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.

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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."

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.

Multiple personality excluded in Texas insanity case

A serial rapist’s attempt to claim insanity based on multiple personality disorder fell flat, as a judge ordered the expert's trial testimony stricken from the record as junk science.

Billy Joe Harris

Psychiatrist Colin Ross testified that Billy Joe Harris, the so-called "Twilight Rapist" who targeted elderly women, suffered from multiple personality disorder -- now known as dissociative identity disorder (DID) -- brought on by childhood abuse.

Ross, who runs the Colin A. Ross Institute that provides trainings on psychological trauma and dissociative identity disorder, testified that the condition’s presence in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association establishes it as a "real and valid disorder."

Ross testified that he gave the defendant three tests for DID. However, in a most unusual procedure, rather than personally administering the tests, he gave them to the defense attorney to administer. Thus, he has no way of knowing for sure who filled in the tests, or under what circumstances. 

Ross testified that the defendant's scores on a screening test, the Dissociative Experiences Scale, were so high that he questioned the test's validity. He also conceded that the defendant was "clearly telling stories that are not true" about other aspects of his life, for example falsely claiming to have served in Iraq when he was actually in Saudi Arabia. However, Ross testified that after getting a chance to talk personally with one of Harris's alters, "Bobby," he was convinced of Harris's claim of multiple personalities.

"I don't think he's faking the dissociative identity disorder," he testified. "I could be wrong."

The real culprit, David the Dog

The defendant, a former prison employee, also took the witness stand, "weaving tales of bestiality, aliens, transvestites and combat heroism," in the words of news reporter Sonny Long. Harris testified that he had three other personalities inside him, including a black Great Dane named David who committed the rapes.

A dramatic moment came during cross-examination, when prosecutor Bobby Bell asked to speak to the defendant's alter, also named Bobby. As Long described the scene:

Harris lowered his head momentarily, raised it back up, rolled his neck and declared in a deep voice to be "Bobby."

Several jurors stifled laughter during the subsequent give-and-take between Harris and Bell, according to Long's account in the Victoria Advocate.

But perhaps even more damaging to Harris's credibility was an audiotape played for the jury in which he talks to his girlfriend about having put on "a good show" in court one day. Earlier that day, he had fallen to the floor and twitched and shook until he was restrained. The girlfriend warned Harris that the telephone call was being recorded, to which Harris replied, "I know it."

Forensic psychologist Walter Quijano also testified for the defense. (If the name sounds familiar, he has been in the spotlight for using race as a risk factor in death penalty cases, as I recently blogged about.) He testified that when multiple personality popped up as an issue, he stepped back because that is not an area of expertise for him. However, he did testify that it is unusual for someone to begin a rape career so late in life. Harris is 54.

Mere presence in DSM doesn’t establish validity

After the defense rested, the prosecution called as a rebuttal witness a Minnesota psychologist and attorney who has made a crusade out of pushing so-called "junk science" out of the courts.

Robert Christopher Barden testified that dissociative identity disorder (aka multiple personality disorder) is a controversial condition looked upon with skepticism by the scientific mainstream. He cited several articles rejecting the condition as a viable diagnosis, despite its presence in the DSM.

"Because something is in the DSM doesn't mean it's reliable or should be allowed in a court of law," he testified, according to an article in the Victoria Advocate. "One of the ways to get junk science out of the legal system is you rely on the relevant scientific community. If something is controversial it means it's not generally acceptable."

Barden said the number of mental health professionals who tout dissociative identity disorder as viable are few and far between.

"There are a few pockets of people left who are doing this," he said. "The scientists I know condemn it to be the worst kind of junk science and dangerous to the public. Controversial and experimental theories should not be allowed to contaminate the legal system."

Concerning the tests given to Harris, Barden said, "There's no magic to these tests. It looks scientific. It looks professional, but when you get down into it, it's junk. It's unusual for a psychiatrist to interpret a psychological test and it's highly unethical for Mr. Cohen [the defense attorney] to give the tests."

After Barden’s testimony that the condition is not generally accepted by the scientific community, despite the fact that it is listed in the DSM, District Judge Skipper Koetter ordered Dr. Ross’s testimony on dissociative identity disorder stricken from the record.

Justice, Texas-style

In the end, the defendant’s overdramatization and courtroom theatrics likely did him in. During the trial, he trembled and twitched and sat in the courtroom with paper stuffed in his ears, which his attorney said was “to keep the voices from speaking to him."

The jury took only 10 minutes to convict Harris, and another 10 minutes later in the month to sentence him to life in prison.

After the verdict, Barden said in a press release that the outcome demonstrates “the power of science-law teams in protecting the legal system from junk science testimony."

Barden has been involved in hundreds of lawsuits, criminal prosecutions and licensure actions across the United States over the past two decades, targeting not only multiple personality disorder but also quack therapists in the repressed memory and rebirthing therapy movements.

Judge Koetter's ruling is not the last word, of course, as it is just one trial judge's opinion. Appellate courts in other states have ruled differently. For example, in the 1999 case of State v. Greene (139 Wn. 2d 64), the Washington Supreme Court held that dissociative identity disorder was a generally accepted diagnosis because it was listed in the DSM-IV, and therefore met the Frye test for admissibility. But the Court went on to say that the applicability of this diagnosis to the issue of criminal responsibility was problematic and that testimony about DID was not "helpful" to the jury. (The Trowbridge Foundation has more information on this case HERE.)

The battle lines over dissociative identity disorder have heated up in the dozen years since that ruling, so who knows how an appellate court might rule today.

For those interested in learning more about the controversy, I recommend the chapter "Dissociative Identity Disorder: Multiple Personalities, Multiple Controversies" by Scott Lilienfeld and Steven Jay Lynn, in their book, Science and Pseudoscience in Clinical Psychology.

Sex offender roundup

So much being generated on the sex offender front that it's hard to keep up. Here, in no particular order, are just a few choice items:

The Atlantic: Overzealous sex offender laws harm public

As the tide begins to turn, The Atlantic magazine has joined the backlash, with a well-written and insightful piece by associate editor Conor Friedersdorf that begins like this:

On the Texas registry for sex offenders, Frank Rodriguez's crime is listed as "sexual assault of a child." If I lived in his neighborhood and had young children, I'd be frightened upon seeing that. Safe to assume that some of his neighbors discovered his status and became alarmed. Needlessly so, as it turns out. Delving into his story, journalist Abigail Pesta has discovered that Rodriguez was arrested for having sex with his high school girlfriend. He was 19. She was 15. They've now been happily married for years, and he has fathered four girls.

The anecdote is part of a larger story about America's sex offender registries and the people on them who don't belong there. It's a timely subject. This month, some state governments are racing to bring themselves into compliance with the Adam Walsh Child Protection and Safety Act in order to avoid losing federal funds. As a result, the sex offender dragnet may pull in even more people. Says Pesta, "Each of the 50 states now has at least one grassroots group dedicated to getting young people -- many high school age, but some under the age of 10 -- off the registry."

So perhaps the backlash will grow too.

The article continues HERE.

Juvenile registries harmful, study finds

Dovetailing nicely with the Atlantic piece, a leading researcher and national expert on sex offender policy has found that placing the names of juveniles on sex offender registries does nothing to make society safer, and has harmful unintended effects on youth and on juvenile case processing.

Based on her research, Elizabeth Letourneau of the Medical University of South Carolina is calling for an end to notification requirements for juveniles.

A summary of her research is HERE.

California releases audit of SVP program

The State Auditor’s Office has issued its long-awaited report on the practical implementation of California’s civil commitment scheme for sex offenders. It isn’t as hard-hitting as I would have liked, but there are a few interesting tidbits.

One I found interesting was the statistic that out of all of the sex offenders who were NOT civilly committed and who were released into the community between 2005 and 2010, only ONE was later convicted for a new sexually violent offense. Talk about a low base rate!

The report also details the program’s meager bang for the buck. From 2005 to 2010, the state paid nearly $49 million in evaluation costs alone to a small group of privately contracted evaluators. Some of these psychologists earned upwards of $1 million per year. And for what return? Last year, the SVP program screened 6,575 prisoners for possible civil commitment. And guess how many were committed? THREE (much less than 1 percent)!

Just think about how much primary prevention work to reduce sexual violence all of those waste millions could have funded.  

The full report is online HERE.

More on the social costs of civil detention 

Unlike the California auditors, who seem to have bought into the promise of the Static-99 as an “actuarial” technique capable of predicting future behavior, law professor Tamara Rice Lave of the Miami School of Law has just published an article in New Criminal Law Review claiming that the Static has little utility in SVP determinations not only because it is inaccurate, but also because it does not link dangerousness to mental illness as U.S. laws require. Here is the abstract of her article, “Controlling Sexually Violent Predators: Continued Incarceration At What Cost?”

Sexually violent predator (SVP) laws are inherently suspicious because they continue to incarcerate people not because of what they have done, but because of what they might do. I focus on three major criticisms of the laws. First, I use recent recidivism data to challenge the core motivation for the SVP laws—that sex offenders are monsters who cannot control themselves. Second, I situate the laws theoretically as examples of what Feeley and Simon call the “new penology.” I argue that the SVP laws show the limited promise of the new penology—that we can use science to predict risk accurately—because the actuarial instruments used in SVP determinations make many mistakes. In making this argument, I focus particularly on the most commonly used such instrument, the Static-99. Finally, I argue that the Static-99 fails to meet the constitutional criteria laid out by the U.S. Supreme Court in Kansas v. Hendricks because it does not link an individual’s mental illness to his dangerousness.

Her full article is available online HERE.

Government SVP reports off target, says Allen Frances

Allen Frances, the chair of the DSM-IV Task Force, has been dabbling with SVP cases as an expert witness for the past year. After reviewing almost 100 cases, he is  – to put it mildly – under-impressed by the reports of government experts:

In not one case did the sexual offender qualify for anything remotely resembling a DSM-IV diagnosis of Paraphilia. And this is in an enriched sample of offenders who have been carefully screened and are presumed to have Paraphilia. Certainly state evaluators are wildly over-diagnosing Paraphilia and the courts are sanctioning unjust psychiatric incarceration based on their misguided opinions.

The evaluators all misinterpreted DSM-IV in just the same way. They routinely equate the act of committing a sex crime with having a mental disorder. Their reports gave remarkably detailed descriptions of the offender's criminal behavior, but provide little or no rationale or justification for a diagnoses of Paraphilia. The write-ups are all long and thorough -- but completely off point and generic. Although written by dozens of different evaluators, they have a rote quality and all repeated exactly the same mistakes.

His full post, at his “Couch in Crisis” blog at the Psychiatric Times, is HERE.

Is porn "driving men crazy"?

Last but not least, the prolific and insightful blogger Vaughan Bell deconstructs a CNN article by social crusader Naomi Wolf, who claims that pornography is “rewiring the male brain” and “causing [men] to have more difficulty controlling their impulses.”

According to her article, … “some men (and women) have a 'dopamine hole' – their brains’ reward systems are less efficient – making them more likely to become addicted to more extreme porn more easily.”

Wolf cites the function of dopamine to back up her argument and says this provides “an increasing body of scientific evidence” to support her ideas.

Porn is portrayed as a dangerous addictive drug that hooks naive users and leads them into sexual depravity and dysfunction. The trouble is, if this is true (which by the way, it isn’t, research suggests both males and females find porn generally enhances their sex lives, it does not effect emotional closeness and it is not linked to risky sexual behaviours) it would also be true for sex itself which relies on, unsurprisingly, a remarkably similar dopamine reward system.

Furthermore, Wolf relies on a cartoon character version of the reward system where dopamine squirts are represented as the brain’s pleasurable pats on the back....

The full post is HERE.

And after all of this if you're still in the mood for further browsing, I highly recommend the wide-ranging Mind Hacks blog; the topics are always fascinating (at least to me).

Psychiatry rejects new rape disorder for DSM-5

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

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

"Important message"

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

Dr. Allen Frances

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

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

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

Exclude coercive paraphilia from appendix

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

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

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

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

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

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

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

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

Related posts:

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

Global alarm mounts: "Will anyone be normal?"

What do some of the world's top mental health experts have in common with best-selling British author Sir Terry Pratchett, the former prime ministers of Australia and Norway, and Kurt Vonnegut Jr.'s son, memoirist Mark Vonnegut? All are issuing calls of alarm over the DSM-5, the American Psychiatric Association's upcoming diagnostic manual, in a special issue of the Journal of Mental Health.

Due to their important public policy implications, the Journal is making the lineup of commentaries available to the public for free. In a press release, the Journal points out that the previous DSM revision led to a wave of false "epidemics" of such conditions as attention deficit hyperactivity disorder, autistic disorder, childhood bipolar disorders, and that the new edition may lead to more of the same.

"The publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is one of the most highly anticipated events in the mental health field," explains Managing Editor Daniel Falatko. "This is the first major rewrite of DSM in 16 years and history has warned us that even small changes to this manual can have extraordinary repercussions in the diagnosis and treatment of mental health issues."

The theme running throughout the special issue is widespread fears in the psychiatric community that the expansion of diagnostic guidelines will allow everyone to qualify for psychiatric disorders, which in turn will lead to greater prescription of psychiatric drugs, many of which have unpleasant and dangerous side effects.

At a joint briefing, mental health experts expressed particular fear over the proposed "psychosis risk syndrome" diagnosis, which could falsely label young people who may only have a small risk of developing an illness.

"It’s a bit like telling 10 people with a common cold that they are 'at risk for pneumonia syndrome' when only one is likely to get the disorder," said Dr. Til Wykes of the Institute of Psychiatry at Kings College London.

The free articles, some by psychiatric patients, include:

• Diagnosis, diagnosis, diagnosis: towards DSM-5 by Til Wykes and Felicity Callard
• Are psychiatric diagnoses of psychosis scientific and useful? The case of schizophrenia by Jim Van Os
• Misdiagnosing normality: Psychiatry's failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment by Jerome C. Wakefield
• DSM-V and the stigma of mental illness by Dror Ben-Zeev, Michael A. Young, and Patrick W. Corrigan
• Conceptualisation of mental disorder and its personal meanings by Derek Bolton
• Patients can diagnose too: How continuous self-assessment aids diagnosis of, and recovery from, depression by Peter C. Groot
• Diagnosing Clapham Junction syndrome by Terry Pratchett
• What my diagnosis means to me by Mike Shooter
• Depression and recovery by Sarah Mitchell
• Personal Reflections on Diagnosis by Mark Vonnegut
• On the impact of being diagnosed with schizophrenia by Frederick J. Frese
• Tackling Depression by Geoff Gallop
• Psyche, soma, and science studies: New directions in the sociology of mental health and illness by Martyn D. Pickersgill

Related news articles:

• Globe and Mail (UK): Mental health experts ask: Will anyone be normal? Binge eating, temper tantrums may become new diagnoses
• BBC News: Mental health: are we all sick now?

I have blogged extensively about the controversies surrounding the DSM-5. These prior blog posts can be conveniently accessed HERE.

Hat tip: Jane

Rape as psychiatric illness: Battle heats up

Prosecutor lobbying for new diagnosis

Even after writing and teaching about the pretextual use of psychiatric diagnosis for legal purposes, I found this one jaw-dropping:

The committee tasked with revising the sexual disorders in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) includes a prosecutor who specializes in prosecuting sex offenders as an invited advisor.

The prosecutor, Paul Stern of Washington, is now lobbying for a new psychiatric disorder for rapists, something that was considered and rejected from an earlier DSM. In an upcoming article in the Archives of Sexual Behavior, he reassures readers that creating this new "Paraphilic Coercive Disorder" would not increase the number of men involuntarily detained as Sexually Violent Predators. Au contraire: It would reduce the number of SVP commitments by improving diagnostic precision.

Stern lambastes psychologists and psychiatrists for engaging in "dangerous" legal analysis, while in the next breath asserts that he knows better than scientists about the validity of a psychiatric diagnosis for rapists! He dismisses concerns about the reliability and validity of the proposed diagnosis from two leading scientists, Raymond Knight and Vernon Quinsey. Likewise, he dismisses as an ideologue Dr. Allen Frances, psychiatry professor emeritus at Duke University and chair of the DSM-IV Task Force.

This article certainly did not seem good evidence of psychiatry as objective, value-neutral science, as Stern argues it should be.

Frances critiques "Paraphilia NOS"

Dr. Frances, meanwhile, continues to sound the alarm over poorly thought out diagnostic proposals for the DSM-5. His concerns arose out of his experience heading up the DSM-IV revision process. Witnessing the many unintended consequences of diagnostic expansion, such as epidemic stigmatization of children, he now regrets that he did not more carefully examine the reliability and validity of proposed diagnoses before approving them for inclusion.

In this week's Psychiatric Times, Frances squarely tackles the creation of psychiatric labels to justify the involuntary detention of criminal rapists.

The most disturbing turbulence at the boundary between psychiatry and the law is the misuse of a makeshift psychiatric diagnosis (“Paraphilia Not Otherwise Specified, nonconsent”) to justify the involuntary, indefinite psychiatric commitment of rapists. This is a disguised form of preventive detention (often for life), a violation of due process, and an abuse of psychiatry. The mental health professions have been placed in the position of providing a dangerous fig leaf to cover an unfortunate correctional gap created by fixed sentencing….

The Supreme Court has chosen to dance around the legal definition of a qualifying mental disorder. It has left this critical question up to the inconsistent and largely uninformed discretion of each lower court. This has led to huge confusion and very questionable practice. Many evaluators in SVP hearings have been led astray by a complete misunderstanding of the intent of the DSM-IV. They have applied the essentially made-up diagnosis ... to justify the psychiatric commitment of rapists who without this "diagnosis" would be regarded as no more than common, if particularly heinous, criminals….

This paradoxical gulf between the original intention of DSM-IV and SVP forensic evaluator misinterpretation of it leads to great confusion in the handling of expert mental health testimony in individual cases. The diagnosis "Paraphilia NOS, nonconsent" is clearly misguided -- almost always incorrect and inappropriate in forensic proceedings, but it has been accepted by enough mistrained "experts" to have acquired a patina of undeserved respectability that may (in a perverse self fulfilling prophecy way) lead to its acceptance.

Wisconsin exemplar: Bartow v. McGee

Frances urged the U.S. Supreme Court to hear the appeal of convicted rapist Michael McGee in order to clarify this issue. McGee's civil commitment rested on two contested diagnoses, "Paraphilia Not Otherwise Specified-Nonconsent" and "Personality Disorder Not Otherwise Specified."

McGee argued in his appeal that these "NOS" diagnoses are "bogus," invented by government psychologists to justify the continued confinement of men like him after they have completed their criminal sentences. He pointed out that the diagnosis of Paraphilia NOS-Nonconsent represents a minority fringe viewpoint that was specifically rejected by mainstream psychiatry.

In its Jan. 27, 2010 decision, the Seventh Circuit Court of Appeals used tortured logic to reject McGee's appeal:

We must inquire only whether the diagnosis was so patently lacking in credibility and validity that its consideration by the factfinder in the Wisconsin courts resulted in a denial of constitutional rights…. We cannot conclude that the diagnosis of a rape related paraphilia is so empty of scientific pedigree or so near-universal in its rejection by the mental health profession that civil commitment cannot be upheld as constitutional when this diagnosis serves as a predicate.

This case represents a perfect opportunity for the U.S. Supreme Court to clarify the nature of a "mental disorder" that justifies civil detention, Frances wrote:

The Court should resist the great temptation to continue to dodge this thorny, but basic, constitutional rights issue.... The Supreme Court must step up to the plate and provide clarity about what qualifies legally as a mental disorder in I was responsible for writing the final version of Paraphilia section in DSM-IV) that the diagnosis "Paraphilia NOS, nonconsent" is indeed 'patently lacking in credibility or validity' and is 'empty of scientific pedigree.' But I cannot argue that it is 'near universal in its rejection by the mental health profession' SVP commitments.

Lower courts have faced a peculiar difficulty in interpreting expert testimony in SVP cases. The wording used by the appeals court in the McGee case clearly illustrates the problem. I would argue (with some authority sincebecause a sizable segment of the community of SVP evaluated have been mistrained into believing that "Paraphilia NOS, nonconsent" is a valid DSM-IV diagnosis.

Clearly, the Supreme Court should accept McGee for review and dispel confusion on what constitutes a mental disorder in SVP cases. McGee is a perfect test case raising a crucial constitutional question that should not be decided haphazardly and inconsistently based a basic misunderstanding of psychiatric diagnosis.

Frances's plea was published a little late. On June 7, the U.S. Supreme Court declined to hear the case.

If prosecutor Stern gets his way, the Paraphilia NOS-Nonconsent controversy will be moot, as the DSM-5 (due out in three years) will include the more legitimate-sounding twin, Paraphilic Coercive Disorder. But the DSM-5 task force may be shooting itself in the foot by publicly aligning itself with a partisan advocate. If an SVP defense attorney had co-authored the opinion piece with Stern, it might appear less partisan and, by implication, pretextual.

To put that in scientific terms, if lobbyists look at least superficially nonpartisan, their claims of scientific legitimacy for this new disorder might have more face validity. Which, as we know, is still a far cry from construct validity.

The abstract of Mr. Stern's article, "Paraphilic Coercive Disorder in the DSM: The Right Diagnosis for the Right Reasons," is HERE, along with contact information if you want to request the full article.

Dr. Frances' article in Psychiatric Times, Rape, Psychiatry, and Constitutional Rights -- Hard Cases Make For Very Bad Law, is HERE. (You must first register, but it's free and easy.)

Related blog posts:

Scientist razes proposed "Paraphilic Coercive Disorder" (Nov. 6, 2009 blog post explaining scholar Raymond Knight's position on this diagnosis - RECOMMENDED)

Fed court OK's unorthodox diagnoses for sex offenders

Graphics credit: DSM-5 (a Spanish punk rock band!)

"DSM-5 and sexual disorders: Just say no"

Psychology urged to oppose psychiatric monopoly

When one introduces new chickens into an existing flock, the flock establishes a pecking order. The older birds peck the new ones into submission. With lower status, the new birds feel -- to anthropomorphise a bit -- inferior.

That's what happened when the upstart field of psychology pushed its way into the bastions of psychiatry. Psychiatrists bristled at the intrusion. Psychologists of necessity submitted to psychiatric authority. Now, years later, psychologists vastly outnumber higher paid psychiatrists in many mental health niches, but as a profession we still have an inferiority complex. Thus, we let a single psychiatric association in the United States dictate how mental functioning and impairment are conceptualized.

As the chorus of critical voices over the American Psychiatric Association's poorly drawn draft DSM-5 manual grows ever louder, some are urging psychology to issue a formal opposition paper. For example, Stephen Diamond, a clinical and forensic psychologist in Los Angeles, writes in Psychology Today that our profession's apathy "is a big part of the problem":

While clinical psychology has to some extent leaped onto this same biological bandwagon driven by contemporary psychiatry, seeking prescription privileges, some psychologists and other non-medical mental health professionals have practically written off the value and importance of psychodiagnosis today -- in part precisely due to its inherent medicalization, biological bias, dehumanizing labeling, and notorious inaccuracy…. [I]t is time for the leadership of the American Psychological Association to take a far more active and public role in the revision and direction of the DSM-5…. What, if anything, [is] the American Psychological Association is doing about DSM-V? Or about the hypermedicalization of psychology?

Allen Frances, the psychiatrist who chaired the DSM-IV task force, has become one of the most vocal critics of the manual's proposals. He too is calling on organized psychology to step up before it is too late. Taking his campaign directly to psychology and the general public, he hosts a "DSM5 in distress" column in the popular magazine Psychology Today that shines a spotlight by turn on various problematic aspects of the draft manual. In his recent call for an organized response from psychology, he writes that:

the American Psychiatric Association (APA) came to hold the DSM franchise only by historical accident…. Now that the DSMs have attained such importance, there have been repeated questions about the appropriateness of its continued sponsorship by more than just one professional organization…. The numerous problems that have bedeviled the development of DSM5 again raise the question whether the American Psychiatric Association should be sole steward of an official diagnostic system that impacts on all mental health disciplines…. Individual psychologists and the professional associations within psychology can play an important role in pointing the way forward for DSM5 and in protecting it from costly mistakes.

Perilous forensic consequences

Frances is increasingly focusing on the monumental potential for negative and unintended consequences in the forensic realm of the proposed changes:

The most obviously detrimental suggestions are in the paraphilia section, where the proposed change to the definition of paraphilia and the likely suggestion to introduce a new diagnosis of "paraphilic coercive rapism" will greatly compound the significant mischief already initiated by a seemingly trivial change in DSM-IV. More generally, even small changes in wording can result in large forensic confusion once parsed by lawyers in their peculiarly rigorous and tendentious fashion. The wording of every suggested option in DSM5 needs careful review by forensic experts.

"DSM-5 sexual disorders make no sense"

In a more recent column, Frances specifically targets the Big 3 sexual disorders that I have extensively blogged about. Of all of the DSM-5 work groups, he writes:

the Sexual Disorders Work Group has strayed furthest off the reservation. It has made a series of radical and dangerous suggestions that need to be dropped.... Each of the Work Group's suggestions is based on the thinnest of research support-usually a handful of studies often done by members of the committee making the suggestion. None has been subjected to, or could possibly survive, anything resembling a serious risk/benefit or forensic analysis.

As he points out, there are few researchers and little good research on sexuality. Consensus on the bounds of "normalcy" does not exist, and cultural bias plays a major role in what is defined as pathological (a point cogently made by Richard Green in his critique of the proposed hebephilia diagnosis). Especially important for my readers, "decisions regarding the diagnosis of sexual disorders can have profound and unanticipated forensic ... implications."

Regarding the three paraphilia proposals that will have the most impact in civil commitment proceedings in the United States, Frances had the following to say:

"Paraphilic Coercive Disorder"

This proposal was explicitly rejected for DSM IIIR and was given no serious consideration for DSM IV. The problem is the impossibility of reliably distinguishing between the small group of hypothesized "paraphilic" rapists (who would be given a mental disorder diagnosis) and the much larger group of rapists who are simple criminals.

The distinction has taken on huge significance because [of] SVP statutes mandating indefinite (usually in practice lifelong) inpatient civil psychiatric commitment for individuals who have (1) completed their prison sentence for a sexually violent crime, (2) have a diagnosed mental disorder, and (3) are deemed likely to repeat.... Although the SVP statutes have twice passed Supreme Court tests, they rest on questionable constitutional grounds and may sometimes result in a misuse of psychiatry.

Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis -- Paraphilia Not Otherwise Specified -- has become a frequent justification for the psychiatric commitment of rapists who are really no more than simple criminals. Raising this diagnosis to official status would greatly compound this misuse of civil psychiatric commitment.

"Hypersexuality Disorder"

This is the strangest of constructs.... The fundamental problem with "hypersexuality" is that it represents a half baked, poorly conceptualized medicalization of the expected variability in sexual behavior.... The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive -- but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire. Making an official mental disorder category of "hypersexuality" would also have serious unintended forensic consequences inthe evaluations of sexually violent predators (SVP).

"Pedohebephilia"

This new category would extend the traditional definition of Pedophilia ... to include pubescent teenagers. Clearly, sex with underage teenagers is reprehensible and deserves appropriate punishment under the penal code. It is, however, anything but clear when (and if) sexual behaviors with teenagers should qualify as a mental disorder. This diagnosis would be subject to the same misuses in SVP cases as has been described above.

With such widespread and vigorous opposition, it's hard to imagine these nutty proposals slipping into the DSM-5. But, stranger things have happened in the field of psychiatry.

Related article:

DSM-5 and "Psychosis Risk Syndrome": Not Ready For Prime Time
Dr. Frances' latest piece, in Psychiatric Times, is on Psychosis Risk Syndrome, one of the scariest diagnostic proposals. If adopted, it would likely lead to a wave of false-positive errors in which teenagers are wrongly identified as future schizophrenics and placed on dangerous antipsychotic medications.

Hat tips: Ken Pope, Andrew H.
Graphics credit: Raul Crimson (Creative Commons license 2.0)