The prize for the most wayward of all the DSM-5 work groups must surely go to the sexual disorders group -- creators of three remarkably off-beat proposals. Fortunately, they have gradually been forced to abandon their entire wish list because each of the proposals triggered near universal opposition from forensics experts and sexual disorders researchers. First to go was hypersexuality (aka sex addiction); next rape (aka coercive paraphilia); and this week the work group has finally admitted in all but the fine print that statutory rape (aka 'hebephilia') is also not a mental disorder. But before rejoicing, we must get down to three errors in the fine print that need to be rectified before the section will be safe from forensic misuse.
1) Defining Pedophilia: Serious forensic mischief still lurks in the recently proposed wording. Here is the problematic DSM-5 criterion:
A. Over a period of at least 6 months, an equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons, as manifested by fantasies, urges, or behaviors.
The phrase 'equal or greater' strikes just the wrong note. The interpretation (or misinterpretation) of these three small words can have huge consequences concerning the constitutionality of involuntary psychiatric commitment as it is applied in Sexually Violent Predator (SVP) cases. SVP statutes explicitly require that mental disorder be distinguished from simple criminality. The sex offender must be mentally disordered to qualify for SVP commitments. In our country, it is never constitutional to force simple criminals into psychiatric hospitals to keep them off the streets as a form of preventative detention.
This crucial distinction, made explicitly by the Supreme Court, seems to be completely lost on the DSM-5 Sexual Disorders work group. An accurate definition of 'Pedophilia' must separate the rarely encountered, mentally disordered 'pedophile' from the much more common run-of-the-mill sex criminal. 'Pedophilia' requires that the offender be intensely and recurrently sexual aroused by prepubescent kids and that they are his preferred or obligatory source of sexual excitement. The contrast is with the simple criminal who preys on kids opportunistically because they are vulnerable or available or perhaps because he is disinhibited by drugs.
This brings us back to the lack of precision in the DSM-5 wording. A drug-addled criminal may be attracted 'equally' to just about anything that walks -- that doesn't make him a mentally disordered 'Pedophile.' Before diagnosing Pedophilia, there must be an established fixation on prepubescent kids.
The solution is pretty straightforward. The DSM-5 wording should substitute 'preferred or obligatory' for 'equal or greater.' The phrase 'preferred or obligatory' is central to the concept of paraphilia, already appears in the differential diagnosis section in DSM-IV, and deserves greater prominence in the DSM-5 criteria set. "Equal or greater" will perpetuate the great confusion about paraphilia that has plagued the proper application of SVP statutes. And one wonders how "equal or greater" would ever be measured reliably -- let's hope this isn't meant as an excuse for expanding phallometric testing beyond its proper competence.
2) Restricting Pedophilia to prepubescent children: Adding 'early pubescent' youngsters is an unwarranted and radical change from the standard definition of Pedophilia. It reflects the fact that the DSM-5 work group is lopsidedly dominated by researchers connected to one center. They have displayed a stubborn ambition to find a place in DSM-5 for their pet diagnosis: 'hebephilia' supported by the unproven suggestion that men attracted to pubescent kids have a mental disorder. Aside from its deep conceptual flaws and extremely thin research base, the proposal ignores the fact that statutory rape is committed for a whole variety of other much more common reasons (eg opportunistic crime, a vulnerable victim, unavailability of other partners, immaturity, substance disinhibition, date rape, etc). Paraphilia would explain only a vanishingly small proportion of the sexual crimes committed with pubescent victims who are under the age of consent. And we already know that 'hebephilia' has been much abused in SVP hearings by evaluators who casually pin the mental disorder label on simple criminals to end run the constitutional protections against preventive detention.
Confronted by universal opposition from the rest of the field, the DSM-5 group has been forced progressively to whittle down their pet, but they so far have refused to just drop it altogether. 'Hebephilia' first lost its free standing independence and was cloaked as Pedohebephilia. When this didn't fly, the term was dropped altogether in the title but the concept was slipped into the definition of Pedophilia -- which was expanded out of recognition by having a victim age cut-off of 14 years. No one accepted this outlandish suggestion and now finally the work group comes back with 'early pubescent children' and tries to keep 'hebephilia' as a term in the subtype. The instability of the criteria sets associated with this concept is additional evidence that the fervor for its adoption stems from emotional loyalty rather than reasoned review of its weak conceptual and research base. How can the group vouch for the reliability of the diagnosis when the concept and criteria are changing every month? This is no way to develop a diagnostic system.
The work group may try to justify inserting 'early pubescent children' on the grounds that it is mentioned in ICD-10. This is misleading in three ways: first, ICD-10 is inconsistent -- its research criteria include only prepubescent children; only its clinical description mentions 'early pubertal children'; second, the goal of DSM-5 is to achieve compatibility with ICD-11 (not ICD-10) and my understanding is that the ICD-11 work group has already identified the phrase 'early pubertal children' as an error that will be corrected; and third, ICD is much freer to be loose in its language because it is not much used for forensic purposes (let alone in SVP commitment hearings that bear so consequentially on the proper application of our constitution and the proper uses of psychiatry in our society.
3) Drop the subtype: "Hebephillic Type -- sexually attracted to early pubescent children (Tanner Stage 2-3)."
Come on guys. This is absolutely absurd just on the face of it. Do clinicians really know what the Tanner stages are? Even if you did, how would you possibly ever determine the Tanner stage of the victim. And how reliably can the different Tanner stages be diagnosed? One waggish critic scorned the Tanner stages as a futile exercise in 'splitting pubic hairs.' Putting Tanner stages in DSM-5 is really that silly. So back to the drawing board, DSM-5 sexual disorders work group. The grand dream is lost -- now at least make sure you don't mess up on the fine print.
And one more thing. Recognizing that the jig is up on the grand design, members of the DSM-5 sexual disorders work group have been heard saying they may have to settle for an Appendix placement for their three hothouse creations. This would create forensic dangers. We have learned from the abuse of 'Paraphilia Not Otherwise Specified' in SVP cases that any (even remote) legitimization by DSM-5 is certain to be misconstrued and misused in the courtroom.
I commend you to an excellent discussion of this and many other issues pertaining to the DSM-5 paraphilia section in an Open Letter authored by Richard Wollert and Thomas Zander. Mental health professionals concerned with these issues can sign on in an effort to improve the DSM-5 paraphilia so that it doesn't continue or greatly worsen the confusion we caused by the poorly written section in DSM IV.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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