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.

RJW

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