Hebephilia flunks Frye test

Photo credit: NY Law Journal

In a strongly worded rejection of hebephilia, a New York judge has ruled that the controversial diagnosis cannot be used in legal proceedings because of “overwhelming opposition” to its validity among the psychiatric community.

Judge Daniel Conviser heard testimony from six experts (including this blogger) and reviewed more than 100 scholarly articles before issuing a long-awaited opinion this week in the case of “Ralph P.,” a 72-year-old man convicted in 2001 of a sex offense against a 14-year-old boy. The state of New York is seeking to civilly detain Ralph P. on the basis of alleged future dangerousness.

State psychologist Joel Lord had initially labeled Ralph P. with the unique diagnosis of sexual attraction to “sexually inexperienced young teenage males,” but later changed his diagnosis to hebephilia, a condition proposed but rejected for the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Under the Frye evidentiary standard, designed to bar novel scientific methods that are not sufficiently validated, a construct must be “generally accepted” by the relevant scientific community before it can be relied upon in legal proceedings.

Judge Conviser found that hebephilia (generally defined as sexual attraction to children in the early stages of puberty, or around the ages of 11 or 12 to 14) is being promoted by a tiny fringe of researchers and in practice is used almost exclusively as a tool to civilly commit convicted sex offenders. Under U.S. Supreme Court rulings, such offenders must have a mental disorder in order to qualify for prolonged detention after they have served their prison terms.

“It is not an accident, as Dr. Franklin outlined, that hebephilia became a prominent diagnosis only with the advent of SVP laws,” the judge wrote in his 75-page opinion. “It is also not a coincidence that each of the three expert witnesses who testified for the State at the instant hearing either work or formerly worked for state [Sexually Violent Predator] programs.”

Conviser’s ruling analyzed both the practical problems in reliably identifying hebephilia and the political controversies swirling around it: Without any standardized criteria, “clinicians are free to assign hebephilia diagnoses in widely disparate ways, many of which are just plainly wrong.” Using age as a proxy for pubertal stage is no guarantee of reliability because pubertal onset is highly variable. Ultimately, he concluded, whether erotic interest in pubescent minors is deemed "pathological" is more about moral values than science.

APA secrecy faulted

The judge was harshly critical of the American Psychiatric Association for its refusal to publicly explain why it rejected hebephilia from the DSM-5 in 2013. The diagnosis was aggressively promoted by a Canadian psychologist, Ray Blanchard, and fellow researchers from Canada’s Centre for Addiction and Mental Health (CAMH), who dominated the DSM-5 subcommittee on paraphilias.

Blanchard rewrote the DSM section on paraphilias (sexual deviances) in a broad way such that virtually all sexual interests other than a narrowly defined “normophilic” pattern became pathological. However, the APA rejected Blanchard’s proposal to expand pedophilia to pathologize adult sexual attractions to pubescent-aged (rather than just prepubescent) minors.

“The proposal was apparently rejected because it was greeted with a firestorm of criticism by the sex offender psychiatric community, which was communicated to the APA board…. As best as this Court can surmise, the APA rejected the pedohebephilia proposal because it was opposed by most of the psychiatrists and psychologists who worked in the field.”

“[S]trikingly,” wrote Judge Conviser, “the process through which proposed new diagnoses are approved or rejected is shrouded in a degree of secrecy which would be the envy of many totalitarian regimes…. With respect to hebephilia, the APA board’s actions will have a direct impact on both public safety and the fundamental liberty interests of hundreds or thousands of people.”

The APA forces those involved in the DSM revision process to sign nondisclosure contracts. That policy came in the wake of a series of published exposes – including Christopher Lane’s Shyness: How Normal Behavior Became a Sickness, Jonathan Metzl's The Protest Psychosis, and Ethan Watters’s Crazy Like Us (to name just a few of my favorites) -- that embarrassed the world’s largest psychiatric organization by shining a light inside the often subjective and political process of diagnosis creation and expansion.

“Overwhelming” opposition

Blanchard and his CAMH colleagues’ 2009 proposal to expand pedophilia into a new “pedohebephilia” diagnosis in the DSM-5 spawned a massive outcry, which mushroomed into at least five dozen published critiques.

In preparation for my testimony at this and similar Frye hearings in New York, I expanded on my 2010 article in Behavioral Sciences and the Law tracing hebephilia’s rise from obscurity, to produce an updated chart containing all 116 articles addressing the construct. If one tallies only those articles that take a position (pro or con) on hebephilia and are not written by members of the CAMH team, fully 83% are critical as compared to only 17% that are favorable. This, Judge Conviser noted, is strong evidence against the government’s position that hebephilia is “generally accepted” by the relevant scientific communities.

“The thrust of the evidence at the hearing was … clear: there was overwhelming opposition to the pedohebephilia proposal in the sex offender psychiatric community,” he wrote. “There is overwhelming opposition to the hebephilia diagnosis today.”

Courts scrutinizing nouveau diagnoses

With the APA’s rejection of hebephilia as well as two other proposed sexual disorders (one for preferential rape and another for hypersexuality), government evaluators continue to shoehorn novel, case-specific diagnostic labels into the catchall DSM-5 category of “other specified paraphilic disorder” (OSPD) as a basis for civil commitment.

Under a 2012 New York appellate court ruling in the case of State v. Shannon S., upon a defense request, a Frye evidentiary hearing must be held on any such attempt to introduce an OSPD diagnosis into a Sexually Violent Predator (SVP) case. That has triggered a spate of Frye hearings in the Empire State, affording greater scrutiny and judicial gatekeeping of scientifically questionable diagnoses.

Ironically, although the Shannon S. court upheld hebephilia by a narrow 4-3 margin, Shannon S. would not have met diagnostic criteria under the narrower definitions presented by the government experts at Ralph P.’s Frye hearing four years later, because his victims were older than 14.

“Assuming hebephilia is a legitimate diagnosis, Shannon S., like many SVP respondents, was apparently diagnosed with the condition not based on evidence he was preferentially attracted to underdeveloped pubescent body types but because he offended against underage victims,” Judge Conviser observed in his detailed summary of prior New York cases.

The three dissenting judges in Shannon S. were adamant that hebephilia was “absurd,” and an example of “junk science,” deployed with the pretextual goal of “locking up dangerous criminals” who had committed statutory rapes.

The opening of the Frye floodgates has led to a flurry of sometimes-competing opinions.

In 2015, in State v. Mercado, Judge Dineen Riviezzo ruled against “OSPD--sexually attracted to teenage females” as a legitimate diagnosis. However, she declined to rule on the general acceptance of hebephilia because it was not specifically diagnosed in that case.

A year later, relying on similar evidence, a judge in upstate New York ruled in State v. Paul V. that hebephilia was generally accepted, in large part because it was backed by the APA’s paraphilias sub-workgroup. Judge Conviser found that reasoning unpersuasive, pointing out that the subworkgroup was dominated by the very same CAMH researchers who were hebephilia’s primary advocates; it was therefore “not a valid proxy" for the scientific community.

In July, another court rejected both hebephilia and “OSPD--underage males” as valid diagnoses, in the cases of Hugh H. and Martello A. The court noted that hebephilia is inconsistently defined, was rejected for the DSM-5, and is primarily advanced by one research group; further, attraction to pubescent minors is not intrinsically abnormal.

Cynthia Calkins, a professor at John Jay College of Criminal Justice in New York, echoed those points in her testimony at Ralph P.'s hearing. She noted that in the United States, the main psychologists advocating for hebephilia are government-retained evaluators in SVP cases, who make up only perhaps one-fourth of one percent of psychologists and psychiatrists in the U.S. and so cannot be a proxy for “general acceptance” in the scientific community.

The government’s choice of experts illustrated Calkins’ point: Testifying for the government were Christopher Kunkle, director of New York’s civil management program for sex offenders, David Thornton of Wisconsin’s civil commitment center, and Robin Wilson, formerly of Florida’s civil commitment center and a protégé of Ray Blanchard’s.

The third expert called by Ralph P.’s attorneys was Charles Ewing, a distinguished professor at the University at Buffalo Law School who is both an attorney and a forensic psychologist and has authored several books on forensic psychology.

Defense attorneys Maura Klugman and Jessica Botticelli of Mental Hygiene Legal Service represented Ralph P. Assistant New York Attorney General Elaine Yacyshyn represented the state.

Ultimately, New York State’s highest court may have to weigh in to resolve once and for all the question of whether novel psychiatric diagnoses like hebephilia are admissible for civil commitment purposes. But that could be years down the road.

----------

The ruling in State v. Ralph P. is HERE. The subsequent order of Sept. 28, 2016 granting Ralph P.'s motion for summary judgment and dismissal of the civil commitment petition is HERE.

A New York Law Journal report on the case, "judge Rejects Diagnosis for Civil Confinement," is HERE.

A search of this blog site using the term hebephilia will produce my reports on this construct dating all the way back to my original post from 2007, "Invasion of the Hebephile Hunters."

New evidence of psychopathy test's poor accuracy in court

Use of a controversial psychopathy test is skyrocketing in court, even as mounting evidence suggests that the prejudicial instrument is highly inaccurate in adversarial settings.

The latest study, published by six respected researchers in the influential journal Law and Human Behavior, explored the accuracy of the Psychopathy Checklist, or PCL-R, in Sexually Violent Predator cases around the United States.

The findings of poor reliability echo those of other recent studies in the United States, Canada and Europe, potentially heralding more admissibility challenges in court. 

Although the PCL-R is used in capital cases, parole hearings and juvenile sentencing, by far its most widespread forensic use in the United States is in Sexually Violent Predator (SVP) cases, where it is primarily invoked by prosecution experts to argue that a person is at high risk for re-offense. Building on previous research, David DeMatteo of Drexel University and colleagues surveyed U.S. case law from 2005-2011 and located 214 cases from 19 states -- with California, Texas and Minnesota accounting for more than half of the total -- that documented use of the PCL-R in such proceedings.

To determine the reliability of the instrument, the researchers examined a subset of 29 cases in which the scores of multiple evaluators were reported. On average, scores reported by prosecution experts were about five points higher than those reported by defense-retained experts. This is a large and statistically significant difference that cannot be explained by chance. 

Prosecution experts were far more likely to give scores of 30 or above, the cutoff for presumed psychopathy. Prosecution experts reported scores of 30 or above in almost half of the cases, whereas defense witnesses reported scores that high in less than 10 percent.

Looking at interrater reliability another way, the researchers applied a classification scheme from the PCL-R manual in which scores are divided into five discreet categories, from “very low” (0-8) to “very high” (33-40). In almost half of the cases, the scores given by two evaluators fell into different categories; in about one out of five cases the scores were an astonishing two or more categories apart (e.g., “very high” versus “moderate” psychopathy). 

Surprisingly, interrater agreement was even worse among evaluators retained by the same side than among opposing experts, suggesting that the instrument’s inaccuracy is not solely due to what has been dubbed adversarial (or partisan) allegiance.

Despite its poor accuracy, the PCL-R is extremely influential in legal decision-making. The concept of psychopathy is superficially compelling in our current era of mass incarceration, and the instrument's popularity shows no sign of waning. 

Earlier this year, forensic psychologist Laura Guy and colleagues reported on its power in parole decision-making in California. The state now requires government evaluators to use the PCL-R in parole fitness evaluations for “lifers,” or prisoners sentenced to indeterminate terms of up to life in prison. Surveying several thousand cases, the researchers found that PCL-R scores were a strong predictor of release decisions by the Parole Board, with those granted parole scoring an average of about five points lower than those denied for parole. Having just conducted one such evaluation, I was struck by the frightening fact – alluded to by DeMatteo and colleagues -- that the chance assignment of an evaluator who typically gives high scores on the PCL-R “might quite literally mean the difference between an offender remaining in prison versus being released back into the community.”

Previous research has established that Factor 1 of the two-factor instrument – the factor measuring characterological traits such as manipulativeness, glibness and superficial charm – is especially prone to error in forensic settings. This is not surprising, as traits such as “glibness” are somewhat in the eye of the beholder and not objectively measurable. Yet, the authors assert, “it is exactly these traits that seem to have the most impact” on judges and juries.

Apart from the issue of poor reliability, the authors questioned the widespread use of the PCL-R as evidence of impaired volitional control, an element required for civil commitment in SVP cases. They labeled as “ironic, if not downright contradictory” the fact that psychopathy is often touted in traditional criminal responsibility (or insanity) cases as evidence of badness as opposed to mental illness, yet in SVP cases it magically transforms into evidence of a major mental disorder that interferes with self-control. 

The evidence is in: The Psychopathy Checklist-Revised is too inaccurate in applied settings to be relied upon in legal decision-making. With consistent findings of abysmal interrater reliability, its prejudicial impact clearly outweighs any probative value. However, the gatekeepers are not guarding the gates. So long as judges and attorneys ignore this growing body of empirical research, prejudicial opinions will continue to be cloaked in a false veneer of science, contributing to unjust outcomes.

* * * * *

The study is: 

The Role and Reliability of the Psychopathy Checklist-Revised in U.S. Sexually Violent Predator Evaluations: A Case Law Survey by DeMatteo, D., Edens, J. F., Galloway, M., Cox, J., Toney Smith, S. and Formon, D. (2013). Law and Human Behavior

Copies may be requested from the first author (HERE).

The same research team has just published a parallel study in Psychology, Public Policy and Law: 

“Investigating the Role of the Psychopathy Checklist-Revised in United States Case Law” by DeMatteo, David; Edens, John F.; Galloway, Meghann; Cox, Jennifer; Smith, Shannon Toney; Koller, Julie Present; Bersoff, Benjamin

My related essays and blog posts (I especially recommend the three marked with asterisks):

• NPR expert panel: Weighing the value of a test for psychopaths ***

• Study: Risk tools don't work with psychopaths (Oct. 8, 2013)

• Remarkable experiment proves pull of adversarial allegiance (March 5, 2013) ***

• Study: Psychopathy score fails to predict sexual recidivism (Oct. 30, 2011)

• Psychopathy: A Rorschach test for psychologists? (March 25, 2011) ***

• Metaanalysis debunks psychopathy-violence link (Sept. 3, 2010)

• Psychopathy controversy goes prime time (June 10, 2010)

• PCL-R inventor wringing his hands over forensic misuse (May 26, 2011)

• Psychopathy brouhaha: It's a wrap (June 17, 2010)

(c) Copyright Karen Franklin 2013 - All rights reserved

DSM-5: Forensic applications (Part II of II)

Courts cling to DSM as "bible"

As alluded to yesterday, in Part I, mental health professionals know not to take the DSM (or the ICD, for that matter) too seriously. It's just convenient fiction, or at best "useful constructs," mainly used to attain insurance reimbursement.

Only, there's this curious phenomenon: In the legal system, where the consequences of error can be grave, DSM diagnoses have taken on a mantra of grand truth. Increasingly, I find myself being asked during court testimony about some nit-picky little criterion or another (such as the six-month specifier for pedophilia) as if it is sacred gospel, rather than the arbitrary creation of some idiosyncratic back-room committee.

One bold colleague, when asked on the witness stand to confirm that the DSM is indeed "the bible of psychiatry," answers with a resounding "YES!" But, he adds, "Bible is Greek for 'book,' and the DSM's are a collection of books or chapters submitted by sundry subcommittees and approved or not based on politics. As with the Christian Bible, some known books (like the Book of Thomas) did not make the cut."

I don't recommend that tactic unless you are well grounded in theological studies. I myself cannot state under oath that the DSM is "the bible," when the attorney is really seeking to have me confirm its status as a learned treatise, that is, sufficiently authoritative that it should be relied upon in court. It may be the only game in town, but it's hardly known for its empirical fidelity. The text's assortment of vague generalities are not even referenced, so we don't know where they came from. If you are going to testify about a specific mental condition, such as delusional disorder, I recommend relying on empirical research from reliable sources that you can cite. 

Turning now to specific changes in the DSM-5 of most potential relevance to forensic work....

The good news is that some of the more outlandish proposals -- such as parental alienation syndrome and hebephilia -- got a resounding thumbs-down. So, here's my first-glance summary of what's new and different. 

Sexual paraphilias

An attempt by an ambitious minority to add a slew of new sexual disorders fell flat. So, you won’t find hebephilia, paraphilic coercive disorder or hypersexuality in the DSM-5. They didn’t even make the appendix for "conditions for further study" (which is populated by such non-starters as caffeine use disorder, internet gaming disorder, and the more worrisome attenuated psychosis syndrome).

These defeats are a big blow for the civil commitment industry, which lobbied for them to replace the shady "not otherwise specified" diagnoses being used to justify indefinite detention of offenders who don't have legitimate mental illnesses.

The section does, however, contain a few pesky little wording changes that may come into play in forensic cases. Each  disorder except pedophilia in the paraphilias chapter now has two remission qualifiers. If the person has not been impaired for five years, the disorder can be said to be "in full remission." This is a nod to the reality that sexual kinks often come and go over time. But there's a catch: The remission must be while the person was "in an uncontrolled environment." Otherwise, a new remission specifier of "in a controlled environment" can be applied. I anticipate that government evaluators in sexually violent predator trials may use this language to argue that a prisoner whose predicate offense was decades in the past is still disordered and at risk today, despite no objective evidence of such.

Another important change is in the text accompanying sexual sadism disorder, which now reads more like it was written for adversarial deployment. There are now two types of sadists -- "admitting individuals" and deniers. For deniers, the fact of having "inflicted pain or suffering on multiple victims on separate occasions" may be sufficient for a diagnosis. As a "general rule," the text instructs, recurrent can be interpreted to mean "three or more victims on separate occasions."

As discussed yesterday in Part I, the DSM-5 does not provide citations to empirical research to back up its recommendations. This is especially problematic in the case of sexual sadism, because even most chronic rapists are not necessarily aroused by a victim's suffering; rather, the victim's suffering fails to inhibit their arousal as it would for other men. The fact of inflicting pain or suffering also says nothing about what is going on in the mind of the inflicter, and three is just an arbitrary number pulled from a hat. These new guidelines will only complicate a problematic diagnosis with abysmally poor reliability and no predictive validity.

Antisocial personality disorder

Early buzz was that this pejorative label -- which can be applied to essentially any chronic offender -- would be revised to more closely align it with the even more pejorative and controversial construct of psychopathy. But the APA abandoned all proposed personality disorder changes (including a radical move to drop half of them altogether and to place the rest of them on a dimensional spectrum), so this diagnosis remains unchanged.

The real news here comes from the field trials. In regard to reliability, antisocial personality disorder came in at the bottom of the barrel, down there with the new mixed anxiety-depressive disorder with a kappa reliability rating of only 0.2. Historically, kappas below 0.4 have been considered poor. Although DSM-5 chief statistician Helena Kraemer is arguing that lower kappas should be deemed "acceptable," a 0.2 essentially means that even trained professionals cannot agree on whether a given individual has a disorder. This makes antisocial personality disorder far too unreliable for use in court.

Speaking of empirically dubious disorders, intermittent explosive disorder got a change worth noting. Whereas the aggressive outbursts at the core of this disorder used to require physical aggression, now "verbal aggression" suffices. If you've ever reviewed psychiatric hospital charts, you know that this is how hospital technicians chart episodes of disquiet among patients. For example, I recently saw a chart notation that "John Doe was verbally aggressive" stemming from an incident in which the involuntarily hospitalized Mr. Doe muttered profanities at hospital orderlies who had barged into his room while he was sleeping and confiscated the gauze pads he was using for an acute injury. In short, look for upticks of this disorder wherever the powerless are concentrated.

Posttraumatic stress disorder

Psychologist Richard Samuels checks his DSM
"bible" during testimony in Jodi Arias murder trial

PTSD got some significant tweaking in the DSM-5, mostly in directions that could increase its prevalence. The requirement of experiencing “fear, helplessness or horror” in reaction to the trauma was eliminated. There are now four "symptom clusters" rather than three. A new symptom of "reckless or self-destructive behavior" has been added, and the symptom of irritable behavior or angry outbursts has some added language, "typically expressed as verbal or physical aggression toward people or objects" and "with little or no provocation" (have fun explaining that one in court!).

In clinical practice, these changes won’t much matter. As Greenberg noted, "Mostly we’re content to find a label that matches people in some vague way and then get on with the business of helping them figure out what's going on in their lives that landed them in our offices." However, in court the devil is in the details. Difference between an "and" or an "or," or a three-month versus a six-month time specifier, can be critical. Unfortunately, there are no side-to-side charts with the changes from DSM-IV to DSM-5 highlighted or crossed out. The biggest benefactor of all this tweaking will be psychological test companies, whose psychometric tests for PTSD will have to be revamped. So get out your pocketbooks now.

Intellectual functioning and the death penalty

Last but not least, changes to the developmental disabilities section could make more criminals eligible for execution. Under the U.S. Supreme Court's Atkins standard, an IQ score of below 70 had been like a magic line in the sand, below which one becomes ineligible for capital punishment. However, the DSM-5's intellectual developmental disorder (renamed from mental retardation) drops IQ scores in favor of the more subjective construct of adaptive functioning, or the ability to live independently in the world.

"There are a lot of courts that are hostile to the basic legal doctrine the Atkins case established," death penalty lawyer David Dow told Reuters. "When you replace a test that is one part objective, one part subjective with a solely subjective test, it becomes easier for courts that are hostile to the constitutional principle of Atkins to evade that criterion."

"We believe that we are providing the courts with a more fine-grained means to consider adaptive functioning more comprehensively and more meaningfully," countered James Harris, of the DSM-5 work group.

Other specified or unspecified disorder

As I just mentioned, the devil is in the details. When a person does not meet minimum criteria for a diagnosis, clinicians can choose between the new categories of other specified disorder and unspecified disorder (the listed example being the unwieldy "other specified depressive disorder, depressive episode with insufficient symptoms"). These quick-and-dirty options are meant for use in the emergency department, where clinicians have little time and not much background information to go on. But the DSM-5 authors open the door for forensic misuse by stating their desire for "maximum flexibility for diagnosis." How's this for a loophole large enough to drive a Mack truck through:

"When the clinician is not able to further specify and describe the clinical presentation, the unspecified diagnosis can be given. This is left entirely up to clinical judgment."

Look to shady evaluators to misuse these "other" and "unspecified" labels to create nonexistent disorders for forensic use. That won't be anything new; it's essentially the same phenomenon we now see in sexually violent predator proceedings with the deployment of the DSM-IV-TR classifier "paraphilia not otherwise specified (NOS)," which these new categories replace. Such improper diagnosis may be legal, but that doesn't make it ethical.

Forensic caveat

One welcome change in the new manual is that the old cautionary statement about use of the DSM in forensic contexts gets more prominent play. Rather than being buried in the introduction, it's got its own little page in the DSM-5:

"... In most situations the clinical diagnosis of a DSM-5 mental disorder ... does not imply that an individual with such a condition meets legal criteria for the presence of a mental disorder or a specified legal standard...."

But when push comes to shove, judges and juries are going to do what they want to do, forensic cautions or no. As Texas lawyer Susan Orlansky -- whose client is slated for execution despite a lower-than-70 IQ -- told Reuters, "If the Texas court system is willing to ignore the DSM-IV, I don't know why they wouldn't be just as willing to ignore the DSM-5."

By all means take a moment to familiarize yourself with the changes in the new diagnostic manual that are relevant to your work. Just don't be conned into taking this whole diagnostic enterprise too seriously. After all, that's what the American Psychiatric Association is counting on to keep itself financially solvent.

I welcome comments, especially if you know of other changes of potential forensic relevance that are not listed here, or if you have a different take on the changes I highlighted.

And, if you are planning to attend the American Psychological Association convention in Honolulu, I invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

DSM-5: Much ado about nothing? (Part I of II)

Ambitious "paradigm shift" fizzles 

By now, you've seen the bad press about the American Psychiatric Association's new diagnostic codebook: Media pundits are labeling it "a manual run amok," so ambitious in scope that almost everyone qualifies for some mental illness or another.

But browsing through my crisp new copy, I find myself curiously dispassionate. Sure, it's even more bloated than the DSM-IV. But mainly, they just moved the chapters around and renamed a diagnosis here and there (dysthymia, for example, is now persistent depressive disorder). Even the typefaces will look familiar.

It's downright anticlimactic.

Remember when they first announced work on the new DSM? It was going to be a revolutionary "paradigm shift," aligning diagnoses with modern science. Disorders were going to be dimensional rather than categorical. All kinds of novel proposals were in play: Parental Alienation Syndrome. Paraphilic Coercive Disorder. Psychosis Risk Syndrome.

Then came the backlash. Prominent work group members walked out over the lack of science in the revision process. Petitions were launched. Special interest groups lobbied. ("Aspies," for example, were furious that psychiatry had bequeathed them an identity and were now taking it back.) The field trials fell apart. Even the National Institute of Mental Health announced it was breaking away from the DSM's diagnostic schema (although switching to its biology-worshipping Research Domain Criteria is like jumping from the frying pan to the fire).

Ultimately, the psychiatrists retreated. With both drug money and membership numbers down, the last thing the American Psychiatric Association needed was more negative flak. Especially when the DSM rakes in a steady profit, $5 to $6 million per year, giving them "fabulous riches" over time.

So, you'll find a few notable changes: There’s disruptive mood dysregulation disorder, a belated effort to undo the damage wrought by overdiagnosis of childhood bipolar disorder. Hoarding disorder and the Big-Pharma-inspired premenstrual dysphoric disorder made the cut. But overall, it's just business as usual.

In the short term, the new manual will give the APA's coffers a big boost. The book alone retails for $130 or more, and -- like a blockbuster Disney movie -- there will be ancillary products including cell phone apps, how-to guides, trainings, and such.

Eventually, however, the DSM will become increasingly irrelevant. It's already being superseded by the World Health Organization's International Classification of Diseases, which even on the APA's home turf of the United States is now required for insurance reimbursement. While some tout ICD codes as preferable, the only real advantage of the ICD is that it is freely available online.

By design, the DSM codes are almost precisely parallel to the ICD's. And the entire diagnostic enterprise, as psychotherapist Gary Greenberg explores in The Book of Woe, is an elaborate fiction -- a shell game perpetrated by psychiatrists on patients, insurance companies, and (most critically for our purposes here) the courts. Greenberg spent two years mucking about in the DSM-5 development trenches, where work group members frankly acknowledged that psychiatric diagnoses are just "fictive placeholders" or "useful constructs" rather than real conditions that carve nature at its joints.

Tomorrow, in Part II, I will highlight some specific changes (and non-changes) potentially relevant to forensic practice. 

If you are planning to attend the American Psychological Association convention in Honolulu, I also invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

Military sexual assault scandal unearths "illegal" psychiatric diagnoses

If you haven't been following the sexual assault scandals in the U.S. military, tune in: It’s yet another arena where bogus psychiatric diagnoses are playing a sordid role.

Women soldiers who report sexual assault are diagnosed with psychiatric conditions such as borderline personality disorder or bipolar disorder that get them drummed out. Not only are their careers ruined, but they are denied benefits and sometimes must even repay any bonuses they got for enlisting.

Because the symptoms of these "preexisting" disorders overlap with the emotional sequelae of trauma -- anger, fear, depression, anxiety, avoidance -- it can be hard to tell the difference.

Women in every branch of the U.S. military are being disproportionately discharged with personality disorders, according to an investigative series, Twice Betrayed, in the San Antonio (Texas) Express-News. The Air Force has the widest disparity: Women make up 20 percent of the force, but 35 percent of personality discharges.

Sometimes, as in one case featured in the Express-News series, military psychologists and psychiatrists are being influenced by officers in the accused's or accuser's chain of command to view accusers as mentally unstable and/or sexually promiscuous.

In a report on "illegal" psychiatric diagnoses, the Vietnam Veterans of America say that in addition to rape victims, many combat soldiers with organic brain trauma or posttraumatic stress disorder continue to be drummed out of the military with bogus personality disorders and adjustment disorders that block their disability benefits, despite Congressional efforts to crack down on this abuse (for example, by requiring that the diagnoses be issued by psychiatrists or PhD-level psychologists).

It was a bit incongruous to find myself sitting in an Air Force courtroom, consulting on a sexual assault case, when the news broke that the chief of the Air Force's Sexual Assault Prevention and Response program had been arrested for sexually assaulting a female stranger in a parking lot.Talk about the fox guarding the hen coop.

That bizarre twist came on the heels of a headline-grabbing survey documenting skyrocketing rates of sexual assault in the military: An estimated 26,000 soldiers were sexually assaulted in 2012, up from 19,000 the year before. Women in the military face about twice the risk of sexual assault as civilian women (one in three versus about one in six). And only a tiny fraction of assaults -- 3,374 last year-- are reported.

That's likely due to the fact that women who do report rape are shunned, disbelieved, and retaliated against, and their assailants are rarely punished. The seven-month investigation by Karisa King of the San Antonio Express-News found that only about 10 percent (302 of 2,900) of the accused were court martialed, with only 177 sentenced to confinement. (The airman in my case was one of those rare few, but then again he was a low-level airman, not an officer. And it probably didn't help his case that all of these scandals were busting out that very week.)

It’s no coincidence that the San Antonio paper ran the series: Outside that city sits the sprawling Lackland base, the Air Force's basic training center for enlisted personnel. In an unfolding investigation there, at least 33 training instructors are suspected of sexually assaulting 63 or more trainees.

If this latest scandal isn't enough to convince people of the link between sexual violence and a climate of hostile masculinity (as researchers such as Neil Malamuth have been arguing for decades), I don't know what is. On the other hand, if psychologists in the sex offender treatment industry got their hands on these training officers, they'd probably label them with some fictional disorder like "paraphilia not otherwise specified (nonconsent)" that decontextualized their behaviors beyond recognition. 

Consulting in a military court martial one week and a sexually violent predator civil commitment hearing the next, I can't help but notice how mental illness strikes in clusters, afflicting sexual assault victims in one setting and offenders in the other. The clue that situational exigency is in play is that in neither case is the diagnosis about helping the supposed sufferer. It's all about punishment, with diagnosis as the weapon.

I highly recommend the series, Twice Betrayed. An in-depth report by the The Vietnam Veterans of America on the misuse of psychiatric diagnoses in the military, Casting Troops Aside, is HERE.

Diagnostic controversies: Registration open for my Hawaii workshop

A shameless plug for my upcoming training workshop in Honolulu, sponsored by the American Psychological Association. CE's in paradise; what's not to like? To register (or get more information), click HERE.

Upcoming trainings: Assessment; personal injury; sexual violence; ethics in diagnosis

If you are planning to be in or around Florida, New Jersey, Hawaii or London over the next few months, here are some recommended forensic trainings on the horizon:

April 19 and onwards: Sexual violence workshops (London) 

Building on the success of the 2011 sexual violence workshops sponsored by the British Psychological Society (at which I spoke), Middlesex University is hosting another round of BPS-sponsored workshops on various aspects of sexual violence. Multiple-perpetrator rape is the topic of the first workshop, coming right up on April 19. (Also check out the new book, the first-ever text on this topic.) Next up are a June 27 workshop on "negotiating ethical sexual relationships," a Sept. 17 workshop on "intersectionality and sexual violence," and a fourth workshop on the investigation and prosecution of rape (date yet to be decided). All the workshops will be held at Middlesex University's Hendon Campus. More details are HERE.

April 20: Assessing Emotional Damages in Personal Injury and Employment Discrimination Cases (New Jersey)

William Foote, president of the American Psychology-Law Society (APA Division 41), will be presenting a five-stage model for assessing psychological damages in personal injury and workplace discrimination cases at the spring conference of the New Jersey Psychological Association. To find out more about this all-day training, click HERE.

May 3-5: New Directions in Forensic and Clinical Assessment (Florida)

Many big names in forensic psychology will descend upon Miami for this training sponsored by Division 42 (Psychologists in Independent Practice) of the American Psychological Association. The three-day conference will feature trainings on risk assessment, malingering, trial consultation, the DSM-5, intellectual disability, and much more. Information and registration can be found HERE. 


July 31: Controversial Psychiatric Diagnoses in Legal Settings (Hawaii) 

Yours truly is the trainer at this all-day continuing education workshop at the American Psychological Association's annual conference, along Honolulu's idyllic Waikiki Beach. I will focus on the scientific and practical limits of psychiatric diagnoses in forensic cases, and provide ethics guidance on how to present diagnostic testimony in court. Details are HERE; I'd love to see you there!

Training: Controversies in sexually violent predator evaluations

I am excited to announce that the American Psychology-Law Society has accepted a panel that I put together on "Emergent controversies in civil commitment evaluations of sexually violent predators." I hope some of you will join me at the annual conference in Portland, Oregon on March 7-9.

The symposium will address three areas of controversy in the sex offender civil commitment field:

• Mental abnormality and psychiatric diagnosis in court (my topic)

• Recidivism risk assessment (addressed by my esteemed colleague Jeffrey Singer)

• Volitional control (Frederick Winsmann, clinical instructor at Harvard Medical School, will present a promising new assessment model)

Here's the symposium abstract:

Over the past three decades, Sexually Violent Predator litigation has emerged as perhaps the most contentious area of forensic psychology practice. In an effort to assist the courts, a cadre of experts has proffered a confusing array of constantly changing assessment methods, psychiatric diagnoses, and theories of sex offending. Now, some federal and state courts are beginning to subject these often-competing claims to greater scrutiny, for example via Daubert and Frye evidentiary hearings. This symposium will alert forensic practitioners, lawyers and academics to some of the most prominent minefields on the SVP battleground, revolving around three central areas of contestation: psychiatric diagnosis, risk assessment, and the elusive construct of volitional control. The presenters will review recent scholarly literature and court rulings addressing: (1) the reliability and validity of psychiatric diagnoses in sexually dangerous person litigation, (2) forensic risk assessment tools and how risk data should be reported to triers of fact, and (3) how best to address the issue of volitional impairment, a Constitutionally required element for civil commitment. The focus will be on how to assist the courts while remaining within the limits of scientific knowledge and our profession's ethical boundaries.

The conference schedule hasn't been issued yet so I don’t know which day our panel is presenting, but I will keep you posted when I find out, probably in January. In the meantime, if you are looking to pick up Continuing Education (CE) credits, the pre-conference workshops are a good way to get some high-quality forensic training:

• The ever-informative Randy Otto on "Improving Clinical Judgment and Decision Making in Forensic Psychological Evaluation," with a heavy focus on identifying and reducing bias (full-day workshop) 

• Paul J. Frick on "Developmental Pathways to Conduct Disorder: Implications for Understanding and Treating Severely Aggressive and Antisocial Youth" (full-day workshop)

• Amanda Zelechoski on "Trauma-Informed Care in Forensic Settings" (full-day workshop)

• Kathy Pezdek on "How to Present Statistical Information to Judges and Jurors" (half-day workshop)

• Steven Penrod on "Things That Jurors (and Judges) Ought to Know About Eyewitness Reliability" (half-day workshop)

Portland is a lovely city, especially in the spring, so register now, and mark your calendars for what is sure to be a lively and educational event.

APA rejects "hebephilia," last standing of three novel sexual disorders

To hear government experts on the witness stand in civil detention trials in recent months, the novel diagnosis of "hebephilia" was a fait accompli, just awaiting its formal acceptance into the upcoming fifth edition of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM).

They were flat-out wrong.

In a stunning blow to psychology's burgeoning sex offender processing industry, the Board of Trustees of the American Psychiatric Association rejected the proposed diagnosis outright, not even relegating it to an appendix as meriting further study, its proponents' fall-back position.

The rejection follows the failure of two other sexual disorders proposed by the DSM-5's paraphilias subworkgroup. These were paraphilic coercive disorder (or a proclivity toward rape) and hypersexuality, an inherently hard-to-define construct that introduced the committee members' value judgments as to how much sex is within acceptable limits.

After abandoning those two disorders, the subworkgroup clung tenaciously to a whittled-down version of its proposed expansion of pedophilia to cover sexual attraction to early pubescent youngsters (generally in the age range of 11-14), ignoring widespread opposition from both within and outside of the APA.

The buzz is that senior psychiatrists in the APA were unhappy with the intransigence of psychologists in the subworkgroup who communicated the belief that if they just stuck to their guns, they could force the ill-considered proposal into the new manual, despite a lack of scientific support.

All three proposed sexual disorder expansions were widely critiqued by mental health professionals, especially those working in the forensic contexts in which they would be deployed. They led to a spate of critical peer-reviewed publications (including a historical overview of hebephilia by yours truly, published in Behavioral Sciences and the Law), and an open letter to APA leadership from more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally.

The unequivocal rejection sends a strong signal of the American Psychiatric Association's continuing reluctance to be drawn into the civil commitment quagmire, where pretextual diagnoses are being invoked as excuses to indefinitely confine sex offenders who have no genuine mental disorders. In marked contrast with the field of psychology, psychiatry leaders have expressed consistent concerns about the use of psychiatric labels to justify civil detention schemes.

Next time around, the APA might want to do a better job selecting committee members in the first place. The "paraphilias subworkgroup" was heavily biased in favor of hebephilia because of its domination by psychologists from the Canadian sex clinic that proposed the new disorder in the first place, and is the only entity doing research on it. But what a waste of time and energy to create a committee that comes up with wild and wacky proposals that are only going to end up getting shot down when the rubber meets the road.

Backpedaling on paradigm shift

As regular readers of this blog know, the DSM-5 developers' grand ambitions to bring forth a revolutionary "paradigm shift" produced alarm among mental health professionals and consumer advocacy groups both in the United States and internationally. The British Psychological Society, the UK's 50,000-member professional body, issued a strongly worded critique, and a coalition of psychological associations garnered more than 14,000 signatures on a petition opposing the wholesale lowering of diagnostic thresholds for disorder.

Yesterday's news release marked an about-face, with the APA now stressing that diagnostic changes in the DSM-5 were intended to be "very conservative."

"Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry," said David J. Kupfer, MD, chair of the DSM-5 Task Force.

Consistent with this, several of the proposed changes that generated the most widespread alarm were rejected. The Board of Trustees rejected the highly controversial "attenuated psychosis syndrome" that could have created an epidemic of false positives, stigmatizing eccentric young people and lowering the threshold for prescribing potentially harmful antipsychotic drugs. It also backed away from an equally controversial, and complex, revamping of the personality disorders. These conditions, as well as a contentious Internet gaming disorder, will all be placed in "section 3" of the new manual as conditions meriting further study.

Allen Frances, the DSM-IV Task Force chair and a high-profile critic of the DSM-5 project, called the spin that the DSM-5 will have minimal impact on psychiatric diagnosis and treatment "misleading":

"This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings…. Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment."

Among the controversial diagnostic changes that will go forward in the DSM-5, due to be published in mid-2013:

• Asperger’s syndrome is being eliminated as a separate disorder (it will be folded into an autism spectrum disorder)
• Depression is being expanded to include some grief reactions
• A brand-new "disruptive mood dysregulation disorder" has critics fearing psychiatric labeling of children who have temper tantrums

Two other sets of changes have particular relevance to forensic practitioners. Substance abuse disorders have been reframed as "behavioral addictions," which Frances warns could be a "slippery slope" leading to "careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets."

Posttraumatic stress disorder (PTSD) will be included in a new chapter on trauma and stress-related disorders, with four distinct diagnostic clusters instead of the current three, and "more attention to the behavioral symptoms that accompany PTSD." Some worry that the reconfigured PTSD may lend itself to misuse of the hot-button diagnosis in forensic cases.

Yesterday’s APA news release outlining the changes can be found HERE. My hebephilia resource page is HERE.

Forensic psychiatrists reject hebephilia - yet again!

Will American Psychiatric Association heed professional consensus?

Twenty years ago, Humbert Humbert went to prison for a series of sexual assaults on his 12-year-old stepdaughter, whom he famously nicknamed "Lolita." Now, as his lengthy prison term draws to a close, Wisconsin is petitioning to have the 60-year-old literature professor indefinitely detained as a Sexually Violent Predator.

The venue for last week's trial of Vladimir Nabokov's fictional protagonist was the annual convention of the American Association of Psychiatry and Law (AAPL) in Montreal. The central question, decided by audience vote, was whether the controversial diagnosis "hebephilia" qualified as a legitimate mental disorder justifying Mr. Humbert's indefinite civil detention.

The rousing theatrical performance featured an all-star cast of attorneys and psychologists, presided over by Toronto Judge Maureen D. Forestell. New Jersey Assistant Attorney General Mark Singer served as prosecutor. His expert witness was prominent psychiatrist Richard Krueger, a member of the paraphilias subworkgroup that has proposed adding "hebephilia" to the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A hebephilic qualifier would extend pedophilia to men with sexual preferences for children who have entered puberty, such as the fictional Lolita.

Defending Mr. Humbert was preeminent Wisconsin attorney Robert LeBell. His expert was Washington psychologist Richard Wollert, who has published peer-reviewed articles on SVP-related topics and testifies for the defense in civil commitment proceedings. Appearing as the court's expert was prominent Canadian psychiatrist John Bradford, an advisor on paraphilia (or sexual deviance) to the DSM-IV, past president of the AAPL and clinical director of the Sexual Behaviors Clinic in Ottawa.

After a spirited and sometimes heated trial, the 131-member audience was given electronic clickers and voted overwhelmingly -- 82 percent -- against including hebephilia as a diagnosis in the DSM-5, due out in mid-2013. A majority also voted against even including the controversial diagnosis in a DSM-5 appendix as a condition meriting further study.

Third time's the charm?

This marks at least the third time in two years that respected professional bodies have voted against the idea of hebephilia as a new mental disorder. At a 2010 vote in Oslo, Norway, members of the International Association for the Treatment of Sexual Offenders (IATSO) were near-unanimously opposed to the newly proposed sexual paraphilia. U.S. forensic psychiatrists followed suit a month later at the 2010 AAPL conference, overwhelmingly voting against hebephilia as well as two other proposed paraphilias, "paraphilic coercive disorder" (aka rape) and hypersexuality, both since scrapped.

Earlier this year, more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally, sent an open letter to the DSM-5 revisers, urging them to nix hebephilia. Since then, at least two peer-reviewed articles have been published deconstructing its legitimacy, one in the respected Journal of Nervous and Mental Diseases ("Hebephilia and the Construction of a Fictitious Diagnosis" by forensic psychologists Paul Good and the late Jules Burstein) and the other a broad review ("Hebephilia as mental disorder?") by scholars Bruce Rind and Richard Yuill in the Archives of Sexual Behavior.

Rind and Yuill said they undertook their extensive review of the historical and cross-cultural evidence after hebephilia proponent Raymond Blanchard (a member of the DSM-5 paraphilias subworkgroup) and his colleagues at Toronto's Centre for Addiction and Mental Health brushed aside numerous published criticisms of the proposed disorder (see Table 1). Building on their earlier research, Rind and Yuill argue that hebephilia -- generally defined as sexual attraction to young pubescents in the age range of 11 to 14 -- is a biologically normal trait found to varying degrees in both human males and our closest mammalian relatives, such as higher apes. They blast hebephilia as a bold example of naked moral values masquerading as science:

"Blanchard et al. … did not invoke comparative evidence…. They did not invoke any evidence…. They declared it a disorder by fiat, bypassing scientific analysis in favor of a pre-given conclusion supportable only because it is, for the current time and place, culturally resonant. Had their pronouncement been the opposite (i.e., hebephilia is functional), their article would never have been accepted in a peer-reviewed journal without massive evidential backing. Strongly resonant opinion can facilely pass through without the kind of scrutiny demanded of non-resonant views."

Why hebephilia still clings to life, despite so much opposition and so little scientific support, is beyond me. It's like an unwanted house guest who just refuses to take the hint and pack his suitcase.

The evidence at trial 

In attacking the government's diagnosis of his client, defense attorney LeBell focused on the dearth of empirical studies on the condition, other than by researchers at a single Toronto clinic, and the likelihood of "false positive" diagnoses in legal cases.

The wording of the proposed new diagnosis has been changed again and again over the past couple of years. In its current iteration, pedophiles are defined as those who have "an equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons, as manifested by fantasies, urges, or behaviors." (The requirements that the fantasies or urges be "recurrent" or "intense" have been removed, broadening the potential pool of sufferers.) Hebephiles are now defined as those with sexual attractions to "pubescent children" in Stages 2 to 3 of Tanner's pubertal stages (e.g., early development of pubic hair and breasts).

Defense expert Wollert testified that the problem of "false positives" -- people incorrectly identified as having a condition -- was extraordinarily high even in the controlled setting of the research laboratory. This problem would be much more acute in the forensic trenches where the hebephilia diagnosis is being deployed, he testified.

One insurmountable problem would be reliably identifying a sexual abuse victim's Tanner stage of pubertal development. Complicating this issue, testified the court's expert, John Bradford, Tanner Stages are highly variable. Because they reflect hormonal developments rather than specific ages, one could not assume a specific Tanner stage based on the age of a victim. About two years ago, alarming research indicated that girls are entering puberty far earlier than in previous generations; this month, a large study by the American Academy of Pediatrics identified a similar trend in boys.

Wisconsin psychiatrist Lynn Maskel, who organized and moderated the mock trial, labeled hebephilia a "weed diagnosis in the botanical garden of DSM."

"The question is not if sex with pubescent year old girls illegal, or if it is immoral," she told the audience of forensic psychiatrists. "The question to the psychiatric field is: Is it a disorder? And if it is, does this translate, for the expert witness, into a requisite mental disorder found in the specific SVP statute?"

Meanwhile, back in the real courtroom trenches …

In my seminal review, published in 2010 in Behavioral Sciences and the Law, I traced hebephilia's sudden emergence and rapid spread in legal discourse to the advent of Sexually Violent Predator laws, which require that the individual being considered for civil detention have a mental disorder that makes him qualitatively different from the garden-variety offender.

Since that article's publication, the introduction of hebephilia in U.S. courts has continued unabated, despite the lack of an official imprimatur by the American Psychiatric Association. In a string of SVP cases brought under the Adam Walsh Act, federal judges in North Carolina have ruled that the faux diagnosis is not a legitimate basis for civil detention.

However, other courts have been less circumspect. For example, just yesterday, in a narrow, 4-3 opinion, New York's high court upheld the civil commitment of a repeat sex offender named "Shannon S." based on the purported conditions of "paraphilia NOS" and "hebephilia." Mr. S. had engaged in a series of forcible rapes of adolescent girls, ages 13 through 16.

As the dissenters conceded, Shannon S. was a "very bad actor" and "the community may well be safer if he is kept behind bars."

"But, they added, "to put him there on the fiction that he has some sort of mental condition other than a tendency to commit the crimes for which he was convicted (and has served his time) is and should be constitutionally unacceptable."

Judge Robert Smith, writing for the minority, labeled as "absurd" the premise that attraction to adolescent girls is abnormal, as the government's two experts testified: "What is abnormal about appellant, and others who commit statutory rape by having sex with girls below the age of consent, is not that they find the girls attractive, but that they are willing to exploit them for their sexual pleasure -- in other words, they commit statutory rape."

Smith labeled hebephilia and the similarly disputed diagnosis of "paraphilia not otherwise specified" (rape) as "junk science devised for the purpose of locking up dangerous criminals." While such a practice might seem appealing from a public safety viewpoint, it creates "dangers of abuse," he eloquently warned:

"Many sex offenders are, or could reasonably be found to be, dangerous, and in common parlance they all have mental abnormalities: Mentally normal people do not commit sex crimes. Thus, unless 'mental abnormality' is defined with scientific rigor, such statutes could become a license to lock up indefinitely, without invoking the cumbersome procedures of the criminal law, every sex offender a judge or jury thinks likely to offend again.

"Some will intuitively respond: Not a bad idea. But it is a very bad idea, because not even a concern for public safety should be allowed to trump certain fundamental rules. Among them are that criminals can be confined only for crimes they have committed, after their guilt is proved beyond a reasonable doubt in a procedure in which they receive the many protections that our Constitution gives to those accused of crime, and that even when convicted they can be incarcerated for no more than the term of the maximum sentence provided by law. If the present sentences for sex offenders are too short, the Legislature should make them longer, but it should not, and constitutionally cannot, simply substitute civil for criminal proceedings as a means of keeping dangerous criminals off the streets."

As Judge Smith seems to recognize, it's a slippery slope. Bogus psychiatric diagnoses for sex offenders now, political dissidents (or others) tomorrow. That's the way they rolled in the former Soviet Union, after all.

Pretextual court rulings aside, the paraphilias subworkgroup has had more than two years to produce evidence for the reliability and validity of hebephilia, and it has not done so.

It is clear to most observers that hebephilia is not accepted by the relevant professional community. What remains unclear is whether the Board of Trustees of the American Psychiatric Association will get the message in time to prevent yet another in a veritable maelstrom of public-relations disasters and historical mistakes.

* * * * *

Additional resources: My resource page on hebephilia is HERE.

Of related interest: DSM-5  field trials discredit the American Psychiatric Association, by Allen Frances, Huffington Post, 10/31/2012

Happy Halloween!