Thursday, May 12, 2011

Here I go again...

The DSM-5 controversy continues...

Last week, I reported late-breaking news that the DSM-5 folks had decided to consider Paraphilic Coercive Disorder for possible inclusion in the Appendix of the book rather than in the main body of the text. They made the same decision regarding Hypersexual Disorder. In addition, they decided that Hypersexual Disorder should be grouped with the sexual dysfunctions rather than with the paraphilias.

These decisions have subsequently drawn attention by Karen Franklin in her blog and have generated quite a discussion on various list serves, especially the ATSA-list. I have excerpted some of those ATSA-list posts below, with permission from the various posters.

Dr. Franklin and her associates have been very critical of the proposed changes to the Paraphilias diagnoses, taking particular aim at Pedohebephilic Disorder (PHD) and Paraphilic Coercive Disorder (PCD), with seemingly lesser complaints about Hypersexual Disorder. Various parties have written letters to the Editor of the Archives of Sexual Behavior (ASB—where much of the discourse has taken place) and Dr. Franklin has frequently blogged on the topic.

In her recent blog, Dr. Franklin quotes DSM-IV Task Force Chair Dr. Allen Frances as having stated the following:

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

So, Dr. Frances is suggesting that we should not diagnose rapists because it will lead to hospitalization and not correctional incarceration. If this logic were true, then wouldn't we find more pedophiles, exhibitionists, and frotteurs in hospitals than in correctional facilities? I have worked in both correctional and hospital settings and I can tell you that, without a doubt, virtually all of the paraphilic clients I saw were either in correctional settings or were in hospital settings being evaluated to determine which correctional setting would be most appropriate. Paraphiliacs go to jail, not hospitals.

Maybe Dr. Frances is referring to Civil Commitment Centers (CCC) when he speaks of hospitals? I work in one of those places, so I have a pretty good idea what they’re all about. I want to be very clear that SVP facilities are not prisons, they are civil facilities for persons not serving a criminal sentence. It is also important to note that the vast, vast majority of persons in CCCs go there after having satisfied a criminal incarcerative sanction (an exceptionally small number of SVPs come into the CCC via a state mental hospital, but that is truly quite rare). In the United States, where CCCs exist almost exclusively, correctional sentences for sexually abusive behaviors are often rather lengthy—certainly more lengthy than in most other G20 nations.

Equating a CCC with a hospital would be a grave mistake. Actually, CCCs are an interesting hybrid—they are secure, so as to further the aspect of preventive detention (and, thus, have many of the trappings of prisons); but the focus is treatment, which means they have a much higher number of clinical staff than you would find in a prison (and, thus, they are a bit more hospital-like). However, these are not “hospitals” like the ones where other psychiatrically diagnosed individuals may find themselves. All in all, I find Dr. Frances’ contention that PCD (or the other two) will result in more rapists or adolescent molesters going to hospital than jail to be a complete and total non-issue. Paraphilic persons are not going to hospitals now, and that is unlikely to change.

As to the oft-heard contention that sexual psychodiagnostics in the SVP world are less than optimal, on this I am likely to agree. Virtually all CCC residents have a paraphilia diagnosis of one sort or another. And, yes, it is true that you are more likely to find a Paraphilia NOS diagnosis (either “nonconsent” or “adolescent victims”) amongst this group than any other group of persons diagnosed with a paraphilia. Either there truly are more NOS persons in the cohort of offenders considered for CCC placement or there is something amiss in the way SVP candidates are being assessed, pre-commitment. In a piece on PCD written for ASB, Washington State prosecutor Paul Stern wrote:

Paraphilic Coercive Disorder would give the judicial system the best opportunity to most accurately identify the small group of men who have previously committed, and are likely in the future to commit, this type of predatory sexual violence.

Mr. Stern’s position is that adding PCD to the diagnostic nomenclature will not lead to greater pathologizing of criminal behavior. Rather, his belief is that having a more clearly defined diagnostic framework will decrease its use in comparison to the mess that is currently Paraphilia NOS nonconsent.

Truth be told, lots of esteemed scientists disagree as to whether or not there is sufficient evidence to establish distinct or different diagnoses, but that is ultimately a question for research. In her blog, Dr. Franklin seems to argue that we as field should issue a pre-emptive strike on these proposed diagnoses, so as to forever consign them to the dustbin of sexology.

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

As a further door-slam, Dr. Franklin points to research and commentary by Brandeis professor Dr. Ray Knight (a well-known rape typologist) as being supportive of doing away with PCD.

(PCD) had met with strong opposition from scientists, including premier rape researcher Raymond Knight of Brandeis University.

In truth, my read of Dr. Knight's criticism is that he believes that paraphilic coercion cannot be reliably distinguished from Sexual Sadism—that paraphilic coercion is not taxonomic on its own. My colleague Jan Looman posted this on the ATSA-list:

I don't think the issue is whether or not men become aroused to rape, but whether a group of men who become aroused to rape can be reliably distinguished from sadists (at least that's what I got from reading Ray Knight's stuff about this). I think that his position is that there are gradations of sadism and that the men who become aroused to rape can be captured in this category.

In his own ATSA-list response to Dr. Looman, Dr. Knight writes:

Your characterization about one of the objections to PCD is correct. There appears to be reasonably strong support for a continuum of "sadistic" fantasies/behaviors, maybe better labeled an "agonistic" scale or some other more inclusive name, and PCD is on that continuum and does not differ in kind from sadism. At the very least the two constructs cannot currently be reliably discriminated.

So, Dr. Knight doesn’t exclude the existence of paraphilic coercion. Rather, he says that it cannot be reliably distinguished from an already existing paraphilia—Sexual Sadism.

Interestingly, one of Dr. Frances’ frequent writing partners, Michael First (see First & Halon, 2008, p. 452), also does not exclude the likely existence of paraphilic coercion:

Conceptually, given the wide variety of stimuli known to be the focus of paraphilias, there is no reason to doubt the existence of a paraphilia in which the aberrant focus of sexual arousal is precisely the nonconsensual aspect of the interaction.

Another colleague, Jon Brandt, recently posted this on the ATSA-list:

Beyond criteria for diagnosis, the DSM has many uses including the benefits of nomenclature, and yielding effective treatment plans rooted in well-established diagnoses. But PCD and Pedohebephilia are not settled science.

There it is…Seemingly always at the heart of the criticism of the proposed diagnoses is that they have not been established in science. But, what does establishment in science look like? What are the critics (I’m not necessarily including Dr. Brandt here) actually calling on the field to do?

Are they suggesting that nobody ever did any research on paraphilic coercion (or paraphilic rape, or rape proneness, or whatever is the nom du jour)? Or, that nobody ever did a study looking at pedohebephilia? Or, are they suggesting that paraphilic diagnoses cannot be considered until they have been subjected to field trials and had their inter-rater reliabilities checked?

Again, I ask you: What does establishment in science look like?

It won't take anybody very long to find out that paraphilic coercion has been the topic of quite a large body of research. The same is true of pedohebephilia—SAJRT Editor James Cantor did a lit search and found a mountain of research and scholarly discourse referring to hebephilia. So, that can't be it. Let's turn then to the question of field trial research.

Without reading last week's blog or Paraphilias Subworkgroup Chair Ray Blanchard's letter to the Editor of ASB (because that would be cheating), how many field trials do you think have previously been conducted on the paraphilias?

I love this part.

That number is 3. Not three studies, not three groups, perhaps not even three paraphilias. Three subjects. That's it...3 (three) subjects studied during preparation for DSM-III. I may not be the sharpest statistician around but, to me, this seems pretty simple. None of the paraphilias we use have been subjected to adequate field trial research.

I repeat, none.

So, if you use the field trial standard, all the rhetoric about the proposed paraphilias not being "settled science" must now also apply to all the others. Differentially picking on PHD or PCD, while letting the others off the proverbial hook, seems to imply that just because some prior iteration of the DSM chose to include Exhibitionism, Pedophilia, Masochism, etc. in the mix, we should accept these diagnoses as somehow more "real" or bona fide. Does anyone else get the logical non sequitur in this?

In closing, my recommendation is this:

Ditch the bluster and let the science do the talking for a while. Research as to the inter-rater reliabilities of the PCD and PHD frameworks is underway. Hopefully, we may get some empirical direction regarding Hypersexual Disorder as well, but this is less likely. If we truly believe that “settled science” is the way forward, then all the pre-emptive conjecture is “pseudoscientific,” to use one of Dr. Franklin’s terms.


PS... The just released issue of the Sex Offender Law Report has three articles on PCD by Knight and Thornton, Stern, and myself.

Wednesday, May 4, 2011

ATSA Announces Videos of Plenary Presentations

Hello All:

For the first time ever, fans of the annual conference of the Association for the Treatment of Sexual Abusers will be able to access some of the Plenary presentations.

Just announced today by the ATSA Office ...

Dear ATSA Members,

To help further ATSA’s commitment to research and shared learning the Education and Training Committee continues to develop new ways to make trainings more accessible. This year, we are pleased to offer the videos of Drs. Ray Knight's and Martin Kafka's keynote presentations from ATSA’s 2010 Research and Treatment conference in Phoenix. These videos are available for a nominal charge of $4.95 at

After looking at the site, please take a few minutes to complete the survey and let us know if you would like to have more trainings offered in this format?! ATSA extends a special thank you to Drs. Kafka and Knight for their generosity in sharing these presentations.

Sexual Offender Assessment: DSM-5 Proposals Modifying Diagnostic Criteria for Paraphilias and Related Disorders
Martin P. Kafka, M.D.
Clinical Associate Professor of
Harvard Medical School

Transforming Prevention and Intervention: What Guidance Does Etiological Research on Rape Provide?

Raymond Knight Ph.D
Department of
Brandeis University

Thank you for your continued support,

The ATSA Office

ATSA plans to do this going forward with future Plenary sessions offered this fall in Toronto. Stay posted...


Sexual Sadism and Paraphilia NOS (Nonconsent) in Civilly Committed Sexual Offenders

As DSM-5 prepares to make important decisions on diagnostic criteria regarding the paraphilias, we are likely to see more and more articles published. Specifically, expect to see several articles each on Paraphilic Coercion, Pedohebephilia, and Hypersexuality.

Familiar civil commitment personalities Dr. Henry Richards (ex of the Washington SVP program) and Dr. Rebecca (Becky) Jackson (presently in the South Carolina SVP program) offer us an interesting article on “Behavioral discriminators of sexual sadism and paraphilia nonconsent in a sample of civilly committed sexual offenders,” just published in our stable-mate the International Journal of Offender Therapy and Comparative Criminology (Volume 55, Issue 2, pp. 207-227). Link to abstract.

Drs. Richards and Jackson examined the offense behaviors of 39 SVPs diagnosed with Sexual Sadism to a group of 39 SVPs diagnosed with Paraphilia Not Otherwise Specified—Nonconsent. As many readers will know, the Paraphilia NOS issue is quite contentious these days; particularly, in the run-up to DSM-5. On the one hand, we have many SVP evaluators who frequently use NOS to categorize coercive sexuality, while on the other we have those who claim this is a “made up” diagnosis with no basis in fact. Many on both sides point to the need for field trial research and some sort of scientific underpinning of the diagnostic frameworks for paraphilias in the DSM.

Interestingly, field trials have never been a big part of the establishment of diagnostic criteria for the paraphilias. Current Paraphilias Subworkgroup Chair Ray Blanchard tells me that in the entire history of the DSM, only three subjects have ever been put forward as “field trial subjects” regarding the paraphilias. This strikes me as odd, and I hope it does you as well. Here’s a selection of quotes from Dr. Blanchard’s recent Letter to the Editor of the Archives of Sexual Behavior:

The field trials for DSM-III, which were sponsored by the National Institute of Mental Health, included three patients with paraphilias … That’s it … The implication of this brief history is simple: Any comparisons, made up to this time, of the DSM-IV-TR diagnostic criteria and the proposed DSM-5 criteria have been based, not only on speculations about how the proposed criteria would perform but also on speculations about how the existing criteria have performed.

In short, all bluster aside about what diagnoses belong and which ones don’t, there is little empirical support (by way of field trial research) for any of the paraphilia frameworks. Of course, that doesn’t take into consideration all the other fine research done looking at the epidemiological aspects of paraphilic presentations. However, this is what Dr. Blanchard has to say about that:

The amount of available information regarding the diagnostic criteria proposed for DSM-5 is already equal to, or perhaps greater than, the amount of information about the existing criteria.

A great deal of the aforementioned controversy in the lead-up to DSM-5 surrounds the apparent “over-use” of the Not Otherwise Specified qualifier regarding “nonconsent” and “adolescent victims” in civil commitment proceedings. In the absence of clear diagnostic frameworks, it would appear that SVP evaluators have used NOS as a way to diagnose difficult sexual behavior patterns not clearly described by existing diagnostic criteria. As noted above, it would appear that some of the literature supports this process, while other papers are condemning of the practice. As I understand it, the DSM-5 Subworkgroup’s intent in revising the criteria is to increase diagnostic precision in all areas regarding paraphilias. This will, perhaps, also have a beneficial side-effect of clearing up some of the NOS grey space, but that is not what the Subworkgroup is specifically aiming to do.

Back to Drs. Richards and Jackson…

Specifically regarding the distinction between NOS Nonconsent and Sexual Sadism, these authors do a fine job of summarizing the existing literature. Very briefly, the existing literature suggests that reliable distinction between sadism and paraphilic coercion is difficult, except in extreme cases where the former is quite obvious. My understanding of all this is that there are “high specificity indicators” (e.g., mutilation, choking, gratuitous violence) that seem to resonate more with a diagnosis of Sexual Sadism, and then there are “low specificity indicators” (e.g., instrumental violence, degradation, confinement) that are, perhaps, more indicative of paraphilic coercion (sometimes referred to as “paraphilic rape”) referred to in this paper as Paraphilia Nonconsent. Admittedly, the research on this high/low specificity distinction is also less than clear.

In the Richards and Jackson study, factors that seemed to differentiate the NOS nonconsent and Sexual Sadism groups were:

+ careful planning of the offense (SS > NOS)
+ duration of at least 90 minutes (SS > NOS)**
+ manual masturbation of male victim (SS > NOS)
+ sexual dysfunction during the offense (NOS > SS)
+ forced oral sex (SS > NOS)
+ cutting/stabbing during sexual act (SS > NOS)
+ violence during sexual act (SS > NOS) **
+ use of physical restraints (SS > NOS) **
+ use of threats to evoke fear (SS > NOS)
+ attempts to verbally calm or comfort victim (SS > NOS)
+ any facial injury (NOS > SS)

These results seem to line up reasonably well with my high and low specificity idea, at least as far as the more significantly violent and “sadistic” elements seem to be more prevalent in those judged a priori as Sexual Sadists.

In the absence of reliable self-report and/or phallometric evidence, evaluators may misinterpret violence as being sexually motivated and hence incorrectly assign a diagnosis of sexual sadism.

Drs. Richards and Jackson note that the three noted above with ** were commonly associated with Sexual Sadism, both across studies and in the current one. They attempt to make distinctions between violence for violence’s sake and violence in the furtherance of another agenda (i.e., to facilitate a rape).

…it is likely that prolonged and excessive control, going beyond what is needed to effect the rape, is a means of inducing humiliation and displaying the power of the assailant and represents an important dimension of sadism that may not be present in nonsadistic rapes.

In the Conclusion of their paper, Drs. Richards and Jackson reiterate that certain factors appear to assist in discriminating between NOS nonconsent and Sexual Sadism:

Differences suggest that certain behaviors, particularly severe violence, efforts to exert control over one’s victim, and fear-provoking threats during a sexual assault, are especially characteristic of [Sexual Sadism].

They encourage evaluators to exercise caution, however, in equating any violence with sadism, noting that many of the non-sadists in their study also used a degree of violence. They suggest that it may be more profitable to look at the timing of the violence and the offender’s reaction to it.

In their closing statements, they issue an often-read caveat: The findings are hampered by small sample sizes; the implication being that further research is needed. Field trial research as to the utility of diagnostic frameworks is particularly needed, in light of the interesting revelations made by Dr. Blanchard in his letter, as highlighted above.

And, in some late breaking news ...

Dr. Blanchard just emailed me to say:

The updated DSM5 Website went live at midnight, announcing various updates and soliciting another round of public commentary. See

There were two changes concerning the paraphilias.

  1. Hypersexual Disorder and Paraphilic Coercive Disorder are described as being considered for the Appendix.

  2. Hypersexual Disorder is grouped with the Sexual Dysfunctions rather than the Paraphilias.