Latest hebephilia critiques: Point-counterpoint

I've just updated my Hebephilia and the DSM-5 Controversy resources page with two new articles in the Archives of Sexual Behavior critiquing the proposed diagnosis of pedohebephilia.

Green: Moral standards masquerading as science

In his boldly titled "Sexual Preference for 14-Year-Olds as a Mental Disorder: You Can’t Be Serious!!," prominent psychiatrist and sexologist Richard Green pulls no punches. Green, who teaches at the Imperial College of London, served on the Gender Identity Disorders subcommittee for DSM-IV. Back in the 1970s he was a forceful advocate for removing homosexuality from the manual of mental illnesses, a struggle he references in his current critique:

The parody of science masquerading as democracy made a laughing stock of psychiatry and the APA when it held a popular vote by its membership on whether homosexuality should remain a mental disorder. Decreeing in a few years time that 19-year-olds who prefer sex with 14-year-olds (5 years their junior) have a mental disorder … will not enhance psychiatry’s scientific credibility.

As he points out, the age of legal consent in several European countries falls within the range that the proposed pedohebephilia disorder would make pathological for the older participant:

If the general culture is accepting of participation by the younger party, but psychiatry pathologizes participation by the older party, then the mental health profession pronounces a moralistic standard and, if successful, becomes an agent of social control.

Green goes on to catalog "biased terms" and "logically frail arguments" in the proposal. In this, he joins a growing chorus of voices sounding the alarm about myriad problems with the proposed pedohebephilia diagnosis.

O'Donohue: Let's go even further

Coming at it from the opposite angle of most critics is William O'Donohue, a psychology professor at the University of Nevada at Reno and co-editor of the second edition of the widely consulted text Sexual Deviance.

O'Donohue argues for keeping it simple: "any sexual attraction to children … is a pathological, abnormal condition." His proposed diagnosis reads as follows: "The person is sexually attracted to children or adolescents under the age of 16" as evidenced by (1) self report, (2) laboratory findings, and/or (3) past behavior. Whether the person has acted on his or her attractions would not matter. The number of victims would not matter. And internal distress would not be required.

O'Donohue expresses a lack of concern over the inevitable false positive errors that such a broad net would ensnare. He argues that we should be more concerned about false negative errors -- pedophiles who escape diagnosis when the criteria are too narrow, for example when more than one known victim is required. And he applauds the move to expand pedophilia to include hebephilia, or attraction to pubescent minors.

Prosecution-retained evaluators in U.S. civil commitment cases will be salivating at the prospects for this one. But consider the source. O'Donohue is the psychologist who has argued for subjecting gay and lesbian parents to special scrutiny in child custody evaluations. (Respected child custody experts Jonathan Gould, David Martindale, and Melisse Eidman wrote an outstanding counterpoint, summarizing the empirical research as indicating that "sexual orientation is not a pertinent factor when considering the best psychological interests of children." In the interest of full disclosure, I share that view, as I wrote in an article published in the same journal a few years earlier.)

And, despite his support for diagnostic expansion, even O'Donohue concedes that the psychometric properties of the proposed diagnosis remain unknown. In other words, neither its reliability nor its validity have been empirically established. A wee problem, that.

A list of published articles on the hebephilia debate, with links to the publisher's web pages, is HERE. For the newest additions, look for the "NEW" icon towards the bottom of the page.

Stalker slain -- "WWBD?"

You evaluate a man who engaged in repetitive stalking of a high school girl. He spied on her, followed her around (rationalizing it as “for her own good”), and even climbed in her bedroom window at night and watched her sleep. He acknowledges a powerful desire to kill her.

Ominous, right? When we encounter men like this, they raise our hackles.

But in pop culture -- movies, music, and videos -- this possessive, condescending, and downright creepy behavior is often glorified as "true love." Such is the case with Edward in the blockbuster Twilight movie series, marketed with great fanfare to young teenage girls.

Appalled by the sexually predatory behavior modeled by Edward in Twilight, freelance Web designer Jonathan McIntosh of Rebellious Pixels asked himself, "What would Buffy do?" Buffy, of course, being the strong woman heroine of the popular TV series Buffy the Vampire Slayer.

If you haven’t seen the resultant video mashup, stop whatever you're doing and take the six minutes to watch it.



The brilliant and hilarious video has been translated into 16 languages and watched by millions of people worldwide. As reported in the L.A. Times, Buffy v. Edward reveals Edward’s supposed charm for the creepy stalker behavior it is:

[T]he Slayer has little patience for the expertly coifed Edward, dazzling or otherwise. "Being stalked isn’t a big turn-on for girls," Buffy tells him. When Edward tries to explain that he's on "a special diet," Buffy replies, "What are you doing? Here, at this table, talking to me like we're some kind of talking buddies?"

McIntosh's essay explaining his project is HERE.

Study: Actuarials fail to predict sexually violent recidivism

In a new prospective study out of Austria, none of the actuarial instruments commonly used to predict sex offender recidivism were able to predict sexually violent recidivism among a group of sex offenders released from prison after treatment.

The interesting study, just published in the International Journal of Offender Therapy and Comparative Criminology, was designed to validate German versions of commonly used actuarial tools, including the Static-99, RRASOR, SORAG, and SVR-20. It followed about 400 Austrian prisoners for an average of three years in the community.

The main problem obtaining significant results was that recidivism was so rare. Obviously, the less likely an event is to occur, the harder it is to accurately predict. Only seven offenders in the entire sample committed a new hands-on offense during the followup period, and most of those were extrafamilial child molesters. Recidivism base rates were especially low for rapists and incest offenders.

The results echoed findings in two other recent studies in which the actuarials failed to demonstrate good predictive validity for predicting sexually violent reoffending.

Most of the instruments did better when recidivism was defined more broadly, to include all sexual reconviction, even hands-off offenses such as voyeurism or exhibitionism that is not typically defined as sexually violent under civil commitment laws. Even including these lesser offenses, the overall base rate for all sexual recidivism among this sample was still quite low, 4.3% (12% among extrafamilial child molesters, 1.7% among rapists, and about 1% among incest offenders).

When extrafamilial child molesters -- the group most likely to reoffend -- were examined separately, all of the instruments except the RRASOR had some predictive utility, with the SVR-20 doing the best. Still, neither the Static-99 (the most widely used actuarial tool) nor the RRASOR could significantly predict sexually violent reoffenses even for that relatively higher-risk group.

"From the results of these studies and of the present study, the actuarial prediction of some reoffence categories in at least some offender subtypes is less accurate than generally assumed,” the authors concluded. "One major aim of most criminal justice systems is to calculate risk by predicting the probability of severe sexual crimes. This goal obviously is not yet achieved satisfactorily by actuarial risk assessment, because results are far from ideal, especially when time-at-risk periods are relatively short."

An important implication of this study is that evaluators need to consider offender subgroups separately, rather than lumping all types of sex offenders together. Recidivism varies tremendously by type of offender (e.g., rapists versus child molesters) and by how recidivism is defined, with the various instruments doing better at some types of predictions than others. Furthermore, so little outcome research exists on certain groups (such as hands-off offenders, juveniles, the intellectually disabled, and offenders with only adult male victims) that the actuarials may be inappropriate to use at all.

The study is:

Rettenberger, M., Matthes, A., Boer, D.P., & Eher, R. (2010). Prospective Actuarial Risk Assessment: A Comparison of Five Risk Assessment Instruments in Different Sexual Offender Subtypes. International Journal of Offender Therapy and Comparative Criminology, 54 , 169-186.

Hat tip: Jeffrey Singer

FURTHER READING: For those of you interested in the actuarials, I also recommend "More prejudicial than probative?," a stastical critique by David J. Cooke, a forensic psychology professor in Glasgow who is an expert scholar and trainer on violence risk assessment. Cooke argues that the actuarials are compelling because they are simple to use by paraprofessionals and have a scientific veneer, but "the scientific basis for actuarial scales, as applied to individuals, may be more illusory than real." The article, in the journal of the Law Society of Scotland, is available online. It also includes useful references to other sources.

Furor over France’s "pornographic" anti-smoking ads

A French anti-smoking campaign comparing smoking to sex slavery is being accused of everything from dissemination of pornography to insensitivity to child sexual abuse victims.

The ads -- set to be published in newspapers and posted in bars -- feature teens smoking cigarettes in such a way that they look like they might be performing oral sex on a man in a suit. The caption reads, "Smoking means being a slave to tobacco."

"Traditional advertisements targeting teens don't affect them. Talking about issues of health, illness or even death, they don't get it," a spokesperson for the Association for Nonsmokers' Rights told AP in explanation. "However, when we talk about submission and dependence, they listen."

The 16-year-old who alerted me to the controversy thought it was quite a hoot. But the family minister of France is not laughing. She is calling for a ban on the ads as "indecent exposure" and "an affront on public decency." Likewise, a child welfare group called the ads cruel and insensitive toward young child abuse victims. Tobacco company representatives are also incensed at being compared to pedophiles. "It's no longer prevention, but out of place provocation," one tobacco association said on its web site.

Ironically, the advance uproar is giving the anti-smoking campaign so much publicity that it will make the formal ad campaign unnecessary.

Hat tip: Greg

UK may end controversial "dangerous and severe personality disorder" program

In what could signal a seismic shift against civil commitment based on pretextual mental disorder, England is rumored to be considering an end to its controversial "Dangerous and Severe Personality Disorder" (DSPD) program.

The program was launched in 1999 and has so far cost an estimated 200 million pounds (more than $300 million USD), with little evidence of efficacy in identifying dangerous criminals or curbing violent crime. The four DSPD units -- two at Broadmoor and Rampton high security hospitals and two at Whitemoor and Frankland prisons -- house about 300 offenders. Critics say the label Dangerous and Severe Personality Disorder is a political invention, not a true psychiatric disorder.

According to an exclusive report by London's independent Channel 4 News, the Ministry of Justice is considering a halt to the program based in part on a report that concludes that the program "has been largely ineffective and should now be abandoned." The report, co-authored by former government advisor Peter Tyrer, is under review for the journal Medicine, Science and The Law, published by the British Academy of Forensic Sciences.

The report follows on the heels of another critical analysis that I recently blogged about, due to be published in the International Journal of Law & Psychiatry. That study, "Dangerous and severe personality disorder: An investigation of the construct," by authors Ullrich, Yang, and Coid, found a very high rate of false positives -- that is, people categorized as DSPD and at high risk of serious reoffending when they actually did not reoffend when tracked in the community.

Ullrich and colleagues found that 26 DSPD offenders would need to be civilly committed to prevent one major violent act. In regard to sex crimes, the researchers found that most were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

If Britain does indeed eliminate the DSPD program, it will be a major blow for those who advocate for civil commitment as a viable means of increasing public safety. Not only is it exorbitantly expensive, but also the civil liberties implications of wrongfully detaining people who are not truly dangerous based on unreliable prediction tools are ominous.

It will also be a blow against the creation of dubious new diagnoses to justify civil commitment on the grounds of purported mental disorder, as is being done here in the United States.

Finally, this scientific setback may also help to discourage those who seek to extend civil commitment to other populations, such as juveniles.

More prominent voices join chorus of DSM5 critics

With the unveiling of the draft DSM5, the chorus of well-aimed criticisms flying in from all sides is becoming truly spectacular. The latest voices are prominent scholars writing in the eminently respectable Wall Street Journal, Los Angeles Times, and Washington Post.

All three focus on what most critics agree is an especially troubling aspect of the proposed manual -- the "wholesale medical imperialization" that eventually will label nearly every human being with one or more psychiatric pathologies. The authors of the DSM, critics assert, have appointed themselves as the arbiters of what is normal and what is not.

Wall Street Journal: Psychiatry in demise

Edward Shorter, a University of Toronto professor and preeminent scholar of the history of medicine, gives a historical overview of the DSM's development to support his verdict that the latest draft manual illustrates a discipline in demise.

To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

Los Angeles Times: Overdiagnosis gone berserk

Allen Frances, chairman of the DSM-IV task force, has been sounding the alarm over this new manual far and wide of late. This latest essay is perhaps his most eloquent to date, and of direct relevance to forensic practice in that it focuses on the proposed sexual disorders that will be used pretextually in civil commitment proceedings:

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping….

Frances urges the public to pay attention and voice opposition to psychiatry's "recklessly expansive suggestions" before the juggernaut becomes unstoppable:

This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.

Washington Post: George Will weighs in

Finally, prominent political columnist George F. Will weighed in on the moral implications of the proposed diagnostic expansions. Will expressed worries about the legal consequences of excusing amoral conduct as a symptom of uncontrollable illness.

The 16 years since the last revision evidently were prolific in producing new afflictions. The revision may aggravate the confusion of moral categories.

Today's DSM defines "oppositional defiant disorder" as a pattern of "negativistic, defiant, disobedient and hostile behavior toward authority figures." Symptoms include "often loses temper," "often deliberately annoys people" or "is often touchy." DSM omits this symptom: "is a teenager." …

[C]onfusion can flow from the notion that normality is always obvious and normative, meaning preferable. And the notion that deviations from it should be considered "disorders" to be "cured" rather than stigmatized as offenses against valid moral norms.

Now that just about every major news outlet in the United States has run highly critical analyses, the question becomes: Will the American Psychiatric Association listen? Or, like an individual in the throes of a manic episode, will it continue its pell-mell rush to diagnose all human behaviors, creating an ever-broader assortment of bizarre pathologies?

Hat tip: Bruce