media write stories that bolster this belief, and politicians pass laws that are responsive to this belief. The effect is to have inevitable recidivism become a socially constructed fact.

When actual evidence of sex offender recidivism is examined, a huge gap exists between what is assumed and what the data actually shows because most sex offenders do not in fact recidivate. Thus there is a galaxy of sexually violent predator laws and an entire branch of Supreme Court jurisprudence that is founded upon a demonstrable urban legend.

The special issue, Beyond Myth: Designing Better Sexual Violence Prevention, was co-edited by professors Eric Janus (author of Failure to Protect, an essential text on sex offender law and policy) and John Douard. Both are, like myself, firm believers that we should be focusing scarce resources on primary prevention of sexual violence rather than on misguided campaigns rooted in moral panic and hysteria. Such campaigns are not only ineffectual, but they may actually increase the very problems they are aimed at solving.

The articles are:

Jerome C. Wakefield:  DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between diagnostic validity and forensic utility [request from author HERE]

Tamara Rice Lave: Inevitable recidivism: The origin and centrality of an urban legend  [full text available online HERE]

A preview of all of the articles in the special issue, Beyond Myth: Designing Better Sexual Violence Prevention, is HERE. Clicking on a preview of an article allows one to email the author to request a reprint.

Brits: American psychiatry needs new theoretical frame

Ever since the American Psychiatric Association launched its multi-million dollar diagnostic industry with the publication of the DSM-III in 1980, the approach to successive editions has been to tinker, fiddle, and tweak: Change a diagnostic threshold here; reword a criterion there; remove an outdated label and add two or three more in its place.

Meanwhile, the underlying structure is so shoddy and out of touch with reality that the best thing to do would be to tear the whole thing down and start over. That's the message of the British Psychological Society, the UK’s 50,000-member professional body for psychologists, responding to the latest draft of the Diagnostic and Statistical Manual. The APA had invited the Society to comment on the DSM-5, currently due out in 2013.

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation…. The putative diagnoses presented in DSM-5 are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations.

The Society critiqued a range of proposed changes in the DSM, including major changes to the personality disorders as well as (of particular relevance to forensic practitioners) the sexual paraphilias. Particular concern was expressed over a proposed "attenuated psychosis syndrome." This proposal is "very worrying" to the British psychologists, as it will "stigmatize eccentric people" and lower the threshold for prescribing potentially harmful antipsychotic medications.

More broadly, the Society commented, the DSM diagnostic system's limited focus leads practitioners to ignore the relational and environmental contexts for psychological problems:

The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors.

Retreat from diagnostic labeling urged

Rather than "applying preordained diagnostic categories," the Society recommends cataloging specific symptoms or complaints, such as "hearing voices" or "feelings of anxiety."

Statistical analyses of problems from community samples show that they do not map onto past or current categories…. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognized, … understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served.... We believe that a description of a person’s real problems would suffice…. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients. We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV.

The 26-page statement is available HERE.

Psychiatrist: Time to drop “silly” hebephilia once and for all

"Striking new evidence" should place the nail in the coffin of a "poorly conceived" proposal to turn sexual attraction to pubescent minors into a new mental disorder, says the chair of the DSM-IV Task Force in a new blog post at Psychology Today.

Allen Frances, professor emeritus at Duke University, has vocally opposed efforts to expand psychiatric diagnoses in the upcoming edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due out in 2013.

In the wake of the DSM leadership's recent abandonment of a controversial new diagnosis for rapists, Frances says it is also past time to relegate "hebephilia" to "the obscurity it has so long and so justly deserved":

'Hebephilia' is a medical-sounding term for what is a purely legal issue--the statutory rape of pubescent youngsters aged 11-14. This is a crime deserving punishment, not a mental disorder deserving psychiatric hospitalization…. The 'hebephilia' proposal was always a poorly thought out, obvious non-starter. It failed on conceptual grounds, was unsupported by scientific evidence, and would create disastrous forensic problems. 

Four strikes and you're out

Frances lists four “strikes” against the proposal. In the first place, he points out, attraction to pubescent teenagers is biologically “hard-wired,” not deviant. Second, the research literature is “pathetically thin, methodologically flawed, and mostly completely irrelevant to whether it should be considered a mental disorder.” Third, the construct is a “forensic nightmare” that is already being abused in Sexually Violent Predator (SVP) civil commitment proceedings.

Lastly, Frances lambasts the claim that the number of sex crimes an individual has committed can be the basis for an accurate diagnosis. According to Frances, an independent data analysis just accepted for publication by Behavioral Sciences and the Law debunks that assertion. The article, by Richard Wollert and Elliot Cramer (online HERE), delivers "a piercing nail to seal the coffin" on hebephilia, writes Frances:

Reanalyzing the original raw data with appropriate statistical methods, they found that (contrary to the original report) there was an extremely high false positive rate in identifying 'hebephilia.' This had been obscured by an obvious statistical error in the original analysis--the highly selective sampling of subjects at the poles of the continuum, arbitrarily excluding those in the middle.

Frances’s full essay, at his Psychology Today blog DSM in Distress, is HERE.

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). 

Wallowa Lake diagnostic training

Sculpture on Main Street of Joseph, Oregon
with Eagle Cap Wilderness Area in background
(K Franklin)

On the day that the world didn't end, I found it fitting to be literally at the end of the road, giving a training on controversies in psychiatric diagnosis. The setting was Oregon’s picturesque Wallowa Lake, where for 26 years the Eastern Oregon Psychological Association has sponsored an annual retreat.


The mental health professionals at the retreat were a bright and independent bunch whose practices take them across scenic mountainous terrain to far-flung rural communities, Indian reservations, jails and psychiatric facilities in eastern Oregon, Washington and Idaho.


Since Oregon has avoided the Sexually Violent Predator quagmire, the practitioners – as well as the psychologists from Eastern Oregon University in La Grande in attendance -- were both amused and appalled to learn about the pseudoscientific constructs of hebephilia and paraphilic coercive disorder for which the sex offender industry is lobbying. Other controversial diagnoses and proposed diagnoses covered in the daylong workshop included:

• Posttraumatic Stress Disorder
• Antisocial Personality Disorder and Psychopathy
• Parental Alienation Syndrome
• Attenuated Psychosis Syndrome
• Mild Neurocognitive Disorder
• Disruptive Mood Dysregulation Disorder
• Premenstrual Dysphoric Disorder
• Traumatic Grief Disorder
• Gambling Disorder

Wallowa River as seen from Chief Joseph
Trail (K Franklin)

If you ever get a chance to attend this annual retreat, which is not well advertised but always takes place the weekend before Memorial Day Weekend, I recommend it highly. Not only is the crowd an enjoyable and intellectual one, but the setting is amazing. It's not for no reason that the Nez Perce consider sacred this valley butting up against the mountains of the Eagle Cap Wilderness Area.

The legendary Chief Joseph is buried on a glacial moraine overlooking the lake. The town named in his honor, Joseph, was a dying old ranching and mining community when it was discovered by artists who have reinvigorated the main drag, opening shuttered storefronts and installing amazing sculptures on every corner. Summer vacationers can now rub shoulders with cowboys and Indians in gourmet restaurants featuring local micro-brews and wines.

It's not an easy place to get to (one must catch a puddle jumper to Walla Walla, Washington or Pendleton, Oregon and then drive for several hours), but its breathtaking beauty and unique character make it well worth a visit.

Special thanks to David Starr, Dwight Mowry, Marianne Weaver, Terry Templeman, Charles Lyons, and Stephen and Beth Condon for all of your work and your kindness in arranging and facilitating this event.

Psychiatry rejects new rape disorder for DSM-5

Regular blog readers will be familiar with the heated battle over a controversial proposed mental condition of "Paraphilic Coercive Disorder" for rapists. Now, the American Psychiatric Association has issued its latest draft of the DSM-5 diagnostic manual, with the condition relegated to the appendix. The proposal was favored by psychologists working for the government in Sexually Violent Predator (SVP) civil commitment cases, as it would have made it far easier to testify that sex offenders are mentally ill. It had met with strong opposition from scientists, including premier rape researcher Raymond Knight of Brandeis University.

Among other outspoken opponents was psychiatrist Allen Frances, an emeritus professor from Duke University who chaired the DSM-IV Task Force. In blog posts soon to go live at the Psychiatric Times and Psychology Today, he cautions that the battle is not over: The current attempt to place the pseudoscientific condition into the appendix of the DSM 5 as a condition warranting further study is still a mistake.

"Important message"

Dr. Frances said the rejection should send a strong message to those involved in the SVP civil commitment industry:

Dr. Allen Frances

The evaluators, prosecutors, public defenders, judges, and juries must all recognize that the act of being a rapist almost always is an indication of criminality, not of mental disorder. This now makes four DSM's (DSM III, DSM IIIR, DSM IV, DSM 5) that have unanimously rejected the concept that rape is a mental illness. Rapists need to receive longer prison sentences, not psychiatric hospitalizations that are constitutionally quite questionable.

This DSM 5 rejection has huge consequences both for forensic psychiatry and for the legal system. If "coercive paraphilia" had been included as a mental disorder in DSM 5, rapists would be routinely subject to involuntary psychiatric commitment once their prison sentence had been completed. While such continued psychiatric incarceration makes sense from a public safety standpoint, misusing psychiatric diagnosis has grave risks that greatly outweigh the gain…. Preventive psychiatric detention is a slippery slope with possibly disastrous future consequences for both psychiatry and the law. If we ignore the civil rights of rapists today, we risk someday following the lead of other countries in abusing psychiatric commitment to punish political dissent and suppress individual difference.

This DSM 5 rejection of rape as mental disorder will hopefully call attention to, and further undercut, the widespread misuse in SVP hearings of the fake diagnosis "Paraphilia Not Otherwise Specified, nonconsent". Mental health evaluators working for the state have badly misread the DSM definition of Paraphilia and have misapplied it to rapists to facilitate their psychiatric incarceration. They have disregarded the fact that we deliberately excluded rape as an example of Paraphilia NOS in order to avoid such backdoor misuse. Not Otherwise Specified diagnoses are included in DSM only for clinical convenience and are inherently too idiosyncratic and unreliable to be used in consequential forensic proceedings.

Exclude coercive paraphilia from appendix

All along, promoters of this new diagnosis have conceded that this would be a tough sell, given its lack of scientific foundation. Indeed, they said publicly that they would consider it a victory if they could even get paraphilic coercive disorder included in the appendix of the upcoming diagnostic manual (due out in mid-2013), as a condition meriting further study. But as Dr. Frances points out, even that would be a major error:

The sexual disorders work group proposes placing "coercive paraphilia" in an appendix for disorders requiring further research. We created such an appendix for DSM IV. It was meant as a placement for proposed new mental disorders that were clearly not suitable for inclusion in the official body of the manual, but might nonetheless be of some interest to clinicians and researchers….

If "Coercive Paraphilia" were like the average rejected DSM suggestion, it would similarly make sense to park it in the appendix -- as has been suggested by the DSM 5 sexual disorders work group. This might facilitate the work of researchers and also provide some guidance to clinicians....

But "coercive paraphilia" is not the average rejected DSM diagnosis. It has been, and is continuing to be, badly misused to facilitate what amounts to an unconstitutional abuse of psychiatry. Whether naively or purposefully, many SVP evaluators continue to widely misapply the concept that rape signifies mental disorder and to inappropriately use NOS categories where they do not belong in forensic hearings.

Including "Coercive Paraphilia" in the DSM 5 appendix might confer some unintended and undeserved back-door legal legitimacy on a disavowed psychiatric construct. Little would be gained by such inclusion and the risks of promoting continued sloppy psychiatric diagnosis and questionable legal proceedings are simply not worth taking. The rejection of rape as grounds for mental disorder must be unequivocal in order to eliminate any possible ambiguity and harmful confusion. We did not include any reference to "coercive paraphilia" in DSM IV and it should not find its way in any form, however humble and unofficial, into DSM 5. 

If you agree that this pseudoscientific condition needs to be placed in the wastebasket once and for all, now is the time to speak up. The current public comment period ends June 15. While you’re at it, you might want to state your opposition to a couple of the other controversial proposals with potential for profound negative consequences in the forensic realm – pedohebephilia and hypersexuality.

Postscript: Thanks to the suggestion of an alert reader, I have added the direct links to the DSM-5 comments pages. You must register in order to submit a comment.

• Click HERE to comment on the proposed diagnosis of Pedohebephilia.
• Click HERE to comment on the proposed diagnosis of Paraphillic Coercive Disorder.

Related posts:

• Psychiatrists ramp up opposition to forensic misuse of DSM: "Pedohebephilia" would make bad situation worse, they warn (March 10, 2011)
• Europeans first to shoot down controversial paraphilia (Oct 26, 2010)
• Psychiatrists vote no on controversial paraphilias (Oct. 24, 2010)
• Rape as psychiatric illness: Battle heats up (June 24, 2010)
• Latest hebephilia critiques: Point-counterpoint (March 12, 2010)
• More prominent voices join chorus of DSM-5 critics (March 1, 2010)
• DSM-V: Will shoddy manual implode years before launch date? (Feb. 20, 2010)
• New Scientist expose of psychiatry’s "civil war" (Dec. 10, 2009)
• Scientist razes proposed "Paraphilic Coercive Disorder" (Nov. 6, 2009)
• Hebephilia struck by third blow: Down but not out? (June 5, 2009)
• Wrangling over psychiatry's bible (Nov 16, 2008)
• DSM makeover: What will they come up with next? (Oct 13, 2008)
• Invasion of the hebephile hunters (Oct 31, 2007)

Psychiatrists ramp up opposition to forensic misuse of DSM

"Pedohebephilia" would make bad situation worse, they warn  

As you will recall, at a recent debate members of the American Academy of Psychiatry and the Law (AAPL) were virtually unanimous in giving the thumbs-down to three controversial sexual disorders being proposed for the fifth edition of psychiatry’s diagnostic manual.

Piggy-backing on that sentiment, the Academy's official journal has just published two additional calls for caution. 

DSM's forensic influence cannot be ignored

Ralph Slovenko, an eminent professor of law and psychiatry at Wayne State University Law School, leads off with an editorial that counters a key claim of the proponents of diagnostic expansion. The oft-repeated claim is that the legal implications of a diagnosis are irrelevant, and should not be considered.

Rebutting this head-in-the-sand mentality, Slovenko gives a comprehensive overview of the DSM's impact in myriad areas of the law, from parental termination to disability determinations. As evidence of the DSM's vast influence, he cites language written into the statutes in 16 states mandating its use for various purposes.

As his overview makes clear, courts and legislatures across the United States have ignored the fine print in the introduction to the Diagnostic and Statistical Manual, stating that use of the manual for forensic purposes risks misunderstanding and misuse.

A case in point: Use of a made-up category, "Paraphilia Not Otherwise – Hebephilia," as justification for preventive detention of men who have served prisont time for sexual relations with adolescent.

No basis for fictional "hebephilia" disorder

Next, two psychiatrists who were influential in developing the current edition of the DSM launch a full-on assault on the use of the bogus diagnosis "hebephilia" in sexual predator civil commitment proceedings.

Michael First, editor and co-chair of the DSM-IV-TR, and Allen Frances, chair of the DSM-IV Task Force, clarify the intention of diagnosing paraphilias, or sexual deviances, and why diagnosing offenders against adolescents with "hebephilia" (a diagnosis that does not exist in any formal diagnostic system) is a flagrant abuse of psychiatric nomenclature. This is not the first time these authors have tried to set the record straight, but their current analysis is especially detailed and unequivocal.

The alleged diagnosis paraphilia not otherwise specified, hebephilia, arose, not out of psychiatry, but rather to meet a perceived need in the correctional system. This solution represents a misuse of the diagnostic system and of psychiatry. That a large number of forensic mental health workers have been mistrained to regard paraphilia NOS as a valid diagnostic category in SVP proceedings should not be construed as proper representation of the views of the entire mental health field. Similarly, the very preliminary studies conducted by a few research groups should not be construed to indicate that hebephilia has any solid scientific support. Hebephilia is not an accepted mental disorder that can be reliably diagnosed and should not be treated as such in SVP proceedings.

First and Frances issue a strong call against adding the pretextual diagnosis of "pedohebephilia" to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders:

Among several radical proposals made by the DSM-5 Sexual Disorders Workgroup is the backdoor introduction of the hebephilia diagnosis into the DSM-5 by expanding the existing well-accepted pedophilia category to include sexual arousal to pubescent individuals and renaming the broadened construct pedohebephilic disorder. There is no apparent need or compelling rationale to include hebephilia in DSM-5 beyond the research interests of a few scientists and the questionable use of hebephilia in SVP proceedings.

Despite opposition from forensic psychiatry, no doubt the wheels will grind on. After all, as legal scholar Charles Patrick Ewing describes in Justice Perverted, preventive detention has taken on a life of its own, becoming a lucrative and self-perpetuating industry. More on psychology's role in that very soon….

Related resources:

On my website, I have created a page of resources on the hebephilia controversy. But if you really want to immerse yourself in these diagnostic controversies, the place to visit is the "DSM-5 Paraphilias Controversy." On one page, blogger Andrew Hinderliter has amassed an impressive array of literature on the disputed paraphilias, including not only hebephilia, hypersexuality, and sexual sadism but also related hot-button topics such as transvestic fetishism.

My comprehensive historical review of hebephilia is now available online. Or, for a shorter version, there's always my oldie but goodie blog post, from Halloween of 2007: "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."

This blogger to give keynotes in Australia, UK

I am excited to announce that I will be delivering keynote addresses at forensic conferences in Australia and the United Kingdom later this year. I hope to be able to meet some of you in person at one or the other.

After the floods and cyclone -- join me on the Sunshine Coast

I will be giving both a keynote address and an all-day training at Australia's national forensic psychology conference, taking place from August 4-6 in Noosa, in the state of Queensland. Other keynote speakers are Australian forensic psychologists Paul Wilson, Don Thomson and Alfred Allan, and fellow Americans Tom Grisso and Leslie Morey.

This year's theme is "Diversity and Specialism in Forensic Psychology." If you think you have a good idea for a forensic talk or workshop, I would encourage you to submit a proposal. Be quick about it, though, as the deadline is the end of February.

Along with an exciting scientific program, the organizers are promising fun social functions and a chance to network "in a friendly and relaxed environment." Noosa is not too far away from the recent catastrophic flooding and Cyclone Yasi, but I'm sure flood waters will have receded by August. I'll be sharing more details in coming months.

Next up: Sexual violence conference in London

On September 8, I will be delivering another keynote at a Sexual Violence conference sponsored by the Forensic Psychological Services program at Middlesex University in London. My focus will be the role of culture and masculinity in multiple-perpetrator rape (the topic of my 2004 theoretical article). Again, stay tuned for more details.

I am excited to be a part of this program because of the organizers' cutting-edge efforts toward preventing sexual violence, especially rape by multiple perpetrators. The Forensic Psychological Services Program at Middlesex University sponsored similar conferences on hate crimes in 2008 and 2010, with an innovative focus on offender motivations and prevention.

You can get involved in this one, too. The organizers are inviting proposals for papers and debate panels pertaining to sexual violence, especially those based on empirical research and/or involving new and emerging topics. One of their major goals is to foster more exchange of ideas among practitioners, academics and policy makers. The deadline for submissions is April 15 (Tax Day, here on the other side of the Atlantic).

International readers: Diagnostic survey please

I am curious about diagnostic practices outside of the United States, as I prepare to give some international trainings later this year. If you are in forensic practice somewhere other than the USA, I would like to invite you to complete this very brief online survey. It is only 10 items, and should take you less than 5 minutes. It will help me out a lot. I will even share the results. I know a convenience sample like this is not scientific, but the more of you who complete it the more educational it will be.

You Americans, please refrain. I already know which manual you use. As a consolation prize, you can complete the one-item trivia poll just below the diagnostic survey. Make your best guess, and instantly learn how others voted.

And if you could pass this along to other colleagues outside of the United States, I would greatly appreciate it. Here's a convenient url that you can just cut and paste to share: http://3.ly/diagnosis. Or, if you would like to bypass this blog page and go directly to the survey site, you can use this url: http://3.ly/diagnosis2.

Thank you very much for your help.

And now, the one-item consolation poll for all readers:

Linguist lambasts DSM-5 proposal as gibberish

Leave it to an asexual linguist to lay bare the convoluted nature of the paraphilia diagnoses being proposed for the DSM-5. Andrew Hinderliter, a former English teacher and grad student at the University of Illinois, says his activism regarding the DSM's Hypoactive Sexual Desire Disorder led him to stumble across disturbing global flaws in the DSM-5 sexual disorders morass.

The wording of the proposed new definition of "paraphilia" (sexual perversion) is so nonsensical that one must ignore the literal text in order to apply it the way the authors say they intend, Hinderliter writes in his new article, "Do Not Disregard Grammar," in the Journal of Sex and Marital Therapy. That article follows a companion piece published in the Open Access Journal of Forensic Psychology.

As I have blogged about previously, the members of the sexual disorders workgroup for the DSM-5 seems oblivious to the potentially disastrous forensic implications of their proposals. Vague and careless wording is not so critical in the clinical arena where, presumably, everyone is working toward the same goals. However, as attorneys know well, in the forensic context every little word matters -- a lot.

"Given that a person can be deprived of procedural due process rights -- possibly for the rest of their life --on the basis of a diagnosis of paraphilia NOS, caution and careful wording in defining paraphilia in DSM-5 is all the more important,” Hinderliter cautions.

Perhaps the workgroup has the clandestine aim of introducing chaos into the civil commitment system for sex offenders. If so, it couldn't be doing a better job. Get ready for skirmish after skirmish over nebulous terms such as "phenotypically normal," "generalized" and "intense."

Crazy Like Us: The Globalization of the American Psyche

A successful virus is adaptive. It evolves as needed to survive and colonize new hosts. By this definition, contemporary American psychiatry is a very successful virus. Exploiting cracks that emerge in times of cultural transition, it exports DSM depression to Japan and posttraumatic stress disorder to Sri Lanka.

Journalist Ethan Watters masterfully evokes the heady admixture of moral certainty and profit motive that drives U.S. clinicians and pharmaceutical companies as they evangelically promote Western psychiatry around the globe. On the ground in Sri Lanka following the tsunami, for example, hordes of Western counselors hit the ground running, aggressively competing for access to a native population "clearly in denial" about the extent of their trauma. Backing up the foot soldiers are corporations like Pfizer, eager to market the antidepressant Zoloft to a virgin population.

Watters has done his homework. Each of his four examples of DSM-style disorders being introduced around the world is rich in compelling historical and cultural detail. Despite their divergences, each successful expansion hinges on the mutual faith of both the colonizers and the colonized that Western approaches represent the pillar of scientific progress.

My review of Crazy Like Us, an engaging and enlightening book that I highly recommend, continues HERE.

Watters' Jan. 8, 2010 essay in the New York Times, "The Americanization of Mental Illness," is HERE.

How the Black man became schizophrenic

Psychiatry, the DSM, and the Black Power movement

Once upon a time, a strange thing happened at the Ionia State Hospital in Michigan: A diagnosis of schizophrenia exited the body of a white housewife, flew across the hospital, and landed on a young Black man from the housing projects of Detroit, burrowing into his body and stubbornly refusing to leave.

As you may know, Black men in the United States (as well as in the United Kingdom) are disproportionately diagnosed with schizophrenia. What you may not know is when this pattern emerged, or why.

Up until the 1950s, the overwhelming majority of those diagnosed with schizophrenia were white. They were the delicate or eccentric -- poets, academics, middle-class women like Alice Wilson in Jonathan Metzl's The Protest Psychosis, "driven to insanity by the dual pressures of housework and motherhood."

Then, in the mid-1960s, the Long Hot Summers hit urban America. Smoldering anger over racism and poverty erupted into mass rioting and harsh repression. In Detroit, a police raid on a party triggered an uprising that left 43 dead, 1,189 injured, and more than 7,000 arrested. Convinced that they would never win civil rights through sit-down strikes, a nascent Black Power movement became increasingly militant.

Coincidentally, just as this urban unrest was reaching its zenith, the American Psychiatric Association was busy revising its Diagnostic and Statistical Manual of Mental Disorders (DSM). Published in 1968, the DSM-II was touted as a more objective and scientific document than its 1952 predecessor.

"However, the DSM-II was far from the objective, universal text that its authors envisioned," writes Metzl, a psychiatry and women's studies professor and director of the Culture, Health and Medicine Program at the University of Michigan. "In unintentional and unexpected ways, the manual’s diagnostic criteria -- and the criteria for schizophrenia most centrally -- reflected the social tensions of 1960s America. A diagnostic text meant to shift focus away from the specifics of culture instead became inexorably intertwined with the cultural politics, and above all the race politics, of a particular nation and a particular moment in time."

The psychoanalytically imbued "schizophrenic reaction" of the DSM-I was an illness meriting pity and compassion rather than fear. In contrast, the DSM-II's more biologically oriented schizophrenia was menacing and required containment. In particular, the language that described the paranoid subtype foregrounded "masculinized hostility, violence, and aggression," implicitly pathologizing militant protest as mental illness.

Almost overnight, the previous class of schizophrenics at Ionia State Hospital was relabeled with depressive disorders. As the formerly schizophrenic exited the hospital en masse in the wake of the Community Mental Health Centers Act of 1963, their places were taken by a new class of schizophrenics -- volatile young Black men from inner-city Detroit.

A mountain of archived charts from the defunct asylum at Ionia provided the raw material for The Protest Psychosis. In his four years of sifting through the treasure trove of data, Metzl found clear evidence of shifting racial and gender patterns in diagnosis. Because the DSM-II was published in the days before computers, clerk typists simply used hatch marks (/) to mark out the old diagnoses, leaving them clearly legible alongside the new.

Randomly selecting a subset of charts of white women patients, Metzl found schizophrenic diagnoses crossed out, and replaced with labels such as Depressive Neurosis or Involitional Melancholia.

In contrast, the charts of African American men saw Psychopathic Personality crossed out to make way for the DSM-II’s schizophrenia, paranoid type.

Neither set of patients had undergone a sudden metamorphosis. Their observable symptoms and behaviors, as documented by their chart notes, remained the same. The only thing that changed was the diagnostic manual.

Metzl is a lyrical writer who has thought deeply and profoundly about this topic. His asylum tragedy does not point fingers or blame the individual psychiatrists of the asylum. They, too, were victims of time and place, just doing their job. Doing it, indeed, by the book.

Lessons learned, or lessons lost?

The lessons of Ionia can be applied to almost any diagnostic saga. Today, the message -- if we choose to listen -- is especially profound. As Ethan Watters explores in Crazy Like Us, American psychiatry is sweeping the globe like a virus, importing PTSD to Sri Lanka and Western-style depression to Japan.

Big Pharma is responsible for much of this McDonald's-like expansion. The pharmaceutical industry is far and away the most profitable business in the United States, and accounts for almost half of the $650 billion-plus global market. In its quest to enlarge profits, this industry perpetually seeks to expand the range and scope of illness. As Christopher Lane describes in Shyness, this expansion is especially easy with psychiatric illnesses, because of their nebulous nature and subjective boundaries.

But Big Pharma did not revamp schizophrenia back in 1968. Nor were nefarious doctors consciously seeking to re-enslave a rebellious race. Like treatment providers today, psychiatrists undoubtedly saw themselves as helpers, even as they functioned as agents of social control, naturalizing today’s long-term containment and incapacitation of African American men.

Psychiatry, as Metzl points out, is inherently focused on the molecular. With their focus on matching individual symptoms to diagnostic codes, the psychiatrists who replaced one diagnosis with another were blind to how institutional racism shaped their choices. Nor did they reflect on their own internalization of the era’s cultural anxiety over menacing Black men, an anxiety that linked mental illness, protest, and criminality.

A focus on the micro-level blinds the actors to the larger forces at play, which construct the very frames governing observations and actions. Larger social and institutional forces rather than conscious intent on the part of individual actors typically drive bias, especially in the 21st century. This explains why “cultural competence” training programs are at best useless, and at worst reinforcing of stereotypes.

We are currently entering another period of diagnostic revision. What I find fascinating is how earnestly the proponents of new and expanded psychiatric diagnoses believe that they are agents of progress, advancing better science as opposed to ideologically driven agendas. Mesmerized by their own brilliance, they wear blinders that prevent them from seeing the larger cultural systems in which their ideas are embedded.

But science is never pure. There is no one objective truth. There are myriad ways to categorize and catalog. Bias is inherent in what is foregrounded and what, in turn, is neglected or ignored. Reification, in which hypothetical categories are transformed into tangible and real objects, keeps us from recognizing and naming the larger systems that dictate these choices.

Occasionally, a historian like Metzl comes along to sift through archival evidence and shine a spotlight on historical biases. But the biases inherent in the present moment remain largely invisible. With the arrogance inherent in power, privileged scientists have no need to confront their own cultural assumptions, or reflect upon how the world might look from the perspectives of their subjects.

Sadly for all of us, as the old axiom goes, those who do not learn from history are doomed to repeat it.

The book is: The Protest Psychosis: How Schizophrenia Became a Black Disease. An online essay adapted from the book is HERE. Metzl is also the author of Prozac on the Couch, Prescribing Gender in the Era of Wonder Drugs and editor of a book forthcoming from NYU Press, Against Health: How Health Became the New Morality. A University of Michigan press release about his published work on "medicalization" is HERE.

If you enjoyed this essay, please visit my abbreviated review at Amazon and click on "YES." This essay is also available at my Psychology Today blog, Witness and at AfroDaddy: A Black Man's Survival Guide (sadly, that site is now defunct, but the post is still available via the ever-amazing Wayback Machine).