Steffan's Alerts #3: Women, children, fire-setting and the public

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JAAPL: Plethora of mental health and law offerings

As always, the new issue of the Journal of the American Academy of Psychiatry and Law is a goldmine for those interested in law and mental health matters. All articles may be accessed for free online. Topics include use of the DSM in litigation and legislative settings, rational understanding and competency to stand trial, treatment of sexual offenders, hebephilia and the DSM-5, competency of pregnant women with psychosis, diversion of women into substance abuse treatment, and analyses of several recent legal rulings, to name a few.

Sins of the father

In a new issue of the British Journal of Criminology, Sytske Besemer and colleagues examine whether children whose parents have been incarcerated are later involved in the criminal justice system at disproportionate rates compared to children whose parents have been convicted but never imprisoned in the Netherlands and England. After controlling for a number of possible intervening variables in their longitudinal study, the authors provide data showing that children in the latter--but not the former--country are adversely affected by their parents' incarceration.

Advancing understanding and predictive utility of childhood firesetting

Although mental health professionals have long held that deliberate fire setting by children is prognostic of future conduct problems, Ian Lambie and Isabel Randell review how science in this area has progressed -- or not progressed -- in a new issue of Clinical Psychology Review. They call for future research to address the relationship between youth firesetting and future antisocial behavior as well as to update best practices in assessing and intervening with children who set fires.

Factors involved in reporting rapes

Data from a national survey of 3,001 women in 2006 indicated that the rate of reporting rape has not significantly changed since the 1990s. In a new issue of Journal of Interpersonal Violence, lead author Kate Wolitzky-Taylor explores barriers and predictors of reporting sexual assaults to law enforcement.

Criminal justice response to female offenders

In a forthcoming issue of Psychology, Public Policy, and Law, Shabnam Javdani, Naomi Sadeh, and Edelyn Verona advance theory on the legal and social policy factors involved in the increasing arrest rates of girls and women.

Public's views on sentencing practices

Does the public really support tougher sentencing of offenders? Preliminary data suggests this is not the case in Australia when members of the public are provided details about the personal lives of offenders. In a new issue of Criminology and Criminal Justice, Austin Lovegrove sampled several hundred participants through their review and discussion of judges' sentences on six offenders in four actual cases.

Steffan's alerts are brought to you by Jarrod Steffan, Ph.D., a forensic and clinical psychologist based in Wichita, Kansas. For more information about Dr. Steffan, please visit his website.

SVP morass: Will psychologists "just say no"?

 Dr. Franklin,

          My understanding is that psychiatrists and the American Medical Association made a conscious, ethical decision to not get involved in the SVP [Sexually Violent Predator] morass. I am not sure why psychologists dove in. Smelling blood in the water, cash in bank accounts or trying to show up the "real doctors" has led to our participation in one of the largest, most expensive frauds put over on society, with the field of psychology becoming the laughingstock of real researchers. We are now participating in a system that systematically violates the Constitutional rights of individuals and uses the shoddiest of data to rationalize our position. Has there been any thought to a movement by psychologists or the APA to "just say no"?

-- Eugene Braaksma, Licensed Psychologist

What a timely question. Privately, many mainstream forensic psychologists agree with your assessment, and some have even gone public with their concerns. Most recently, two psychologists in the San Francisco Bay Area have gone so far as to echo your call for a professional boycott. But for several reasons, I think the major impetus for change will come not from within, but from larger systemic forces outside psychology.

Photo © Karen Franklin 2011

Calling for a boycott are forensic psychologists Paul Good and Jules Burstein. Writing in the American Journal of Forensic Psychology, they liken preemptive detention laws to a "modern-day witchhunt":

Psychologists testifying for the state in SVP civil commitment trials are using contrived mental disorders and the scientific veneer of actuarial formulae…. [The ‘predator’ paradigm] gives the public a false sense of security by concentrating vast sums of money on incarcerating a small group of sexually violent offenders, in place of a more useful public health approach to the problem of sexual violence. The consequences of this misguided effort include emphasizing incarceration over treatment, draining scarce resources from a multi-pronged approach to preventing sex crimes, demonizing sex offenders, and promoting the "slippery slope" of preventive detention…. Psychologists should put the public interest ahead of their guild interest and expose this mistake in social policy. One dramatic step would be to resign from state SVP panels.

"Full Employment for Psychologists Act"*

But, as this semi-facetious title by Charles Patrick Ewing suggests, two decades into these laws the sheer number of embedded psychologists makes a boycott impractical. These psychologists will not boycott a system that is making them "boatloads" of money, as one testified – up to a cool $1.5 million a year. As Ewing lays bare in Justice Perverted, the opportunity has proved irresistible for psychologists, many with little scientific sophistication or prior expertise in forensic psychology or sex offending:

In the short run the payoff, especially for some individual practitioners, has been great, but in the long run, the damage done to their professions and the people who would be served by them may prove to be much greater…. It is difficult to picture … psychologists who now earn their living developing checklists that purport to predict sex offender recidivism, doing evaluations and testifying in sex offender civil commitment trials, and/or training others who do so, encouraging state legislatures to put them out of work.

Photo © Karen Franklin 2011

Most of these psychologists are well intended. They believe they are doing righteous work to protect the public from dangerous predators. If they thought otherwise, cognitive dissonance would force them to quit the lucrative panels, as a minority of their colleagues have done. Their structural position of embeddedness creates blinders. When one is walking among the trees, one cannot see the forest. And there is an element of group-think. Surrounded by like-minded professionals, they mistake these colleagues' concordance for a consensus in the broader profession.

More alarmingly, as psychiatrists Michael First and Allen Frances point out in the current issue of the Journal of the American Academy of Psychiatry and Law, these practitioners are being systematically mistrained as to proper diagnostic and risk assessment practices. Just last week, I heard about a government evaluator (annual earnings from SVP evaluations: $500,000) who testified in support of civilly detaining a rapist based upon a previously unknown mental disorder called "paraphilia not otherwise specified – attracted to power and control."

You can't make this stuff up. 

Even if psychology had the unified will to step into this minefield, I doubt that our field has the political clout to impact the industry in any significant way. Embedded psychologists are mere functionaries, interchangeable cogs in a machine, scoring checklists and regurgitating memorized formulas. Unless and until legislatures and courts recognize that these laws are not doing much (if anything) to reduce sexual violence or keep the public safe, the growing chorus of critical scholars in the fields of psychology, criminology and law will remain as tiny voices crying out in the wilderness.

Will the courts step up?

In a critical overview just published online in Psychiatry, Psychology and Law, a leading forensic scholar in Australia says the courts shoulder some of the responsibility for failing in their role as gatekeepers. If the courts were more rigorous, fatally flawed approaches to risk assessment would not predominate in sex offender cases, argues Ian Coyle of Bond University in Queensland.

At a minimum, Coyle suggests, the playing field should be leveled. In Australia, as elsewhere around the world, the government has vastly superior resources for expert witnesses than does the defense:

The theoretical equality of all before the law is thus subverted in practice by inequality of means.

Another barrier to justice is the complexity of the statistics and measurement theory invoked in these cases. Lacking advanced scientific training, it is hard for the average judge or attorney to make sense of the competing claims and accurately determine which are valid and which are not.

Making matters worse, even when individual judges educate themselves so that they can detect and reject pseudoscience, for example by rejecting the fictional diagnosis of "hebephilia" as a basis for civil commitment, higher courts often overturn their decisions. The disappointing truth is, judges are mere functionaries, too.

The coming crash

Photo © Karen Franklin 2011

In the end, I predict the system will ultimately crumble not due to principled opposition but by virtue of its own excesses. In the United States, as many states teeter on the edge of bankruptcy, it is hard to justify spending $1 billion per year or more to civilly detain a tiny handful of sex offenders at the expense of public schools, higher education, and even prisons.

It is a tricky business, because legislators and judges do not want to incur public wrath by appearing "soft" on sex offenders. Still, as citizens feel the effects of massive cutbacks in public services, I expect they will become less tolerant of government waste across the board.

The backlash is already starting. For example, last week in Minnesota a legislative auditor released a report slamming the sex offender civil commitment program as costly and ineffective:

Hundreds of sex offenders confined in state treatment facilities receive inadequate therapy from under-qualified staff at excessive cost, according to [the] report…. At the same time, many other offenders present such low risk to the public that they could safely be released to community group homes, saving taxpayers millions of dollars. And in what they describe as a public safety paradox, auditors found that some sex offenders are held indefinitely, even though they pose less risk than dangerous felons in state prisons who are being released back to the streets. Auditors called on state officials to replace this "all or nothing'' system and develop a plan for low-cost alternatives, while spending more on treatment of the most dangerous offenders.

California is following suit, with an audit of its SVP program due out in June. Psychologists may be especially interested in one particular task of the audit, to examine "the qualifications of staff or contractors who conduct the evaluations and determine if they are consistent with professional standards and laws and regulations."

Bottom line, the bough will come crashing down when the massive costs finally become too much for governments to bear, and when citizens figure out that SVP laws -- while symbolically appealing -- are a wasteful and ineffective approach to reducing sexual violence.

How will our misguided colleagues pay their mortgages and fund their children's college educations then? Hopefully they're putting some of those millions in the bank for a rainy day.

*from Justice Perverted 

Psychiatrists ramp up opposition to forensic misuse of DSM

"Pedohebephilia" would make bad situation worse, they warn  

As you will recall, at a recent debate members of the American Academy of Psychiatry and the Law (AAPL) were virtually unanimous in giving the thumbs-down to three controversial sexual disorders being proposed for the fifth edition of psychiatry’s diagnostic manual.

Piggy-backing on that sentiment, the Academy's official journal has just published two additional calls for caution. 

DSM's forensic influence cannot be ignored

Ralph Slovenko, an eminent professor of law and psychiatry at Wayne State University Law School, leads off with an editorial that counters a key claim of the proponents of diagnostic expansion. The oft-repeated claim is that the legal implications of a diagnosis are irrelevant, and should not be considered.

Rebutting this head-in-the-sand mentality, Slovenko gives a comprehensive overview of the DSM's impact in myriad areas of the law, from parental termination to disability determinations. As evidence of the DSM's vast influence, he cites language written into the statutes in 16 states mandating its use for various purposes.

As his overview makes clear, courts and legislatures across the United States have ignored the fine print in the introduction to the Diagnostic and Statistical Manual, stating that use of the manual for forensic purposes risks misunderstanding and misuse.

A case in point: Use of a made-up category, "Paraphilia Not Otherwise – Hebephilia," as justification for preventive detention of men who have served prisont time for sexual relations with adolescent.

No basis for fictional "hebephilia" disorder

Next, two psychiatrists who were influential in developing the current edition of the DSM launch a full-on assault on the use of the bogus diagnosis "hebephilia" in sexual predator civil commitment proceedings.

Michael First, editor and co-chair of the DSM-IV-TR, and Allen Frances, chair of the DSM-IV Task Force, clarify the intention of diagnosing paraphilias, or sexual deviances, and why diagnosing offenders against adolescents with "hebephilia" (a diagnosis that does not exist in any formal diagnostic system) is a flagrant abuse of psychiatric nomenclature. This is not the first time these authors have tried to set the record straight, but their current analysis is especially detailed and unequivocal.

The alleged diagnosis paraphilia not otherwise specified, hebephilia, arose, not out of psychiatry, but rather to meet a perceived need in the correctional system. This solution represents a misuse of the diagnostic system and of psychiatry. That a large number of forensic mental health workers have been mistrained to regard paraphilia NOS as a valid diagnostic category in SVP proceedings should not be construed as proper representation of the views of the entire mental health field. Similarly, the very preliminary studies conducted by a few research groups should not be construed to indicate that hebephilia has any solid scientific support. Hebephilia is not an accepted mental disorder that can be reliably diagnosed and should not be treated as such in SVP proceedings.

First and Frances issue a strong call against adding the pretextual diagnosis of "pedohebephilia" to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders:

Among several radical proposals made by the DSM-5 Sexual Disorders Workgroup is the backdoor introduction of the hebephilia diagnosis into the DSM-5 by expanding the existing well-accepted pedophilia category to include sexual arousal to pubescent individuals and renaming the broadened construct pedohebephilic disorder. There is no apparent need or compelling rationale to include hebephilia in DSM-5 beyond the research interests of a few scientists and the questionable use of hebephilia in SVP proceedings.

Despite opposition from forensic psychiatry, no doubt the wheels will grind on. After all, as legal scholar Charles Patrick Ewing describes in Justice Perverted, preventive detention has taken on a life of its own, becoming a lucrative and self-perpetuating industry. More on psychology's role in that very soon….

Related resources:

On my website, I have created a page of resources on the hebephilia controversy. But if you really want to immerse yourself in these diagnostic controversies, the place to visit is the "DSM-5 Paraphilias Controversy." On one page, blogger Andrew Hinderliter has amassed an impressive array of literature on the disputed paraphilias, including not only hebephilia, hypersexuality, and sexual sadism but also related hot-button topics such as transvestic fetishism.

My comprehensive historical review of hebephilia is now available online. Or, for a shorter version, there's always my oldie but goodie blog post, from Halloween of 2007: "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."

Paint brushes and soap: The slippery slope of unfettered power

Courts rebuke detention centers for arbitrary and pretextual practices 

The case of the killer paint brush

When the government filed a petition seeking to civilly commit M.F. for sex crimes he might commit in the future, the elderly artist decided to go quietly. He gave up his right to a trial, in exchange for a legal order that he be allowed to do his art in his remaining years.

But officials at Missouri’s detention center resisted being told how to operate. M.F.’s security level was changed from green (low risk) to red (high risk), and his art supplies were taken away. When he challenged this in court, a government psychologist testified that the art supplies posed a threat to the institution’s security: Another patient could use them to hurt someone, or they might even block an evacuation route in the event of an emergency.

Calling the invocation of security “pretextual,”* a judge ordered the institution to return the paint brushes.

No soap unless we say so

In detention sites across the United States, objects far more innocuous than paint brushes are being wielded as weapons against captive sex offenders who -- like M.F. -- decline to enroll in proffered treatment.

In New Jersey, “A.J.,” a sex offender who declined treatment (insisting he is innocent) was denied basic hygiene items such as toilet paper, soap, shampoo, toothpaste, shaving cream and laundry detergent unless he could pay for them. The items were given free as prizes to sex offenders who enrolled in treatment. After a 3-day hearing, a judge ruled that the jailers were being “arbitrary and capricious”:

“Like food and clothing, personal hygiene items are central and core requirements of civilized existence. The refusal of the department of corrections to provide personal hygiene items to inmates at regular intervals is unreasonable. I also find that in this particular case the department of corrections sometimes observes its own rule and sometimes it doesn’t. So it’s capriciously applied as well.”

Tip of the iceberg

Arbitrary, vindictive, petty and sometimes just plain silly practices like these are not rare. Rather, they are commonplace experiences in the state hospitals where thousands of U.S. sex offenders are detained indefinitely based on future risk, after having finished their prison sentences.

The organizational culture is a setup for petty tyranny to run amok.

Unlike in a real hospital, there is an inherent tension between detainees and staff. Under the civil commitment laws, detention sites are supposed to provide treatment to reduce the sex offenders' future risk. But most of the residents decline to engage in treatment. They are resentful about being detained, and see the generic group therapy as a humiliating sham. For staff, in turn, the impossibility of their task lowers morale and can spawn resentment of offenders.

It is hard not to feel morally superior to the offenders. Many are not sympathetic characters. They have assaulted their way through life, leaving behind a swath of psychic destruction to children and women. Their mistreatment is easy to justify as deserved, or in service to the greater good of public safety.

Add to this incendiary mix the few bad apples in any organizational barrel. Literary trickster Carlos Castaneda called them little petty tyrants, who persecute and inflict misery without causing death. If you have ever worked in a prison or mental hospital, you know that such environments provide fertile soil for pinches tiranitos.

As we saw at Abu Ghraib, a frustrated work force with unfettered power over a maligned and powerless population is a recipe for abuse. Indigent prisoners don’t exactly have a voice to complain about abuses of authority. This is especially true for sex offenders. No one wants to hear a victimizer whining about being a victim. 

Alienation and despair

When Martin Seligman played mind games on dogs, giving punishments arbitrarily and not allowing escape, the dogs became apathetic and depressed. "Learned helplessness" resulted from their absolute lack of control or agency. The same thing happens with humans.

The arbitrary and capricious treatment that sex offenders are subjected to creates a vicious cycle. It ramps up alienation, despair, and bitterness. And this mindset is not exactly conducive to the types of prosocial change that we want to see in offenders.

Conditions are so unbearable in these facilities ostensibly designed for care and treatment that three offenders are using “necessity” as a defense for an attempted escape. The three tried to escape from Minnesota’s Moose Lake facility, which was the subject of an ACLU complaint over alleged violations of patients’ rights.

Last week, the would-be escapers unsuccessfully pleaded with a judge to let them stay in the county jail rather than returning them to the hospital, where they said conditions were intolerable:

“Please don’t subject me to any more mental and physical abuse without recourse. Please don’t send me back. I’d rather be euthanized.”

The judge nonetheless ordered the man sent back:

“I don’t have the jurisdiction to address the conditions [at the detention site] or the circumstances of your placement there.”

And therein lies the rub. Legislatures enact civil detention laws and set their parameters. But once the massive and costly facilities are up and running, it is easy for administrators and staff to forget that they are just functionaries, beholden to higher authorities for guidance. When this happens, the courts should step up. They hold ultimate responsibility for making sure that government operations are legal and fair.

A.J. and M.F. were lucky to have tenacious lawyers protecting their rights. Even then, their victories were tiny -- the right to soap and paint brushes. More typically, detainees are out of sight and out of mind. No one is watching, and no one cares.

Back in the day, Russian writer Fyodor Dostoyevsky mused that the degree of civilization in a society could be judged by entering its prisons. I wonder what his verdict would be if he could travel through time and visit a modern civil detention facility.

Related posts:

• "Treatment": Backwards and upside down? Don't focus on "denial" or "lack of empathy," warn sex offender treatment experts

• "Consumed With Sex": Sex offender treatment in risk society

*In the context of mental health law, legal scholar Michael Perlin defines pretexuality as “the ways in which courts accept—either implicitly or explicitly—testimonial dishonesty and engage similarly in dishonest and frequently meretricious decision-making, specifically where witnesses, especially expert witnesses, show a high propensity to purposely distort their testimony in order to achieve desired ends.” I used the term in the title of my just-published historical review of the term “hebephilia,” citing its use in court as a pretextual mental disorder.

Bipolar disorder by proxy proposed for DSM-5

New diagnosis to address "critical clinical need"

Although some scholars warn of dangers posed by the proposed expansions of psychiatric disorders, others say there remains a critical shortage of accurate diagnoses for those who need them. At a forensic psychiatry conference last month, for example, proponents said three new sexual disorders are needed to address an urgent clinical reality.

Incorporation of such broad-brush conditions as "psychosis risk syndrome," "temper dysregulation disorder," and "hebephilia" into the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due out in 2013, will help address the diagnostic shortfall, the clinical realists say. But more should be done.

To help meet the needs of those few who remain undiagnosed, California psychologist Michael Donner has proposed an umbrella disorder. To qualify for the newly minted Bipolar by Proxy (BPP), patients must meet at least one of the following criteria during the preceding two-year period:

1. A pervasive sense of well being
2. Repetitive episodes of sadness or pleasure while engaging in pleasant or unpleasant activities, typically lasting for the duration of the activity
3. A minimum of one episode of feeling extremely excited or irritated
4. Two or more episodes of crying, or three or more episodes of an urge to cry
5. Engaging in laughing behavior when confronted with something humorous
6. A general willingness to comply with a prescription medication regimen despite having no overt symptoms
7. One or more major medical health insurance reimbursement plans

As a rule-out, the disorder must not occur in the presence of any other previously undiagnosed mental illness. Nor can it be due to the direct physiological effects of exogenous substances (e.g., drugs of abuse or medications).

There may be no need to market a new drug for this condition. The prescription depressant Despondex (see below video) has been on the market for more than a year and targets annoying exuberance, a core symptom of Bipolar by Proxy that often alerts clinicians to conduct a more thorough diagnostic workup.

Although the reliability of the proposed diagnosis has not yet been established through clinical replication studies published in peer-reviewed journals, this should not be a barrier as field trials are being planned in time to make it into the manual just under the wire. The sites for the field trials will be strategically selected to maximize positive findings. Similarly, high inter-rater reliability will be assured through careful selection, training, and certification of raters by the Bipolar By Proxy Promulgation Association. The journal whose editorial board is dominated by that Association is expected to publish the positive findings. The larger question of validity is not thought to be a problem, as many other current and proposed diagnoses lack real-world validity.

Related post:

Despondex: Is psych mania overreaching? (June 22, 2009)

Photo credit: Eva Blue, Creative Commons License, Peaceful Heart Doctor, San Francisco Chinatown

Europeans first to shoot down controversial paraphilia

Resounding 100-to-1 vote against "pedohebephilia"

I was impressed by the unanimity of opposition to the sexual paraphilias among forensic psychiatrists at their annual conference last week in Tucson, Arizona.

But as it turns out, the sex experts of Europe had the Americans beat, both in numbers and timing.

At last month's meeting of the International Association for the Treatment of Sexual Offenders (IATSO) in Oslo, Norway, the vote was approximately 100 to 1 against the controversial diagnosis of "pedohebephilia," according to two reliable sources. The lone dissenting voice was a member of the DSM-5 committee.

I hope the DSM revisers are listening. If not, they are going to end up the laughingstock of the world.

Richard Green, MD: "Hebephilia is a Mental Disorder?"

The vote at the IATSO conference, where European psychiatry is strongly represented, came after a talk by Richard Green, a prominent psychiatrist, sexologist, and professor at the Imperial College of London. Green served on the Gender Identity Disorders subcommittee for DSM-IV, and was a leading advocate for removing homosexuality from the DSM back in the 1970s. In a published critique of the hebephilia proposal, he pointed out the parallels:

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

He has also pointed out that the age of legal consent in several European countries falls within the range that the proposed disorder would make pathological for the older participant.

A separate audience poll at the IATSO conference on the proposed diagnosis of hypersexuality was more mixed, with about a third favoring the diagnosis, a third opposing it, and a third undecided, according to one of my sources.

NPR report on AAPL debate

Meanwhile, National Public Radio has reported on Saturday's AAPL vote against the paraphilias. Reporter Alix Spiegel blogged about it on NPR's health blog, "SHOTS," under the heading "Forensic Psychiatrists Don't Favor Some Proposed Sexual Diagnoses."

These negative votes will have no a direct impact on the DSM-5, now due out in 2013. In the case of the controversial sexual paraphilias, one Canadian research group is dominating the process and most of the upcoming field trials will be done at government detention facilities where insular opinion runs heavily in favor of the diagnoses.

Proponents of the paraphilia revisions are urging supporters to lobby the DSM committee. It seems that, as we have seen in the past, lobbyists may have an inordinate impact, overshadowing valid science.

But if the American Psychiatric Association kowtows to this special interest niche and ignores the broader consensus of psychiatrists and other mental health professionals around the world, this will certainly reduce the credibility of the manual in years to come.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

Psychiatrists vote no on controversial paraphilias

By an overwhelming majority, a group of seasoned forensic psychiatrists who work with sex offenders voted last night against three controversial new sexual disorders being proposed for the DSM-5.

The votes were 31-2, 31-2, and 29-2, respectively, against Paraphilic Coercive Disorder, Pedohebephilia, and Hypersexual Disorder. The votes came at the end of a debate at the annual meeting of the American Association of Psychiatry and Law (AAPL) in Tucson, Arizona.

The rejection is symbolic, but sends a strong message to the DSM-5 developers. One of the six debate panelists, Richard Krueger, is a member of the Paraphilias SubWorking Group. Two other panelists serve as advisors to the committee. In the audience were prominent forensic psychiatrists who took stances regarding similar proposals during previous revisions of the DSM.

The American Psychiatric Association, to which most forensic psychiatrists belong, publishes the influential Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition. But psychiatrists have not played a central a role in the 20-year-old sex offender civil commitment industry, which is lobbying for these new diagnoses. Much of the planned field testing will be done at civil commitment sites.

The debaters

Arguing for and against Hypersexual Disorder were two prominent psychiatrists with decades of experience in assessing sexual disorders. Richard Krueger, on the "pro" team, is a Columbia University professor and medical director of the Sexual Behavior Clinic at the New York State Psychiatric Institute. John Bradford, an advisor to the DSM-IV and past president of AAPL, is a Distinguished Fellow of the APA, last year earning its prestigious Isaac Ray Award. The University of Ottawa professor is founder and clinical director of the Sexual Behaviors Clinic in Ottawa. He expressed concern about how clinicians would determine how much sexual preoccupation is excessive, and voiced worry that homosexual men might be disproportionately given the label.

Two Wisconsin psychologists debated "Paraphilic Coercive Disorder," which would apply to rapists. Thomas Zander took the "con" position while David Thornton of the Sand Ridge Secure Detention Center for sexually violent predators was "pro." This is the third time that the American Psychiatric Association has considered such a diagnosis.

Tackling Pedohebephilia were two Northern Californians, forensic psychiatrist Douglas Tucker ("pro") and your faithful blogger ("con"). The controversial proposal would expand pedophilia from its current definition, in which the target of sexual attraction must be prepubescent, to young pubescents as old as 14.

The debate was organized by forensic psychiatrist Lynn Maskel, a clinical professor at the University of California-San Diego.

Clinical versus forensic utility?

The three-member "con" team focused on two main themes:

• All three proposed diagnoses lack a sufficient scientific basis.

• They are highly likely to be misused in the forensic context, the primary site for their application.

The "pro" debate team repeatedly insisted that these diagnoses are being proposed based on their scientific merit, not their utility to government evaluators in civil commitment cases. They said these new diagnoses are needed so people suffering with these conditions can get adequate treatment.

The clinical needs argument is a red herring. Clinicians are not turning away patients with problematic sexual behaviors because the proper billing code is missing from the Diagnostic and Statistical Manual of Mental Disorders. Rapists will not flock in for needed treatment when they hear that a Paraphilic Coercive Disorder label is now available for them.

The audience of forensic psychiatrists clearly did not buy the clinical justification. As more than one audience member asked the panel, If the rationale is strictly clinical, why are attorneys serving as advisors to the work group?

Back in 1986, the last time Paraphilic Coercive Disorder was proposed for the DSM, it was defeated in large part due to the opposition of forensic psychiatrists (not pesky feminists, as the historical revisionists would have it). Hopefully, history will repeat itself with respect to all three of these poorly conceptualized and dangerous proposals.

The debate was audiotaped, and will be available for purchase from AAPL. The texts of the proposed diagnoses can be viewed at the DSM-5 website. My resource page on Hebephilia is HERE. Thomas Zander’s article, Inventing Diagnosis for Civil Commitment of Rapists, is online HERE.

Photo: (L to R) John Bradford, Karen Franklin, Thomas Zander, David Thornton, Douglas Tucker, Richard Krueger. Photo credit: Luis Rosell.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

"Hebephilia: Quintessence of Diagnostic Pretextuality"

New from Behavioral Sciences & the Law ...

I never set out to become an expert in this terra incognita. But, alas, here I am. Despite my mixed feelings, I am excited to announce that Behavioral Sciences & the Law has just published my research article deconstructing this pseudoscientific construct. Here is the abstract:

Hebephilia is an archaic term used to describe adult sexual attraction to adolescents. Prior to the advent of contemporary sexually violent predator laws, the term was not found in any dictionary or formal diagnostic system. Overnight, it is on the fast track toward recognition as a psychiatric condition meriting inclusion in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This article traces the sudden emergence and popularity of hebephilia to pressure from the legal arena and, specifically, to the legal mandate of a serious mental abnormality for civil commitment of sex offenders. Hebephilia is proposed as a quintessential example of pretextuality, in which special interests promote a pseudoscientific construct that furthers an implicit, instrumental goal. Inherent problems with the construct's reliability and validity are discussed. A warning is issued about unintended consequences if hebephilia or its relative, pedohebephilia, make their way into the DSM-5, due out in 2013.

After providing the history and scientific status of hebephilia, I conclude:

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.

Links to more articles on this topic can be found on my HEBEPHILIA RESOURCES PAGE; my blog essay from 2007 on the "Invasion of the Hebephile Hunters" is HERE.

"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)

Latest hebephilia critiques: Point-counterpoint

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

Green: Moral standards masquerading as science

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

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

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

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

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

O'Donohue: Let's go even further

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

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

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

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

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

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

New Scientist expose of psychiatry’s "civil war"

Proposed diagnoses of hebephilia and paraphilias NOS critiqued

On Saturday, the world's leading science and technology news weekly is publishing a scathing expose of the political and financial shenanigans underlying the DSM-V revision process. Accompanying the report in the New Scientist is an editorial calling for a halt to the print version of the American Psychiatric Association's money-making diagnostic bible:

The final wording of the new manual will have worldwide significance. DSM is considered the bible of psychiatry, and if the APA broadens the diagnostic criteria for conditions such as schizophrenia and depression, millions more people could be placed on powerful drugs, some of which have serious side effects. Similarly, newly defined mental illnesses that deem certain individuals a danger to society could be used to justify locking these people up for life.

Given such high stakes, we should all be worried by the controversy. Proponents of some of the changes are being accused of running ahead of the science, and there are warnings that the APA is risking "disastrous unintended consequences" if it goes ahead with plans to publish DSM-V, as the new manual will be known, in 2012.

"Psychiatry’s civil war" is the title of the hard-hitting expose by award-winning science writer Peter Aldhous, San Francisco bureau chief for New Scientist magazine.

As Aldhous reports, professional disputes over the form and content of the upcoming edition "are getting ugly." He notes that respected Duke University scholar Jane Costello has resigned from the work group on childhood and adolescence disorders, citing a lack of scientific rigor across the whole DSM revision. "I felt that there was not enough empirical work being achieved or planned," she says.

In a sidebar, Aldhous shines a spotlight on controversial proposals of pivotal importance to forensic psychology, including the pseudoscientific diagnosis of "hebephilia" that I have previously blogged about:

You may have never heard of "hebephilia", but this obscure diagnosis has huge significance in the courts. If it becomes accepted it could lead to hundreds of sex offenders who have served their jail time being locked up indefinitely - on grounds that some say are spurious.

The proposed diagnosis has been condemned by critics as dangerously blurring the boundary between paedophilia and normal male attraction to teenage girls -- which isn't necessarily acted upon. Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. "People didn't used to live so long and mating started earlier," she says.

The work group is also considering whether some men are specifically turned on by rape -- a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.

The rows over hebephilia and paraphilic coercive disorder aren't academic, because 20 US states have passed laws that allow sex offenders who have served their sentences to be detained indefinitely in a secure hospital if they are deemed "sexual predators." This can only be done if the offenders have a psychiatric disorder that increases their risk of reoffending -- which few do, according to DSM-IV.

Franklin says that if hebephilia and paraphilic coercive disorder make it into DSM-V, they will be seized upon to consign men to a lifetime of incarceration.

In a call to put the brakes on this speeding train, the New Scientist's accompanying editorial points out that this would hurt the coffers of the American Psychiatric Association, which has earned more than $40 million since 2000 from DSM sales. But, the editorial concludes, "it's hard to see who else stands to gain from the current exercise -- and if the critics' dire predictions come to pass, patients will be the biggest losers."

Diagnosing Michael Jackson

You have probably seen some of the postmortem efforts to pin psychiatric diagnoses on Michael Jackson, in the wake of his untimely demise. It's a pedantic enterprise, with no shortage of diagnostic contenders: Pedophilia, anorexia, body dysmorphic disorder, and a dual diagnosis (that's a psychiatric disorder plus a substance abuse disorder). Most recently, we've got J. Michael Bailey, the man transgender activists love to hate, wading into the fray with erotic identity disorder and a paraphilia called autogynephilia.

"Whoa, folks! Not so fast!" say others.

Calling for a little reflection on this whole paraphilia-hebephilia-whateverphilia diagnostic craze is Scientific American columnist Jesse Bering, a research psychologist at Queen's University Belfast:

Would you really have wanted Oscar Wilde euthanized as though he were a sick animal? Should André Gide, whom the New York Times hailed in their obituary as a man 'judged the greatest French writer of this century by the literary cognoscenti,' have been deprived of his pen, torn to pieces by illiterate thugs? It's complicated. And although in principle we know that all men are equal in the eyes of the law, just as we did for Michael Jackson during his child molestation trials, I have a hunch that many people tend to feel (and uncomfortably so) a little sympathy for the Devil under such circumstances.

I highly recommend Bering's muse, "Pedophiles, Hebephiles, and Ephebophiles, Oh My: Erotic Age Orientation" (which, by way of full disclosure, cites yours truly).