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.

New critique of APA’s detainee interrogation policies

Interrogation of Canadian citizen Omar Khadr, age 15, at Guantanamo

Prominent psychology ethicist Ken Pope, a former chair of the American Psychological Association's Ethics Committee who resigned from the APA in 2008, has authored a new article critiquing the APA's controversial policies on detainee interrogations.

Pope said his purpose is to "highlight key APA policies, procedures, and public statements that seem in urgent need of rethinking and to suggest some questions that may be useful in a serious assessment."

He questions the ethical legitimacy of standing behind policies and practices that can cause harm to individuals -- such as detainees -- based on the stated desire to do "the most good for the most people."

Pope provides a history of the APA’s controversial 2002 decision to reject the so-called "Nuremberg Ethic" by permitting psychologists to forego ethical responsibilities when they conflict with government authority (Ethics Code Section 1.02).

Psychologists came under intense criticism from human rights proponents in the wake of 9/11 for their critical role in detainee interrogations. Unlike organized psychiatry and other medical professions, the American Psychological Association promoted its role in detainee interrogations as contributing to national security in a time of crisis.

"APA promoted support for its interrogation policies in its press releases, its journals, its web site, its Internet lists, its conventions, the APA Monitor on Psychology, and other venues," Pope noted. For example, it "submitted a statement on psychology and interrogations to the US Senate Select Committee on Intelligence explaining that 'psychologists have important contributions to make in eliciting information that can be used to prevent violence and protect our nation's security'; that 'conducting an interrogation is inherently a psychological endeavor'; and that 'psychology is central to this process.' "

Accordingly, psychologists under contract with the CIA were given a green light to design aggressive interrogation techniques to break down detainees, while other psychologists on the outside assured the public that techniques such as waterboarding were safe and would not cause lasting mental harm.

The article, "Are the American Psychological Association's Detainee Interrogation Policies Ethical and Effective? Key Claims, Documents, and Results," is slated for publication in the journal Zeitschrift fur Psychologie / Journal of Psychology, the oldest psychology journal in Europe and the second oldest in the world.

Pope's critique is timely. For one thing, the policies authored by the APA's controversial Presidential Task Force on Psychological Ethics and National Security (PENS Task Force) remain in place. Additionally, the issues he raises have broader implications for current ethical practice of psychologists in other custodial settings, such as prisons, jails, and mental hospitals.

Pope has made the article available at his website (HERE), which also has many other useful resources on ethics and interrogations.

First joint psychology-law program with disability focus

New York Law School and John Jay College of Criminal Justice have announced a new joint degree program in forensic psychology and law that will launch in Fall 2012 and focus on disability law.

New York Law School already offers 13 courses on mental disability law, while John Jay already offers an M.A. in forensic psychology. But this will be the first program of its kind, according to New York Law School professor Michael Perlin, who is also the director of he law school's Mental Disability Law Program.

"I'm very excited about the joint program because it highlights the interdisciplinary nature of what we are trying to do through our mental disability law program," Perlin told the National Law Journal. "We created courses specifically to appeal to both lawyers and mental health professionals. This program helps create a synergy that ensures, as best we can, that graduates will have a deep understanding of the other discipline."

"Our graduates will be well-trained lawyers for people with mental disabilities issues and have the potential to become legal advocates, work on public policy or become law professors in this unique niche," said James Wulach, the director of the M.A. Program in Forensic Mental Health Counseling at John Jay College.

Students must apply and be accepted to both schools separately and will finish with a Master of Arts in forensic psychology from John Jay and a Juris Doctor from New York Law School. Perlin expects an initial enrollment of about 25 students.

The National Law Journal story is HERE.

Good tidings: Violence at all-time low

How does this sound for entertainment: Your date asks you out to the theater to watch a live cat slowly lowered into a fire and burned to death, howling with pain as it is singed, roasted, and finally carbonized?

If that isn't your idea of a good time, don't hop into the next time machine heading back to medieval Europe.

In 16th-century Paris, throngs –- including kings and queens -- flocked to watch such gruesome spectacles, shrieking with laughter as cats and other animals were tortured to death on stage.

"The Catherine Wheel"

Torture and violence were woven into the fabric of life, from the sexualized sadism of London, where elaborately designed and decorated torture devices were the pinnacle of artistic creativity, to the widespread practice of hacking off the nose of anyone who disrespected you (the source of the strange idiom, "to cut off your nose to spite your face").

In contrast, whether we know it or not, we are now enjoying the most peaceful period in all of human history. Indeed, the precipitous decline in violence of all types may be “the most significant and least appreciated development in the history of our species,” argues Steven Pinker, a renowned professor of psychology at Harvard University, in an epic tome, The Better Angels of Our Nature: Why Violence Has Declined.

"The Judas Cradle"

Given the tenor of the daily news headlines, Pinker knows his claim sounds far-fetched. But in 800 pages of research and analysis, augmented by hundreds of charts and tables, he convincingly establishes that violence is indeed heading in one direction: down.

The decline is drastic across-the-board, in both state-sanctioned and individual violence: International wars, civil wars, terrorism (an obsession far out of proportion to its prevalence), slavery, sexual violence, child abuse, infanticide....

Click HERE to read my full Amazon review of this recommended text. If you appreciate the review, please click on "yes."

Breivik insanity finding showcases Norway’s progressive system

Sensible and efficient are words that come to mind in reviewing the Norwegian government's handling of mass killer Anders Behring Breivik's legal case.

The court appointed two psychiatrists who worked collaboratively to evaluate Breivik,who admits killing 77 people and injuring 151 others in a mass shooting spree in July.

The psychiatrists spent 36 hours interviewing Breivik on 13 separate occasions before finding him insane at the time of the crimes. Breivik was psychotic and inhabited a ''delusional universe,'' they wrote in their 243-page report.

Although many have expressed surprise, there's not the kind of political grandstanding one might expect with such a politically charged case in the United States or some other Western countries. Even prosecutors are not voicing any objection to the insanity finding.

''Anders Behring Breivik during a long period of time has developed the mental disorder of paranoid schizophrenia, which has changed him and made him into the person he is today,'' prosecutor Svein Holden announced at a press conference.

Inga Bejer Engh, speaking for government prosecutors, also said she was ''comfortable'' with the finding.

An expert panel from the Norwegian Board of Forensic Medicine is expected to approve the finding. If so, Breivik will likely be detained indefinitely in a psychiatric hospital and will not stand trial.

Rehabilitation a central goal

Norway’s criminal justice system stands in stark contrast to the more punitive systems in many other countries. Rehabilitation, rather than just punishment for punishment's sake, is its central goal.

Even if Breivik had been found sane and convicted at trial, his maximum prison sentence would have been 21 years, or at most 30 years if he had been found guilty of crimes against humanity.

For example, a male nurse found guilty of murdering 22 of his elderly patients was released in 2004 after serving just 12 years in prison.

"A lot of resources are put into this. The idea is for people to be able to leave prison and lead a life free from crime,” criminology professor Hedda Giertsen of the University of Oslo told the BBC. "There is help to find accommodation, help with personal finances, education -- nearly half of Norway's prison population is offered some sort of course or education."

Statistics indicate this policy works: Reconviction rates in Norway are about 20 percent, far lower than in other European countries or the United States.

And just think about all of the money Norway will save by avoiding the public spectacle of a lengthy and high-profile trial featuring dueling psychiatric experts. 

Rationality: Don't you love it?

MnSOST-3: Promising new actuarial for sex offenders to debut

Note: See below postscript for a link to the MnSOST-3 instrument and manual, now available online.

Regular readers know that I've criticized our field's overreliance on imprecise and atheoretical screening instruments to predict whether or not an individual will behave violently in the future.

As Patrick Lussier and Garth Davies of Simon Fraser University point out in the current issue of Psychology, Public Policy, and Law, the actuarialist approach of searching for external variables that distinguish individuals "is somewhat at odds with the rationale of risk assessment, which is intended to assess the risk of an individual but also takes into account any changes in the level of risk over time for a specific individual."

In their new longitudinal study, Lussier and Davies identified heterogeneous trajectories in sexual and violent offending over time. They suggest that by turning "a blind eye" to criminological research on the developmental course of offending, the actuarialists have produced measures that are a misfit for many if not most individuals, overestimating risk in some cases and underestimating it in others.

While I agree philosophically with their critique, we have to be realistic.

Legislatures and courts love the so-called actuarials, which rate an individual's risk based on the presence of various preselected risk factors. They're quick and easy to administer. And they offer an illusion of scientific certitude that legitimizes current laws and criminal justice practices.

So, until a more theoretically informed, person-oriented approach gains traction, we should at minimum insist on more accurate actuarials, and better acknowledgment of their limitations. That was the goal, for instance, of the Multisample Age-Stratified Table of Sexual Recidivism Rates (MATS-1), a collaborative project by researchers in the United States, New Zealand, and Australia to more accurately incorporate advancing age into predictions of risk for sex offenders.

With that more modest goal in mind, I am cautiously optimistic about a newly developed actuarial tool for assessing recidivism among sex offenders, the MnSOST-3.

A better actuarial?

Before you recoil in shock based on the name alone, let me reassure you that it's a completely different tool from the old Minnesota Sex Offender Screening Tool (the MnSOST or MnSOST-R). Only three of the new instrument's items are the same, and even those are measured differently, so I don't even know why they kept the tainted name. As many of you know, the original MnSOST (pronounced MIN-sauced) oversampled high-risk offenders and so produced artificially inflated estimates of risk. Also, research on its development was never published in a peer-reviewed journal.

Based on an article by developers Grant Duwe and Pamela Freske accepted for publication in the journal Sexual Abuse, the new and improved MnSOST-3 appears to have several advantages over existing actuarial instruments for assessing sex offender recidivism.

The developers took advantage of advances in statistical modeling, using a predictive logistic regression model that enables a more nuanced measurement of the effects of continuous predictors such as age and number of prior offenses. Risk is adjusted based on whether an offender will be under any kind of supervision in the community, something other actuarials do not consider. Scoring is done on an Excel spreadsheet, which should reduce data entry errors.

A major strength of the MnSOST-3 is that it was developed on a contemporary sample that included 2,315 sex offenders released from Minnesota prisons between 2003 and 2006. Given the plummeting rates of sexual offending in the Western world over the past couple of decades, this is imperative in order not to overestimate risk.

The developers report that the MnSOST-3 is well calibrated with actual recidivism rates for all but the highest-risk offenders, for whom it overestimates risk. In other words, the predicted probabilities of recidivism match up pretty closely with the actual rates of reoffending except for the very highest-risk offenders. Overall, about four percent of the released offenders were reconvicted of a new sex crime within four years, a base rate that is consistent with other recent research findings. 

Moose Lake sex offender facility, Minnesota

The authors frankly acknowledge the problem that this low base rate poses for accurate identification of recidivists. While offenders who scored in the top 10 percent on the MnSOST-3 were more likely than lower-scoring men to reoffend (their rate of reconviction was 22 percent), if you predicted that any given individual in this top bracket would reoffend, you would be wrong four times out of five.

The optimism-corrected accuracy of the MnSOST-3 for the contemporary sample, as measured by the Area Under the Curve (AUC) statistic, was .796. This means that there is about an 80% chance that a randomly selected recidivist will have a higher score on the instrument than a randomly selected non-recidivist -- although this applies only to the sample from which the instrument was developed and is not generalizable to other samples.

Although we must wait to see whether this moderate accuracy will generalize to sex offender populations outside of Minnesota, the MnSOST-3 may be about as good as it gets. After a decades-long search for the Holy Grail of risk prediction, consensus is building that the obstacles are insurmountable. Low base rates of recidivism, along with fluid and unpredictable environmental contexts, place a firm ceiling on predictive accuracy.

Which gets us back to the point made by Lussier and Davies: Consistent with a large body of criminological theory, we need to recognize the criminal career as a process with a beginning, a middle and an end. In other words, it's time to start looking at the individual offender and understanding his specific offense trajectory, rather than just continuing to amass collections of external variables to measure him against.

Oh, in case you were wondering how well the old MnSOST-R did at predicting which men in the contemporary Minnesota sample would reoffend, it had an AUC of .55. That's about as good as a coin flip.

So, if nothing else, the MnSOST-3 should seal the death warrant of its worn-out ancestors. Given their inaccurate and bloated estimates of risk, that will be a very good thing.

The articles are:

Lussier, Patrick and Davies, Garth (2011) A Person-Oriented Perspective on Sexual Offenders, Offending Trajectories, and Risk of Recidivism: A New Challenge for Policymakers, Risk Assessors, and Actuarial Prediction? Psychology, Public Policy, and Law 17 (4), 530–561. (To request a copy from the author, click HERE.)

Duwe, Grant and Freske, Pamela (In Press), Using Logistic Regression Modeling to Predict Sex Offense Recidivism: The Minnesota Sex Offender Screening Tool-3 (Mnsost-3), Sexual Abuse. (To request a copy from the author, click HERE.)

POSTSCRIPT: The MnSOST-3 is now being used by the Minnesota Department of Corrections; thus, the instrument and the scoring manual are available online -- HERE. 

Related blog posts:

• MnSOST-R actuarial instrument critiqued (July 3, 2008)
• SVP industry sneak peek: Problems in Actuaryland (Oct. 4, 2009)
• Study: Actuarials fail to predict sexually violent recidivism (March 5, 2010)
• Delusional campaign for a world without risk (April 3, 2010)
• New study: Do popular actuarials work? Newer instruments outperform Static-99 and RRASOR (April 20, 2010)
• Groundbreaking study of sex offender life courses: Challenge to actuarials: 4 distinct trajectories ID'd (June 4, 2010)
• Metaanalysis debunks psychopathy-violence link (Sept. 3, 2010)
• Age tables improve sex offender risk estimates (Dec. 1, 2010)