Open letter opposing DSM-5 paraphilias expansion

Photo credit: Dr. Joanne Cacciatore

As readers of this blog are aware, proposals to expand the sexual disorders in the American Psychiatric Association's upcoming DSM-5 have generated significant controversy among forensic psychologists and psychiatrists. Now, forensic psychologists are banding together to urge APA President John Oldham to reject the proposed diagnoses of pedohebephilia, paraphilic coercive disorder and hypersexual disorder. The text of an open letter drafted by Richard Wollert, an Oregon psychologist with extensive experience in sex offender treatment and evaluation, follows. If, after reading it, you would like to become a signator, just click on the indicated link, and provide Dr. Wollert with your name and professional credentials. Don't delay, as I understand that this important letter is being submitted very soon. 

CLICK HERE TO ADD YOUR NAME TO THE LETTER

 

Dear Dr. Oldham:

As a mental health professional and/or sex educator I am writing to you to encourage the American Psychiatric Association to leave invalid sexual disorders out of DSM-5. 

In 1999, the Dangerous Sex Offender Task Force of the American Psychiatric Association issued a strongly worded statement about psychiatry's failed efforts to meaningfully define and classify sexual deviance. In contrast to the cautious approach advised by the Task Force, a Paraphilias Subworkgroup of the DSM-5 is vigorously lobbying for the adoption of three highly controversial expansions of sexual disorders (Hebephilia, Paraphilic Coercive Disorder, and Hypersexual Disorder). The expansions would be a major mistake, due to poor reliability, unproven validity and -- most of all -- the potential for vast and harmful unintended consequences. 

The Subworkgroup is now proposing to add a "Hebephilic" type to Pedophilia, extending the diagnosis of Pedophilia from covering those with sexual attractions to prepubescent children to those with sexual attractions to pubescent children under age 15. It also proposes to add new diagnoses of "Paraphilic Coercive Disorder" and "Hypersexual Disorder" to the Appendix as "Criteria Sets for Further Study." I am dismayed by each of these recommendations for the following reasons. 

Hebephilia lacks conceptual coherence. Most men are attracted to sexually maturing 14-year-olds, as reflected in the large number of industrialized countries where the age of sexual consent is 14 (Green, 2010). Normative attractions may be criminal when acted upon, but they should not be labeled as mental disorders. "Hebephilia" is an archaic term that languished in psychiatric obscurity until the passage of modern civil commitment laws in the United States (Franklin, 2010). Since then, some evaluators who confuse statutory rape with mental disorder have invoked Hebephilia as a condition that justifies civil commitment (Ewing, 2011). Such usages do not provide a cogent explanation for behavior that is illegal in the United States but legal in other countries being classified as a mental disorder. Finally, Hebephilia lacks adequate diagnostic reliability (Wollert and Cramer, 2011). Most of the research has been conducted by a single Canadian research team that is overly represented on the Paraphilias Subworkgroup. Although the DSM-5 Task Force has indicated that final decisions about proposed revisions will be made on the basis of field trial data, a November 2011 change in the proposed criteria for the diagnosis rules out the application of even this meager safeguard. 

Paraphilic Coercive Disorder (PCD) was initially proposed for inclusion in DSM-5 as a diagnosis that would be limited to men who preferred rape over consensual sex. Because only a very small percentage of rapists prefer rape over consensual intercourse (American Psychiatric Association, 1999), clinicians are unable to reliably apply this label (Wollert, 2011). This is one reason for the American Psychiatric Association's consistent rejection of rape-based paraphilias in three previous editions of the DSM (Zander, 2008). In the face of overwhelming opposition, the Subworkgroup has taken the fallback position of recommending PCD only for inclusion in the Appendix as a condition meriting "further study." However, this would confer an undeserved back-door legitimacy to the invalid construct. Rather than a mental disorder, rape is a crime for which the proper placement is prison. 

The proposed criteria for Hypersexual Disorder (HD) are the product of a recent ad hoc literature review by Martin Kafka, a member of the Subworkgroup. His review indicated their validity has not been empirically confirmed. Given the inherent difficulty in determining at what point a normal human drive becomes abnormal, it is not surprising that the proposed diagnosis is marred by conceptual confusion and vague verbal anchors (Moser, 2011). Its poor reliability and validity will translate to a high rate of false positives in both civil commitment trials and outpatient clinics that serve the community in general. With the proposal becoming a magnet for ridicule both by academic scholars and the popular press, it too has been relegated to the Appendix. However, the Appendix was not intended as a storage site for criteria sets that, like Hypersexuality Disorder, have never been tested. 

These three proposals all lack adequate empirical support. They will increase false positive diagnoses by labeling behaviors that are normative, developmental, or criminal as mental disorders. Promoting the misclassification of juveniles and other vulnerable populations as dangerous sex offenders, they will undermine the reputation of forensic practitioners and those who study sexual behavior. Collectively, professions that endorse the use of unreliable diagnoses run the risk of losing their credibility. 

The British Psychological Society, the American Counseling Association, and the Society for Humanistic Psychology and many other divisions of the American Psychological Association have all submitted petitions or letters of concern to the American Psychiatric Association regarding revisions proposed for the DSM-5. These documents express concerns about the lack of empirical support for many DSM-5 proposals, the likelihood of “false-positive epidemics” flowing from decreased diagnostic thresholds, and the negative effects of "over-medicalizing" human behavior. They also point out that the prevention of false-positive epidemics should take precedence over "nomenclatural exploration" and that the temptation to adopt new diagnoses should be tempered by the recognition that diagnostic labels tend to be confounded with normative social expectations. 

I share these concerns as they apply to sexual disorders. I further support the adoption of sexual disorder criteria sets only after they have been established to have high true positive rates and acceptable false positive rates. Therefore, I urge the DSM Task Force to remove the Hebephilia qualifier from the proposed diagnosis of Pedophilia, and to eliminate Paraphilic Coercive Disorder and Hypersexual Disorder from any inclusion in the DSM-5. 

Sincerely, 

CLICK HERE TO ADD YOUR NAME TO THE LETTER

(email your name and professional credentials to Dr. Wollert)

References 

American Psychiatric Association (1999). Dangerous sex offenders: A task forcereport of the American Psychiatric Association. Washington D. C.: American Psychiatric Association.

Ewing, C. P. (2011). Justice perverted: Sex offense law, psychology, and public policy. New York: Oxford University Press. 

Franklin, K. (2010). Hebephilia: Quintessence of diagnostic pretextuality. BehavioralSciences and the Law, 28, 751-768. 

Green, R. (2010). Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! [letter to the editor]. Archives of Sexual Behavior, 39, 585-586. 

Moser, C. (2011). Hypersexual Disorder: Just more muddled thinking [letter to theeditor]. Archives of Sexual Behavior, 40, 227-229. 

Wollert, R. (2011). Paraphilic Coercive Disorder does not belong in DSM-5 forstatistical, historical, conceptual, and practical reasons [letter to the editor]. Archives of Sexual Behavior, 40, 1097-1098. 

Wollert, R. & Cramer, E. (2011). Sampling extreme groups invalidates research on the Paraphilias. Behavioral Sciences and the Law, 29, 554-565. 

Zander, T. (2008). Commentary: Inventing diagnosis for civil commitment of rapists. The Journal of the American Academy of Psychiatry and the Law, 36, 459-469.

Hebephilia bites the dust -- again

  Federal judge rules that faux diagnosis cannot be basis for civil detention 

In yet another blow to those seeking to expand mental illness in order to civilly detain U.S. citizens for possible future crimes, a judge has again held that the faux diagnosis of  "hebephilia" is not valid for this purpose.The Good Friday ruling was one in a string of defeats for the federal government in its efforts to civilly detain ex-convicts under the Adam Walsh Act.

Judge Terrence Boyle rejected the testimony of two government psychologists who had diagnosed George Hamelin with hebephilia based on his sexual misconduct with one 13-year-old boy and another boy under the age of 13 (whose precise age was not specified).

Calvin Klein billboard: Fashion industry banking on hebephilia

As opposed to pedophilia, hebephilia involves sexual attraction to youths who have reached puberty. The controversial diagnosis was first proposed by a team of psychologists at a sex clinic up in Toronto. Two members of the Canadian team also belong to the sexual disorders work group for the DSM-5, the upcoming revision of the American Psychiatric Association’s influential diagnostic manual. With sexually violent predator statutes enacted by the federal government and 20 U.S. states requiring a mental disorder as a prerequisite for civil commitment, government evaluators have taken to invoking the label against sex offenders who are neither pedophiles nor rapists.

Wrote the judge in rejecting the label as a basis for civil commitment:

Hebephilia is not listed as an accepted mental disorder in the DSM-IV-TR. Although hebephilia has been proposed to be included as a mental disorder in the revision of the DSM, it has been rejected as a proper mental disorder by numerous psychologists…. [N]oted mental health professionals have opined that sexual arousal to pubescent and post-pubescent minors is not an inherently deviant sexual interest, albeit one that, in this country, if acted on might violate the law.

The Court finds persuasive the testimony of Dr. [Joseph] Plaud on this issue, who states in his report that "a possible diagnosis of a deviant sexual interest in pubescent/post-pubescent males, termed by some psychologists as 'paraphilia NOS hebephilia/ephebophilia,' ... is an invalid diagnosis."

Given that the characterization of hebephilia is a contested issue in the mental health community, the Court finds that it would be inappropriate to predicate civil commitment on a diagnosis that a large number of clinical psychologists believe is not a diagnosis at all, at least for forensic purposes.

I hope the American Psychiatric Association is listening. If they let the proposed diagnosis of pedohebephilia sneak into the DSM-5, it will only contribute to the already massive outpouring of criticism being leveled against them for expanding the range of mental illnesses. A grassroots petition protesting the diagnostic expansions has garnered almost 13,000 signatures to date.

My report on Judge Boyle's January ruling rejecting hebephilia in the case of Jeffrey Neuhauser (Federal judge tosses hebephilia as basis for civil detention) is HERE. My online resource page on hebephilia is HERE. Wikipedia has further background and links on the controversial diagnosis. A USA Today probe of the beleaguered federal SVP program is HERE.

New competency resources

Case report added to resources page

Thanks to colleague Denis Zavodny, who found this report on the web, I have added another competency case to the rogue's gallery. For those of you who don't know, this is a collection of publicly accessible resources on legal competencies that I put together some time back. For training purposes, I have found that it's hard to beat real-life reports and videos, especially from high-profile or otherwise fascinating cases.

 

The newest report is on Thomas A. Shay (bottom right photo, above), arrested in 1991 for a bomb blast that killed one Boston police officer and maimed another.  A Bridgeport State Hospital psychologist found nothing wrong with him other than a bad case of immaturity and self-centeredness.

CLICK HERE TO GO TO THE COMPETENCY RESOURCES PAGE 

New review of competency assessment tests

Marvin Acklin

The Journal of Personality Assessment has just published a handy overview of three competency assessment instruments. The report, by Hawaii forensic psychologist (and forensic psychology blogger!) Marvin Acklin, focuses on the psychometric properties of two tests that are fast becoming standards, as well as a newer test of response style that’s still on shakier ground.

Acklin describes the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA) and the Evaluation of Competency to Stand Trial–Revised (ECST-R) as indispensable to the forensic clinician's toolbox, a statement with which we would all likely agree. 

He especially lauds the MacCAT-CA, "the queen of CST instruments," because its vignette method enables us to drill down into the defendant's core reasoning skills, essential to decisional competency. The ECST-R, meanwhile, is most useful when the issue is psychosis and malingered psychosis. On the negative side, he points out, neither instrument provides sufficient sampling of basic legal knowledge, which must be ascertained through a detailed interview.

Acklin is less sanguine about the new Inventory of Legal Knowledge (ILK), developed to assess for malingered incompetency. Echoing Steve Rubenzer's astute critique in the Open Access Journal of Forensic Psychology, he notes concern about the its potentially high rate of false positives, or people falsely labeled as malingerers. This has been a concern of mine, too; the recommended cut score of 47 lends itself to overdiagnosis of malingering in adversarial settings.

The article, The Forensic Clinician's Toolbox I: A Review of Competency to Stand Trial (CST) Instruments, may be requested directly from the author (HERE).

"Mental Competency: Best Practices Model"

And since we're on the topic of competency resources, don't forget to check out the National Judicial College's newly launched website. It's got a lot to offer. My previous blog post on the site, with links to it, is HERE.

180-year sentence overturned over lack of mental health testimony

  Lawyer erred by not calling psychologist, appellate court holds   

A trial counsel’s failure to call a psychologist to testify at the sentencing hearing of a Missouri man with borderline intelligence constitutes reversible error, an appellate court has ruled.

The court upheld a trial court decision that the attorney's performance was deficient, and that the failure to present psychological evidence may have prejudiced the defendant.

A jury deliberated for just a little over an hour at the sentencing hearing of 24-year-old Skylor Radmer before recommending a prison sentence of 180 years. Earlier, the jury had convicted him of two counts of statutory sodomy for molesting his 5-year-old niece.

In upholding the lower-court ruling reversing the sentence, the Court of Appeals for the Western District of Missouri said that psychological testimony about Radmer's borderline intelligence might have resulted in a different outcome.

Radmer's attorney, Bert Godding, knew about Radmer's intellectual handicap because he had represented him in a prior case in which his comprehension of a police Miranda warning was at issue. In that case, he retained psychologist Bill Geis, who testified at an evidentiary hearing that Radmer was functioning at the borderline intellectual level, with an IQ score of 75.

At a hearing on the ineffective assistance claim, Dr. Geis testified that Radmer's low intelligence might have been relevant to explaining his sex offending as a product of poor judgment rather than pedophilia.

The trial attorney also testified at the hearing, admitting that he had no strategic reason for not calling a mental health expert to testify at the sentencing phase of the trial: "I don't believe that I necessarily had a reason not to or to do that," he testified. "I don't know why I didn't call someone like that."

The appellate court rejected the prosecution’s argument that the jury would have found Dr. Geis biased because he had worked for the public defender in the past. Geis is a research professor at the University of Missouri-Kansas City.

The defense lawyer's "failure to call Dr. Geis or a similar expert during the sentencing phase fell below an objective standard of reasonableness," the appellate court unanimously held.

Hat tip: Ken Pope

Damning reconstruction of notorious false confession case

Here's one from the annals of outrageous true crime cases:

On April 17, 1989, a woman was practicing tai chi in New York's Central Park, when a man sexually assaulted her. The rape was interrupted by a passerby who heard her yelling, but not before the woman was severely beaten to the point of requiring hospitalization. The woman gave police a detailed description of her attacker, including the fact that he had fresh stitches on his chin. Checking local hospitals, a detective found a match to an 18-year-old Puerto Rican man who worked nearby.

Mysteriously, the man was never questioned. The victim left town, the detective was transferred out of the sex crimes unit, and the case was closed as unsolved.

But as it turned out, this wasn't just one more rape in the Big Apple.

The East Side Slasher

The man escalated his attacks, terrorizing women in New York City. Dubbed the "East Side Slasher," he raped at least five other women and murdered one. His pattern was to beat or stab the women around the eyes, so they would not be able to identify him.

He was finally caught, when a woman broke free from him and alerted her doorman and a neighbor, who subdued him. Within hours, he had confessed on videotape to four rapes and the murder. With eyewitness identification and DNA evidence conclusively tying him to the crimes, he took a deal of 33 years to life.

Have you recognized this case yet?

While police knew that Matias Reyes was slashing and raping women around Manhattan's East Side during 1988 and 1989, there was one case they didn't think to link him to. That was the assault on Trisha Meili on April 19, 1989, as she was jogging in Central Park -- an assault that would quickly rivet the world.

Trisha Meili

In hindsight, it seems incomprehensible that Reyes was not a suspect. The crime fit his modus operandi, in that Meili was beaten most heavily around her eyes. The assault occurred just two days after the one on the tai chi practitioner, also in Central Park. And, most amazingly, a police officer who knew Reyes chatted with him as he strolled out of the park just minutes after Meili was raped and left for dead.

On his head, Reyes was wearing the victim’s distinctive headphones.

Reyes left his DNA behind. But police never thought to compare it to him. Not until more than a decade later, after he voluntarily confessed.

As we now know, police failed to consider Reyes as a possible suspect in the infamous Central Park Jogger case because they already had their suspects: A group of African American and Latino boys who were causing trouble in the park that night.

Sarah Burns

Through legal documents and myriad interviews (including with Matias Reyes), author Sarah Burns reconstructs this landmark miscarriage of justice, focusing on the role of racism in generating a collective hysteria that overwhelmed all reason: "Race not only inspired the extreme reactions to the crime; it also made it easier for so many to believe that these five teenaged boys had committed the crime in the first place, and no one was suggesting that they might, in fact, be innocent."

(Actually, a couple of intrepid columnists from New York Newsday, Jim Dwyer and Carol Agus, were expressing public doubts during the trial about the strength of the evidence connecting the youths to the crime, but their voices were not enough to turn the tide of public opinion. "We are waiting to see if there is any believable evidence that will connect these kids to the crime. So far, we haven't heard any," wrote Agus. And when referring to one of the youths' statement to police, both columnists placed quotation marks around the word confession, expressing skpeticism that it was authentic, Burns notes. Wrote columnist Dwyer, "nothing close to the words in this statement ... ever sat on the lips of a 14 and a half year old.")

Burns provides fascinating insights into the investigatory myopia that is so often present in false confession cases. Based on her access to the entire trial transcripts, she also critiques the weak defenses the boys received, which made their convictions all the more guaranteed. And she corrects much of the misleading mythology built up around the case. For instance, these boys were not the serious delinquents that the media portrayed them as, nor did most of them come from broken homes.

The first trial

Perhaps most amazing about this case is the vitriolic manner in which certain media outlets and high-profile people continue to insist that the boys are guilty, despite all evidence to the contrary. I hope this excellent historical reconstruction may help to set the record straight. I'm also looking forward to the documentary, which Burns is now working on with her father, filmmaker Ken Burns.

My Amazon review of The Central Park Five: A Chronicle of a City Wilding, is HERE. (If you like it, please click "yes," this review was helpful.) 

POSTSCRIPT:  You've read (or at least read about) the book; now see the movie. The Central Park Five just premiered at a special screening in Cannes. National broadcast on PBS is planned for 2013 or 2014. Meanwhile, the filmmakers -- who include book author Sarah Burns, her father Ken Burns and David McMahon -- are angling for a theatrical release. The Hollywood Reporter has the Cannes review (HERE).

'Case of the missing militant' resolved

Attorney Paul Harris
reads from  To Kill A Mockingbird.*
Photo credit: San Jose Mercury

A quick update on the case of Ronald Bridgeforth, the man I blogged about who turned himself in on shooting charges after 42 years underground: A judge in San Mateo County imposed a very reasonable sentence of one year in county jail. The judge also ordered Bridgeforth to work with at-risk youth in Alameda County (Oakland), California upon his release. That should be no problem for the 67-year-old former militant, who has dedicated his  life to public service.

My original post, Predicting behavior: The case of the missing militant, is HERE.The San Mateo Times and The Daily Mail (UK) have more on the sentencing. A San Jose Mercury slide show is HERE.

*I don't know what passage from To Kill A Mockingbird the defense attorney was reading from at the sentencing hearing, but I am curious.