It is not particularly surprising that proposed revisions to diagnostic criteria suggested for DSM-5 have resulted in considerable debate. For our readership—persons who work with persons affected by sexual violence (either as victims or as offenders)—the proposed changes to the criteria for diagnosing Paraphilias have drawn both strong support and strong opposition.
In this unique entry to http://sajrt.blogspot.com/, we hope to give you something of a point-counterpoint experience. Two letters to the President of the APA have been drafted:
- A letter outlining concerns with the proposed changes to the Paraphilias diagnostic criteria, written by Drs. Richard Wollert and Thomas Zander.
- A letter outlining support for the proposed changes to the Paraphilias diagnostic criteria, written by Drs. Robin J. Wilson, Jill Levenson, Richard Packard, and Mr. David Prescott.
In this blog, we will present the two letters and allow readers to make comments. In a subsequent blog, we will present additional commentary by each group on the other’s perspective. We hope you find this point-counterpoint exercise to be both intellectually stimulating and of importance to the ongoing work all of us engage in attempting to better understand the difficult phenomenon of sexual violence.
For those who are interested, the APA has reopened its DSM-5 website for general comments. The link is http://www.dsm5.org/Pages/Default.aspx.
Each of the letters below is addressed to the new President of the American Psychiatric Association, Dr. Dilip V. Jeste. For those who are interested, Dr. Jeste’s contact details are as follows:
Dilip V. Jeste, M.D.
President, American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
An Open Letter Urging the APA to Exclude
Unreliable Paraphilic Proposals from DSM-5
Dear Dr. Jeste:
As mental health professionals, sex educators, and researchers we are 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 ParaphiliasSubwork Group 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 Subwork Group is now proposing to add the equivalent of 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.” We are 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 & Cramer, 2011). Most of the research has been conducted by a single Canadian research team that is overly represented on the Paraphilias Subwork Group. 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 Subwork Group 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 Subwork Group. 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 expressed 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 pointed 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.
We share these concerns as they apply to sexual disorders. We 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, we 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.
Richard Wollert, Ph.D. Thomas K. Zander, Psy.D., J.D., ABPP
Clinical Psychologist Clinical & Forensic Psychologist
Vancouver, WA Indian Rocks Beach, FL
American Psychiatric Association (1999). Dangerous sex offenders: A task force report of the American Psychiatric Association. Washington DC: 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. Behavioral Sciences 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 the editor]. Archives of Sexual Behavior, 40, 227-229.
Wollert, R. (2011). Paraphilic Coercive Disorder does not belong in DSM-5 for statistical, 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.
An Open Letter to the APA in support
of Proposed Revisions to DSM-5 Paraphilia Disorders
Dear Dr. Jeste:
As a scientists and practitioners, we believe that the sexual disorders in the DSM-5 must be evidence-based. We are writing to express our support for the inclusion of the proposed revisions for the Paraphilic disorders. We believe the revisions provide a more precise taxonomy for diagnostic decision-making that will benefit clinicians and clients.
The Paraphilias Subworkgroup of the DSM-5, made up of some of the world's leading experts in the area of pathological sexual behaviors, has developed a set of thoughtful and empirically based revisions to the existing schema. These refined and revised disorders (Pedophilic Disorder, Paraphilic Coercive Disorder, and Hypersexual Disorder) have shown acceptable validity and reliability in recent field trials, and represent the consensus of clinicians in the field. The Subworkgroup, chosen specifically for their vast experience and expertise, is aware of concerns expressed by other parties and has considered the potential for overuse and misuse of DSM diagnoses in forensic cases. With these concerns in mind, they have carefully crafted a set of criteria designed to improve the precision of the application of these diagnoses to individuals.
The Subworkgroup is proposing to add a "Hebephilic" subtype to Pedophilia, which would assist in the clinical conceptualization of individuals with persistent, exclusive, or primary sexual attractions to early pubescent children, generally ages 11 to 14, as opposed to older, more physically mature adolescents. It also proposes to add new diagnoses of "Paraphilic Coercive Disorder" and "Hypersexual Disorder" to the Appendix as "Criteria Sets for Further Study." We believe that these recommendations represent improvements in the taxonomy of Paraphilias for the following reasons.
Some regard Hebephilia as a conceptually complex and confusing construct. This is exactly why refinements in the DSM criteria are necessary. Although research indicates that some men find themselves attracted to sexually maturing 14-year-olds (Green, 2010), these attractions are not normative when they represent an enduring, primary, or exclusive attraction to young pubescent individuals and lead to distress or impairment in functioning. An erotic preference for, or orientation toward, children in the early stages of puberty (Tanner stages 2 and 3, generally ages 11 through 14) is not normative. In fact, the proposed change would bring the DSM in line with the World Health Organization’s definition of Pedophilia in the International Classification of Diseases (ICD-10): “A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age” (World Health Organization, 2007).
Heeding concerns about potential misuse of the Pedohebephilia subtype as a justification for sexual offender civil commitment in the U.S. (Ewing, 2011), a field trial investigated this question using cases from the Florida Civil Commitment Center (Wilson, Pake, & Duffee, 2011). Results indicated that 36% of the clients diagnosed with Paraphilia NOS (adolescent victims) using the DSM-IV-TR did not in fact meet the proposed DSM-5 criteria for Pedohebephilia. In other words, whatever one’s opinion of sexual offender civil commitment might be, DSM-IV-TR diagnoses offer little guidance to evaluators and have resulted in a wider diagnostic net. Despite claims to the contrary, the proposed empirically based revisions would actually serve to narrow the group of individuals who meet criteria for designation as a sexually violent predator. The revisions are long overdue, and without them, clinicians are left with the current, less precise classifications that perpetuate exactly the type of problem identified by opponents of the revisions. When inter-rater reliability was tested in Florida, kappa coefficients were significant for the proposed diagnostic schemes for Pedophilic Disorder (.71; Wilson et al., 2010). A second field trial in Wisconsin obtained similar results (kappa = .66; Thornton, Palmer, & Ramsey, 2011).
Paraphilic Coercive Disorder (PCD) has been proposed for inclusion in the DSM-5 Appendix as a diagnosis for future research. The disorder would apply only to men with established preferences for sexual coercion over consensual sex. Previous editions of the DSM have rejected coercion manifested in rape as a disorder for a variety of political and clinical reasons (Zander, 2008). Currently, the Subworkgroup is recommending PCD only for inclusion in the Appendix as a condition meriting "further study." Regardless of how state legislatures address the criminal aspects of sexually coercive behavior, clinical and empirical evidence suggest that a small group of men prefer non-consensual sex and that this desire represents a pathological and deviant sexual interest. In DSM-5 field trials, many civilly committed sexual offenders who had been given the frequently utilized Paraphilia NOS (nonconsent) diagnosis did not meet criteria for PCD using the proposed diagnostic scheme (D’Orazio, Wilson, & Thornton, 2011). Inter-rater reliability for PCD from the aforementioned field trials in FL and WI were k = .66 and k = .50, respectively.
With the vast volume, variety, availability, accessibility, and affordability of sexual material on the Internet, the past twenty years have brought new manifestations of what some have called "sexual addiction." Though consensus for such a construct does not yet exist, clinicians reveal an increase in requests for therapy services related to sexual self-regulation and its potential consequences. Hypersexual Disorder (HD), proposed for the DSM-5 Appendix, would be helpful for clinicians to be able to refine the conceptualization of harmfully excessive sexual behavior and the parameters by which it deviates from normal sexual patterns. The proposed diagnostic criteria are explicitly descriptive and atheoretical and do not depend on models of “addiction” or “compulsion” (Kafka, 2010).
In summary, for those who express legitimate concern about overuse or misuse of Paraphilia NOS diagnoses in sexual offender civil commitment cases, field trials revealed that DSM-5 proposals resulted in a significantly lower proportion of potential candidates who would meet criteria for commitment. It is also important to note that while opponents of civil commitment are among the most vociferous challengers to the proposed DSM-5 revisions, civil commitment is far from the only clinical application of these diagnoses. In fact, less than 1% of the 739,000 registered sex offenders in the U.S. are civilly committed (Ackerman, Harris, Levenson, & Zgoba, 2011).
It is unclear what constitutes "adequate empirical support" for inclusion in the DSM, and all mental health disciplines have grappled with this question for decades. It is noteworthy that few field trials of any disorders took place prior to the publication of the DSM-IV, and no field trials of the Paraphilias occurred. Valid concerns exist regarding problems of false positive diagnoses, and clinicians should avoid labeling as mental disorders those behaviors that are normative, developmental, or criminal. On the other hand, labeling has been noted as a general concern with many DSM categories since its inception. As science and knowledge evolve, evidence should be folded into our diagnostic systems and our clinical understanding of the patients we serve.
In the end, the integrity of the DSM-5 demands that scientific evidence weigh most heavily in determining and refining diagnoses. Research findings and clinical utility should take precedence over debates about civil commitment policy. We are sure we all agree that clients and clinicians alike deserve no less.
Robin J. Wilson, Ph.D., ABPP Jill Levenson, Ph.D.Clinical Psychologist Clinical Social Worker
Sarasota, FL Boca Raton, FL
Richard Packard, Ph.D. David Prescott, LICSW
Clinical Psychologist Clinical Social Worker
Bainbridge Island, WA Falmouth, ME
Ackerman, Harris, Levenson, & Zgoba, (2011). Who are the people in your neighborhood? A descriptive analysis of individuals on public sex offender registries, International Journal of Law and Psychiatry. doi:10.1016/j.ijlp.2011.04.001
D’Orazio, D., Wilson, R.J., & Thornton, D. (2011, November). Prevalence of Pedohebephilia, Paraphilic Coercive Disorder, and Sadism Diagnoses Produced with the Proposed DSM-5 Criterion Sets. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.
Ewing, C.P. (2011). Justice perverted: Sex offender law, psychology, and public policy. New York: Oxford.
Green, R. (2010). Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! Archives of Sexual Behavior, 39, 585-586.
Kafka, M.P. (2010). Hypersexual Disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377-400.
Thornton, D., Palmer, S., & Ramsay, R.K. (2011). DSM-5 Pedohebephilia, PCD, and Sadism diagnoses: Reliability in WI. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.
Wilson, R.J., Pake, D.R., & Duffee, S. (2011, November). DSM-5 Pedohebephilia, PCD, and Sadism diagnoses: Reliability in Florida. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.
World Health Organization. (2007). International statistical classificationof diseases and related health problems (10th rev., version for 2007). Retrieved from: http://apps.who.int/classifications/apps/icd/icd10online/index.htm?gf60.htm
Zander, T. K. (2008). Inventing diagnosis for civil commitment of rapists. Journal of the American Academy of Psychiatry and Law, 36, 459–469.