California high court upholds parolee confidentiality right

Two years ago, I reported on a California appellate opinion upholding the sacredness of patient-therapist confidentiality even for convicted felons who are mandated to treatment as a condition of parole. Today, the California Supreme Court upheld the gist of the ruling -- but with a proviso. Using strained logic, the court held that the breach of confidentiality was not so prejudicial as to merit overturning Ramiro Gonzales's civil commitment, as the Sixth District Court of Appeal had done.

Gonzales is a developmentally disabled man whose therapist turned over prejudicial therapy records to a prosecutor seeking to civilly detain him as a sexually violent predator (SVP). Forensic psychology experts Brian Abbott and Tim Derning testified for the defense; called by the prosecution were psychologists Thomas MacSpeiden and Jack Vognsen.

As I wrote two years ago, the ruling is good news for psychology ethics and should serve as a reminder that we are obligated to actively resist subpoenas requesting confidential records of therapy.

Today's California Supreme Court ruling is HERE. My prior post, with much more detail on the case, is HERE. The Sixth District Court of Appeal opinion from 2011, available HERE, provides a nice overview of both federal and California case law on confidentiality in forensic cases.

 

Hat tip: Adam Alban

Related blog posts:  

• Do sex offenders have right to confidential therapy? (Feb. 22, 2008)

• Confession to prison psychiatrist not confidential (Dec. 11, 2007)

• Treating therapist as police interrogator (Nov. 30, 2008)

• Abandon ethics, all ye who enter here: Special ethics exemption sought for SVP work (Oct. 6, 2010)

Upcoming forensic training opportunities

American Psychology-Law Society, March 7-9

For those of you planning to attend the American Psychology-Law Society conference in Portland Oregon on March 7-9, early-bird registration ends on February 1. This year’s lineup is very exciting. The conference website is HERE; details on the March 8 symposium that I will be chairing, "Emergent controversies in civil commitment evaluations of sexually violent predators” (as well as the pre-conference continuing education lineup) are HERE. 

Juvenile sex offender training, Feb. 11

Coming right up at the Institute of Law, Psychiatry, and Public Policy in Charlottesville, Virginia is an advanced training on “Understanding and Treating Juvenile Sexual Offenders.” The presenter is nationally recognized expert John Hunter. Details are HERE.

Ethics in forensic practice training, May 3

Later in the spring, the Institute is offering another advanced workshop by nationally recognized presenter Alan Goldstein. Topics include competence to practice; confidentiality; roles of the expert; issues in assessment; responding to subpoenas; release of raw test data; report writing; and ultimate opinion testimony. The emphasis is on reducing the likelihood of potentially damaging cross-examination, ethics complaints and malpractice actions. Attendees are encouraged to prepare, in advance, a problem they encountered in their practice and submit it at the start of the workshop for review and possible discussion. More information is HERE.

Judge bars Static-99R risk tool from SVP trial

Developers staunchly refused requests to turn over data

For several years now, the developers of the most widely used sex offender risk assessment tool in the world have refused to share their data with independent researchers and statisticians seeking to cross-check the  instrument's methodology.

Now, a Wisconsin judge has ordered the influential Static-99R instrument excluded from a sexually violent predator (SVP) trial, on the grounds that failure to release the data violates a respondent's legal right to due process.

The ruling may be the first time that the Static-99R has been excluded altogether from court. At least one prior court, in New Hampshire, barred an experimental method that is currently popular among government evaluators, in which Static-99R risk estimates are artificially inflated by comparing sex offenders to a specially selected "high-risk" sub-group, a procedure that has not been empirically validated in any published research. 

In the Wisconsin case, the state was seeking to civilly commit Homer Perren Jr. as a sexually dangerous predator after he completed a 10-year prison term for an attempted sexual assault on a child age 16 or under. The exclusion of the Static-99R ultimately did not help Perren.  This week, after a 1.5-day trial, a jury deliberated for only one hour before deciding that he met the criteria for indefinite civil commitment at the Sand Ridge Secure Treatment Center.*

Dec. 18 note: After publishing this post, I learned that the judge admitted other "actuarial" risk assessment instruments, including the original Static-99 and the MnSOST-R, which is way less accurate than the Static-99R and vastly overpredicts risk. He excluded the RRASOR, a four-item ancestor of the Static-99. In hindsight, for the defense to get the Static-99R excluded was a bit like cutting off one's nose to spite one's face.

The ruling by La Crosse County Judge Elliott Levine came after David Thornton, one of the developers of the Static-99R and a government witness in the case, failed to turn over data requested as part of a Daubert challenge by the defense. Under the U.S. Supreme Court's 1993 ruling in Daubert v. Merrell Dow Pharmaceuticals, judges are charged with the gatekeeper function of filtering evidence for scientific reliability and validity prior to its admission in court.

Defense attorney Anthony Rios began seeking the data a year ago so that his own expert, psychologist Richard Wollert, could directly compare the predictive accuracy of the Static-99R with that of a competing instrument, the Multisample Age-Stratified Table of Sexual Recidivism Rates," or MATS-1. Wollert developed the MATS-1 in an effort to improve the accuracy of risk estimation by more precisely considering the effects of advancing age. It incorporates recidivism data on 3,425 offenders published by Static-99R developer Karl Hanson in 2006, and uses the statistical method of Bayes's Theorem to calculate likelihood ratios for recidivism at different levels of risk.

The state's attorney objected to the disclosure request, calling the data "a trade secret."

Hanson, the Canadian psychologist who heads the Static-99 enterprise, has steadfastly rebuffed repeated requests to release data on which the family of instruments is based. Public Safety Canada, his agency, takes the position that it will not release data on which research is still being conducted, and that "external experts can review the data set only to verify substantive claims (i.e., verify fraud), not to conduct new analyses,"  according to a document filed in the case.

Thornton estimated that the raw data will remain proprietary for another five years, until the research group finishes its current projects and releases the data to the public domain.

While declining to release the data to the defense, Hanson agreed to release it to Thornton, the government's expert and a co-developer of the original Static-99, so that Thornton could analyze the relative accuracy of the two instruments. 

The American Psychological Association's Ethics Code requires psychologists to furnish data, after their research results are published, to "other competent professionals who seek to verify the substantive claims through reanalysis" (Section 8.14).

At least three five researchers have been rebuffed in their attempts to review Static-99 data over the past few years, for purposes of research replication and reanalysis. As described in their 2008 article, Hanson's steadfast refusals to share data required Wollert and his colleagues, statisticians Elliot Cramer and Jacqueline Waggoner, to perform complex statistical manipulations to develop their alternate methodology. (Correspondence between Hanson and Cramer can be viewed HERE.) Hanson also rejected a request by forensic psychologists Brian Abbott and Ted Donaldson; see comments section, below.


Since the Static-99 family of instruments (which include the Static-99, Static-99R, and Static-2000) began to be developed more than a decade ago, they have been in a near-constant state of flux, with risk estimates and instructions for interpretation subject to frequent and dizzying changes.

It is unfortunate, with the stakes so high, that all of these researchers cannot come together in a spirit of open exchange. I'm sure that would result in more scientifically sound, and defensible, risk estimations in court.

The timing of this latest brouhaha is apropos, as reports of bias, inaccuracy and outright fraud have  shaken the psychological sciences this year and led to more urgent calls for transparency and sharing of data by researchers. Earlier this year, a large-scale project was launched to systematically try to replicate studies published in three prominent psychological journals.

A special issue of Perspectives on Psychological Science dedicated to the problem of research bias in psychology is available online for free (HERE).

*Hat tip to blog reader David Thompson for alerting me that the trial had concluded. 

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

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

They were flat-out wrong.

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

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

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

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

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

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

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

Backpedaling on paradigm shift

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

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

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

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

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

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

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

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

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

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

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

Groundbreaking research: One out of every 10 rape convictions wrong?

As a young man, Michael Jones pleaded guilty to back-to-back attempted molestations of two girl strangers. However, he adamantly maintained his innocence while in prison and on parole. He said his lawyer had coerced him into pleading guilty by threatening him with life in prison if he went to trial. Michael was one of a handful of Black people in a rural white community; both of the little girls were white. He was identified when police brought him to the station and showed him to the girls. There was no lineup procedure with foils; he was the only choice the girls were given. On the basis of his two convictions, government evaluators diagnosed Michael with pedophilia and recommended civil commitment.

As a teenager, Paul Smith tried to molest a younger boy. He was arrested at the scene and confessed. He disputed only one point in the victim’s statement: that he had threatened the younger boy with a gun. Police searched his home and found no gun. Pre-conviction polygraph testing indicated he was being truthful when he denied having a gun. Over the ensuing years, however, clinicians in sex offender treatment programs hammered at him to admit that he had used a gun. Government evaluators said Paul’s “denial” and “minimization” of his gun use influenced their recommendation for civil commitment.

In cases such as these, I am consistently struck by the naïveté of clinicians and forensic evaluators alike, who accept police reports and especially victim accounts as the gospel truth. From my former career as a criminal investigator, I can attest to the fact that even impartial observers with no conscious motivation to distort are never 100 percent accurate in describing events they have witnessed. As Daniel Schachter so clearly articulates in Seven Sins of Memory, distortion is the nature of the human animal. It is even more likely to occur in situations involving high levels of stress, fear and emotionality.

So I was happy to see that the issue of false convictions for sex offenses is getting some much-needed and long-overdue attention. Or, let me qualify that: Happy about the empirical research, but less than thrilled with a theoretical article on the psychological dynamics underlying false accusations. Let me take those up one at a time.

Dredging old cases for DNA matches

The most methodologically rigorous study to date, released in June, suggests that somewhere between 8 and 18 percent of men convicted of sexual assault may be innocent. The federally funded research project randomly sampled convictions in Virginia between 1973 and 1987, before DNA testing was widely available, and compared preserved physical evidence with the DNA profiles of convicted men.

After poring through more than half a million cases, researchers found 422 sexual assault cases in which DNA evidence was preserved. In 8 percent (33) of those cases, the DNA evidence was exculpatory and supported exoneration. Because many of the DNA comparisons were inconclusive, this amounted to 18 percent of the cases in which it was possible to make a definitive determination one way or the other based on DNA analysis. (The data and the analyses are complex and not without flaws, so I recommend reading the study itself before relying on these numbers.) Noted the researchers:

"Even our most conservative estimate suggests that 8 percent (or more) of sexual assault convictions in a 15-year period may have been wrongful. That means hundreds, if not more than a thousand, convicted offenders may have been wrongfully convicted. That also means hundreds (if not more) victims have not received the just result, as previously believed. Therefore, whether the true rate of potential wrongful conviction is 8 percent or 15 percent in sexual assaults in Virginia between 1973 and 1987 is not as important as the finding that these results require a strong and coordinated policy response."

Bennett Barbour. Photo credit: 

Joe Mahoney, Times-Dispatch

Unfortunately, the researchers ran out of money before they could do more exhaustive analyses of the cases in which innocence was suggested. In the project’s wake, the government is battling with false confession activists who want access to the data, reports the Richmond (Virginia) Times-Dispatch. Police and prosecutors want to restrict access; exoneration activists argue that people have a right to know when their DNA does not match that collected in the crime for which they were convicted.

The project has led to the exoneration of at least four men. Putting a face to them is Bennett S. Barbour, who served a prison sentence for a 1978 rape. He had moved and did not receive the 2010 letter notifying him that the DNA specimen cleared him and matched a convicted rapist instead. A volunteer lawyer finally tracked him down and broke the good news by phone 18 months later.

Research into wrongful convictions has pinpointed several leading causes. These include:

Top sources of wrongful convictions. The Innocence Project

• False witness testimony (including mistaken identification and lying codefendants) 
• Faulty forensic evidence (especially comparisons of hair and bite marks) 
• False confessions 
• Police being influenced by prior knowledge of a suspect 
• Brief jury deliberations 

These problems are compounded by racial bias both in the criminal justice system and in society more broadly. African American men make up far more than their share of those who were convicted and later exonerated based on DNA evidence.

False accusations: A role for psychology?

Flat-out false accusations of rape -- like that depicted in To Kill A Mockingbird -- are rarely the cause of exonerations. But they do occur. Now, a prominent forensic psychology professor and his student propose 11 pathways to false allegations, and suggest that psychology could play a role in helping to sort reliable from unreliable reports. Write Jessica Engle and William O'Donohue in the Journal of Forensic Psychology Practice:

"[W]e suggest that some psychological disorders may increase the likelihood of believing a sexual assault occurred when it did not. Additionally, some psychological disorders may be related to an increase in motivation to fabricate an allegation of sexual assault in an effort to achieve what may be believed are the positive consequences of a false report…. [P]sychological evaluations may inform forensic evaluators of psychological processes by which a person may either intentionally or unintentionally file a false allegation of sexual assault."

The motivational and information processing pathways they propose lean heavily on psychiatric disorders -- including antisocial personality disorder, borderline personality disorder, histrionic personality disorder, psychotic disorders and intellectual disability -- as causes of false allegations. For example, here’s how they suggest that a histrionic personality style could lead to a false allegation:

"[A] person who is histrionic may, after a co-worker complements her clothing and accidentally bumps into her during the day, construe these actions as intentional communications of sexual interest. This misperception can lead her to feel that if the individual had touched her chest while bumping into her, it was an intentional action of unwanted assault. Thus, a pathway to false allegations of sexual assault may be through individuals with a diagnosis of histrionic personality disorder who for reasons of attention and misinterpretation may knowingly or unknowingly make a false allegation of sexual assault."

Okay, I’m not saying that people don’t lie, or make mistakes. Other research suggests that anywhere from 2 to 10 percent of all sexual assault reports may be false. But some of the examples provided in this article stretch credulity, and reek of sexism. I don’t know too many women, histrionic or not, who don't know the difference between an innocent compliment and a sexual assault.

A classification system based largely on pathologizing women runs the risk of reifying the mythology of so-called “rape myths,” in which only “good,” virtuous women can be raped. It seems especially problematic to disbelieve women with psychiatric problems when -- as the authors acknowledge -- they are the ones most likely to be sexually victimized.

More broadly, it is improper for clinicians to wade into the waters of truth-telling or lie detection. We weren’t there, and we don’t know what happened. It's problematic enough when we use character traits to predict the future. Stating that people (read: women) with this or that disorder are more likely to be lying or distorting reality opens the door for yet more improper use of psychiatric diagnosis in court.

Rather, as suggested by the Virginia data, we need to be skeptical at all times, and to keep our minds open to competing hypotheses based not on psychiatric stereotyping, but on the individual case facts. Maybe an assault happened, maybe it didn’t. Maybe the witnesses have their facts straight, maybe they don’t. Maybe the person who was convicted is the real culprit, and maybe he isn’t.

It’s clear that false convictions and false allegations are two separate beasts. And if that’s not complicated enough, there are true cases that are falsely recanted! For example, in a recent Welsh case, “Sarah” was repeatedly raped and forced into prostitution by her husband. When she recanted her report, she was convicted for perverting justice.

So, did Michael Jones (top of post) try to molest the two little girls? Maybe. Maybe not. The point is that we will never know for sure, and we should embrace -- rather than avoid -- that uncertainty. Present the competing scenarios, and analyze the case both ways, so that the trier of fact has all of the information.

The complexities in understanding sexual assault patterns are mind-boggling, and can make your head spin. False convictions, false accusations, false retractions. And then there's the other end of the spectrum: A vast proportion of sexual assaults – probably somewhere between 85 and 95 percent – are still going unreported altogether. And when victims do come forward, prosecution is rare, and convictions even rarer.

It's one gigantic mess, all around.

The U.S. Department of justice Study is: Post-Conviction DNA Testing and Wrongful Conviction by John Roman, Kelly Walsh, Pamela Lachman and Jennifer Yahner.

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.

Blogger urges new paradigm for sex offenders

Clarence Opheim, sentenced to 4 years
in prison back in 1988

Among sex offenders in Minnesota, Clarence Opheim is a very important man. After 20 years of treatment, the 64-year-old pedophile will be the second person ever released from civil detention in the North Star State, which holds the dubious distinction of having the highest per capita civil commitment rate.

The other 639 detainees are pinning all their hopes on next month's provisional release. If Opheim can make it, maybe they can too. The only other guy who came out except in a body bag violated his release conditions and in 2003 was returned to detention, where he died at age 45 of a heart attack. [See comments section for more on him.]

The program has been under pressure to release someone; otherwise, it might be found Unconstitutional: The legal premise behind civilly detaining people for crimes that are only remote future possibilities is not that they will be locked up forever, but that they will be treated and then released.

Although some are cheering this as a major turning point in the civil commitment industry, one prominent Minnesota clinician says the celebration is premature: What we really need is a bold paradigm shift in which industry leaders reject civil commitment altogether.

Comparing the civil commitment of sex offenders to the interment of Japanese during World War II, Jon Brandt asks, “If hindsight is 20/20, when we look back at sex offender civil commitment many years in the future, will we be proud of the roles that we had today?"

Brandt, a social worker, directs a residential treatment program for adolescent boys. He is also an expert witness in juvenile proceedings and a frequent professional trainer and media commentator who has addressed the Minnesota legislature on child welfare issues.

In his guest post on the blog of the influential Association for the Treatment of Sexual Abusers (ATSA), Brandt says the industry may have painted itself into a corner through its timidity about releasing sex offenders back into the community:

The Moose Lake detention site

It is not just in everyone's interest that Mr. Opheim succeeds; it is imperative. Consider the alternative: If the second of only two discharges in MSOP [the Minnesota Sex Offender Program] history fails, for any reason, both failures will be seen as a malfunction of both MSOP and SOCC [sex offender civil commitment]. A second unsuccessful discharge is not only likely to have far-reaching consequences for sexual offender management in Minnesota; a seismic "thud" may well be heard at ATSA listening posts across the country. In addition, it would be hard for the courts to ignore.

SOCC in Minnesota may now be painted into a corner. In the interest of public safety we may have compromised Constitutional protections beyond integrity. Perhaps Ben Franklin's quote is apt, that "those who would give up essential liberty to purchase a little safety deserve neither liberty nor safety."

Brandt urges ATSA to take the lead in challenging civil commitment, based on the low rates of sex offender recidivism established through empirical research including a new survey in Connecticut that found that only 3.6 percent of parolees who had served a prison term for a sex crime were arrested and charged with a new sex crime:

We have very solid empirical evidence to challenge current misguided public policies. We need to get good research to the right folks. We need to infuse policy makers with the necessary information for bureaucracies to champion productive recommendations into meaningful change…. If we use our knowledge and expertise to educate the public, inform our colleagues, and persuade policymakers that best practices should emanate from good science, we might not have to settle for incremental changes. We can help create new paradigms….

If professionals who work with sexual offenders do not challenge the politics, misinformation, and misguided management of sex offender civil commitment, where is a more credible voice going to come from? In an area of public policy where reason is often eclipsed by emotion, ATSA members may be in the best position to know the research, understand competing principles, and advocate for sound rationales. If forensic psychology with sexual offenders is being dominated more by forensics than psychology, I would suggest that the tail might be wagging the dog.

I recommend reading the entire post, available HERE.

More developments on the sex offender front

Study finds problems with real-world reliability of Static-99

Evaluators differ almost half of the time in their scoring of the most widely used risk assessment instrument for sex offenders, the Static-99, according to a report in the current issue of Criminal Justice and Behavior. Even a one-point difference on the instrument can have substantial practical implications, both for individual sex offenders and for public policy. In by far the largest and most ecologically valid study of interrater agreement in Static-99 scoring, the research examined paired risk ratings for about 700 offenders in Texas and New Jersey. The findings call into question the typical practice of reporting only a single raw score, without providing confidence intervals that would take into account measurement error. The study, the latest in a line of similar research by Marcus Boccaccini, Daniel Murrie and colleagues, can be requested HERE.

California reining in SVP cowboys

Psychiatrist Allen Frances has more news coverage of a memorable state-sponsored training at which Sexually Violent Predator (SVP) evaluators were cautioned to be more prudent in their diagnostic practices. Ronald Mihordin, MD, JD, acting clinical director of the Department of Mental Health program, warned evaluators against cavalierly diagnosing men who have molested teenagers with “hebephilia” and rapists with “paraphilias not otherwise specified-nonconsent,” unofficial diagnoses not found in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. California evaluators have come under fire in the past for billing upwards of $1 million per year conducting SVP evaluations of paroling prisoners. The PowerPoints of the 3-day training are now available online, at the DMH's website.

The neuroscience of sex offending

In preventive detention trials of sex offenders, forensic evaluators often testify about whether an offender lacks volitional control over his conduct. But how much do we really know about this? In the current issue of Aggression and Violent Behavior, forensic psychologist John Matthew Fabian explores the neuroscience literature on sex offending as it applies to civil commitment proceedings. The article can be viewed online, or requested from the author HERE.

Challenge to sex offender registry

Although the sex offender niche is by far the most partisan and contentious in forensic psychology, one thing that just about all informed professionals agree about is that sex offender registration laws do more harm than good. By permanently stigmatizing individuals, they hamper rehabilitation and reintegration; as Elizabeth Berenguer Megale of the Barry University School of Law explores in an essay in the Journal of Law and Social Deviance (full-text available HERE), they lead to a form of “social death.” Now, the California Coalition on Sexual Offending (CCOSO) and the Association for the Treatment of Sexual Abusers (ATSA) have filed a joint amicus brief in a challenge to California's "Jessica's Law," which bars registered sex offenders from living within 2,000 feet of any school or park. The amicus contends that the restriction is punishment without any rational purpose, in that it does not enhance public safely or deter future criminality. The challenge was brought by Steven Lloyd Mosley. After a jury found Mosley guilty of misdemeanor assault, a non-registerable offense, the sentencing judge ordered him to register anyway, ruling that the assault was sexually motivated. The 4th District Court of Appeal granted Mosley’s appeal, and the California Department of Corrections has appealed to the state's supreme court. We'll have to wait and see whether the high court will tackle the issue of registration laws directly, or will sidestep with a narrow, technical ruling.

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.

Sexual violence prevention: Recommended journal issue

The current issue of the International Journal of Law and Psychiatry features an excellent collection of diverse scholarship on the prevention of sexual violence. Papers address the empirical and moral foundations of prevention from the perspectives of law, psychiatry, criminology, psychology, and public policy. Here's a preview of a couple of the articles I've read so far….
 

Paraphilia battle pivotal to future of U.S. civil liberties

Jerome Wakefield, a professor at New York University and an influential theorist of mental disorder, provides a searing analysis of the messy paraphilia debacle that the DSM-5 task force has waded into. After providing a brief history, he dissects the current proposals to show how their conceptual invalidity will open the door to widespread abuse in forensic practice:

 

Needless to say, prosecutors availing themselves of civil commitment processes and wishing to keep offenders from release find it in their interest to argue for the most expansive possible interpretation of the DSM criteria for paraphilic disorders -- lending enormous weight to the details of the diagnostic criteria…. The convenience of these criteria in forensic evaluations seems more than offset by the potential for prosecutorial abuse and the long-term undermining of the credibility of the distinction – sanctioned by the Supreme Court as a constitutionally crucial one – between mental disorder-driven behavior and other motives for criminal behavior.

Wakefield joins the ranks of other respected figures to recognize the high stakes involved in the battle over whether sex crimes equate to mental disorder. As he bluntly puts it, the struggle over how sexual paraphilias are defined is “tactically central to the future of civil liberties in our country.” If the government can indefinitely detain men who have served prison time for sex crimes based on bogus psychiatric labels that supposedly impair their volitional control, it's only a matter of time before other groups are rounded up, too. 

Of all of the controversial paraphilias, Wakefield asserts, the “most flawed and blatantly overpathologizing” is pedohebephilia, which would expand pedophilia to encompass attraction to pubescent minors. Arguments by its proponents are both weak and misleading, he writes:

The first argument for the expanded category is that hebephilia is similar to pedophilia in that both involve attraction to physically immature individuals. This is about as valid an argument as saying that both dyslexia and illiteracy involve difficulties reading, thus illiteracy should be considered a disorder. The kind of immaturity involved in pubescence is vastly different from the kind in prepubescence from the specific perspective of its ability to trigger normal sexual interest, so in fact the dissimilarity is more important than the similarity…. The other two arguments – that some prosecutors are currently using the diagnosis “Paraphilia Not Otherwise Specified (Hebephilia)” and that the ICD [the World Health Organization’s diagnostic system] allows sexual preference for early pubescence as a disorder – ignores the critical question of whether these uses are valid…. Hebephilia as a diagnosis violates the basic constraint that disorder judgments should not be determined by social disapproval. This is a case where crime and disorder are being hopelessly confused.

Although the sexual disorders work group has backed down on two of its three most controversial proposals, it is clinging tenaciously to pedohebephilia, the brainchild of the Canadian laboratory that employs two members of the work group. Hopefully, a newly established scientific review committee for the DSM-5 will heed the increasingly strong warnings emitting from mainstream social scientists and psychology-law practitioners such as Wakefield, and have the common sense to squelch this ridiculous proposal. Otherwise, as Wakefield puts it, “the forensic tail [will be] wagging the validity dog, and we are likely to get criteria that possess a misdirected pseudo-validity that will not serve us in the long run and set a dangerous precedent for future tensions between civil liberties and civil commitment for mental disorder.”

Inevitable recidivism: An urban legend

Tamara Rice Lave, a law professor at the University of Miami, tackles the essential premise underlying current social policy toward sex offending: that apprehended sex offenders (especially child molesters) will continue to re-offend. As Lave shows, the courts and the public accept this premise with an unquestioning and almost religious fervor, ignoring a growing body of empirical evidence to the contrary.

Inevitable recidivism has saturated the media, political and popular discourse, and thus it has become the dominant frame due to its availability…. This sets up a dialectical process in which the public believes that sex offenders inevitably recidivate; the media write stories that bolster this belief, and politicians pass laws that are responsive to this belief. The effect is to have inevitable recidivism become a socially constructed fact.

When actual evidence of sex offender recidivism is examined, a huge gap exists between what is assumed and what the data actually shows because most sex offenders do not in fact recidivate. Thus there is a galaxy of sexually violent predator laws and an entire branch of Supreme Court jurisprudence that is founded upon a demonstrable urban legend.

The special issue, Beyond Myth: Designing Better Sexual Violence Prevention, was co-edited by professors Eric Janus (author of Failure to Protect, an essential text on sex offender law and policy) and John Douard. Both are, like myself, firm believers that we should be focusing scarce resources on primary prevention of sexual violence rather than on misguided campaigns rooted in moral panic and hysteria. Such campaigns are not only ineffectual, but they may actually increase the very problems they are aimed at solving.

The articles are:

Jerome C. Wakefield:  DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between diagnostic validity and forensic utility [request from author HERE]

Tamara Rice Lave: Inevitable recidivism: The origin and centrality of an urban legend  [full text available online HERE]

A preview of all of the articles in the special issue, Beyond Myth: Designing Better Sexual Violence Prevention, is HERE. Clicking on a preview of an article allows one to email the author to request a reprint.

Leading psychiatrists critique proposed sexual disorders

• Dangerous.
• Unnecessary.
• Sloppy.
• Inaccurate.

These adjective express the sentiment of prominent forensic psychiatrists about a set of controversial new sexual disorders being proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Four critiques in the current issue of the flagship journal of the American Academy of Psychiatry and Law follow two well-attended meetings in which forensic psychiatrists were "decidedly negative" toward the proposed paraphilias, in the words of psychiatrist Howard Zonana.

Pandering to legal pressure 

A primary concern of forensic psychiatrists is that the proposals are being developed not based on clinical need or scientific discovery but, rather, to meet demands from the legal system. Specifically, broadening of paraphilias will make it easier to:

• Increase prison terms for Internet pornography users 
• Win civil detention for repeat sex offenders who have no genuine mental disorders

"The sexual disorders in the current and proposed DSM contain a potpourri of categories that increasingly intersect with the criminal justice system," notes Zonana, a psychiatry professor at Yale:

"Caveats saying the DSM is designed for clinical and not legal purposes notwithstanding, our classification system has difficulty distinguishing what we consider criminal behavior from culturally unacceptable behavior and mental disorder. Several current proposals continue this trend and seem more responsive to criminal justice concerns than mental illness considerations. They also lack sufficient specificity to warrant being called a disorder."

Loosening categories will reduce accuracy

J. Paul Fedoroff echoed Zonana's concern about legal influence, and also highlighted the reduction in accuracy that the diagnostic expansions will engender:

"The [proposals] raise more questions than answers. The proposed revisions to current DSM-IV-TR criteria will decrease the specificity of ascertained and diagnosed conditions by dramatically loosening the diagnostic categories. While the proposed changes may increase diagnostic reliability, they will certainly decrease diagnostic accuracy. Given the consequences of mistaken diagnosis, the proposed revisions are both unhelpful and dangerous."

Federoff, chair of  AAPL's Sexual Behaviors Committee, also directs both the Sexual Behaviors Clinic at Royal Ottawa Mental Health Care Centre and the forensic research program at the University of Ottawa Institute of Mental Health Research. 

Hypersexuality: Pathologizing young adults

Both Zonana and Federoff critiqued the conceptual and practical problems with the big three proposals that were resoundingly rejected in an audience poll after a debate at last year's AAPL meeting. These include hypersexuality, pedohebephilia and paraphilic coercive disorder (which the DSM revisers recently agreed to shelve). Wrote Zonana:

"The amount of time a person spends thinking about and engaging in sexual behavior varies enormously across the life cycle, with a sharp peak in adolescence and early adulthood. The most striking feature of the current criteria for hypersexuality is that, in my experience, it will be especially hard to find a young adult of college age who does not meet all of the criteria. The same will be true of many adults. The amount of time adolescents spend fantasizing and engaging in sex-related behavior is enormous.... To call this a mental disorder will include far too many false positives."

Pedohebephilia: Confusing illegality with disorder

Zonana, Federoff, and two other prominent forensic psychiatrists – Johns Hopkins University psychiatry professor Fred Berlin and Columbia University professor Michael First – all criticized the proposal to expand pedophilia to include adults with sexual interests in minors who have reached puberty.

"What is the great need to expand the definition to make more diagnoses?" asked Zonana. "Their rationale seems to conflate law enforcement with mental illness even more. There certainly are no new good treatments to justify a need to identify more cases."

“Our culture has initiated a 'war on sex offenders' and the legal system has geared up to wage it. Since we have made the diagnosis almost completely overlap with the crime, we have become overly enmeshed with legal goals.”

Federoff agreed:

"With the broadening of the age range of interest that will satisfy the diagnosis, more people will be labeled. By definition, expansion of the range of diagnostic criteria reduces sensitivity (true positives). Is this a good idea?"

Critical voices encouraged

Introducing the critiques, Richard B. Krueger, a psychiatry professor at Columbia University and medical director of the New York State Psychiatric Institute's Sexual Behavior Clinic, invited others to submit input – especially in published form:

"We hope that these articles will stimulate further discussion and submission of thoughtful criticism. Forensic psychiatrists are particularly well suited to offer commentary concerning the use or misuse of paraphilia diagnoses in legal proceedings, and observations on any aspect of the proposed criteria would be welcome. Indeed, editors of relevant journals have been generous in publishing commentary and articles. The Journal of the American Academy of Psychiatry and the Law, Sexual Abuse, the Archives of Sexual Behavior, the Journal of Sex Research, and The Journal of Sexual Medicine have published criticisms of DSM-5. There is still time to submit comments. Even if suggestions are not actually incorporated or reflected in the revised criteria, the published record would be valuable and relevant for the future."

While I would certainly echo Krueger's encouragement, I am skeptical that some members of the DSM-5 Sexual Disorders Work Group will willingly give up their pet diagnoses – especially the scientifically suspect pedohebephilia construct that is already being misused on a widespread basis in Sexually Violent Predator cases.

As psychiatrist John Sadler noted in his book dissecting the conflictual history of the DSM's, Values and Psychiatric Diagnosis, the DSM committees claim openness and seek input, “but how such input is to influence the actual decision-making process is not discussed.”

At any rate, Krueger makes the excellent point that having a formal record of the opposition will be important in the future. If any of these three proposals makes it into the DSM-5, vigorous Daubert challenges by increasingly sophisticated attorneys will be certain to follow. Indeed, use of any of the paraphilias in court only calls attention to the scientifically weak underpinnings of the entire category. As Zonana points out:

"The work group has a difficult set of disorders to contend with. The category lacks a principled basis for considering inclusions and exclusions, which makes it vulnerable to societal pressures rather than advances in science. The proposals discussed should not be accepted in their current form, as they create more problems than they solve."

Daubert challenges will be especially likely in that the American Psychiatric Association has decided not to conduct any formal field tests of the proposed paraphilias. This means that even their interrater reliability -- far easier to establish than actual scientific validity (accuracy) -- will remain in doubt. Unofficial field trials being conducted at the Sand Ridge Detention Center in Wisconsin and in California will not alleviate this concern, as the coordinators of these trials have a vested interest in a positive outcome. It's something like hiring the fox to guard the chicken coop.

I predict that the paradoxical consequences of this shaky endeavor are going to come back and bite organized psychiatry in the future. As I wrote in the conclusion to my historical review of hebephilia's sudden emergence:

Significant unintended consequences are likely if novel syndromes of primary benefit to the sex offender commitment industry are incorporated into the upcoming edition of the DSM. First, at a time of mounting controversy over partisan influence and lack of scientific rigor in the DSM diagnostic system, critics will seize on this as a glaring example of arbitrary and unscientific use of psychiatric diagnosis in the service of a pragmatic goal. This could have the paradoxical effect of reducing the scientific credibility of the DSM and the fields of psychiatry and psychology more broadly. In the forensic arena, where the diagnosis will most often be invoked, it may paradoxically invigorate defense challenges on the grounds that psychiatry is being deployed in a pretextual manner. In the end, hebephilia will come to haunt not only those who are civilly committed on pretextual grounds, but the entire mental health field, for years to come.

As always, the Journal of the American Academy of Psychiatry and Law is available online for free downloading. The current issue includes some other interesting articles, including a critique by forensic psychologist Brian Abbott of a current push in the sex offender industry to combine actuarial scores with clinical judgment. I encourage you to check it out (HERE).