A Guest Blog by DSM-5 Paraphilias Subworkgroup Chair Dr. Ray Blanchard on Proposed Criteria for Pedophilic Disorder

NOTE: This guest blog comes to you authored by Ray Blanchard, Ph.D., who is an Adjunct Professor, Department of Psychiatry, University of Toronto and an Affiliate Scientist, Centre for Addiction and Mental Health, Toronto, Ontario, Canada. He is also the Chair of the Paraphilias Subworkgroup for the DSM-5 Work Group on Sexual and Gender Identity Disorders and was the 2010 recipient of ATSA's Significant Achievement Award.

The Proposal to Add Intense or Preferential Sexual Interest in Early Pubescent Children to the DSM-5 Diagnosis of Pedophilic Disorder

Ray Blanchard, Ph.D.

The proposal of the DSM-5 Work Group on Sexual and Gender Identity Disorders to extend the definition of Pedophilic Disorder to include preferential attraction to children in the early stages of puberty has prompted an extraordinarily vigorous and often misleading rhetorical campaign by its opponents. Although debate on this topic may be healthy, deliberate distortion and disinformation are not. I am therefore writing this piece to give an accurate account of the Work Group’s reasons for this proposal. All of the arguments in it have previously been made in conference presentations, in print documents (usually authored by members of the Paraphilias Subworkgroup of the Work Group on Sexual and Gender Identity Disorders), and in on-line sources (http://www.dsm5.org/). This piece simply puts these arguments together in one convenient and readily accessible place.

Reasons for Expanding Pedophilic Disorder to Explicitly Include Men with a Marked or Preferential Sexual Interest in Early Pubescent Children

The classical definition of pedophilia, going back to the introduction of this term by Krafft-Ebing, is the erotic preference for prepubescent children. (Prepubescent children are children in Tanner Stage 1. There are five Tanner stages of physical development, with Tanner Stage 5 representing full maturation.) The classic definition may have been more honoured in the breach than in the observance. Many persons labeled by the lay public as pedophiles, or even formally diagnosed by psychiatrists as pedophiles, are not pedophiles according to a literal reading of the classic definition but rather something a little different, as will be explained below.

It is beyond question that there exist men who are most attracted to children in the early stages of puberty, that is, in Tanner stages 2 and 3 (generally ages 11 through 14). We know this because many patients, with no reason to lie about this particular point, state that they are more attracted to pubescent children than to prepubescent children, on the one hand, or to older adolescents or adults, on the other. We also know this because many “minor-attracted adults,” on Internet discussion groups and similar Internet venues, describe themselves as most attracted to pubescent—not prepubescent—children. The existence of these men has been explicitly recognized for over half a century, and they have their own label: hebephiles (Glueck, 1955).

Neither the DSM nor the ICD has fully come to terms with the phenomenon of hebephilia. Both have employed strategies that can fairly be described as “waffling.” The ICD-10 defined Pedophilia as “A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age” (ICD-10 F65.4; emphasis added), although the term pedophilia has, since its introduction by Krafft-Ebing, been understood by psychiatrists to refer to the erotic preference for prepubertal children. The DSM-III-R, DSM-IV, and DSM-IV-TR evaded the problem by stating that prepubescent children are “generally age 13 years or younger.” It is undoubtedly true that there is some percentage of children 13 years old who have not yet entered Tanner stage 2. It is most likely, however, that the main effect of this guideline has simply been to allow clinicians to diagnose hebephilia as pedophilia rather than Paraphilia NOS. That is a convenience purchased at the price of accuracy and transparency.

The real question is not whether hebephilia exists but whether it is a mental disorder. The class of all mental disorders is a “fuzzy set.” This is stated clearly in the Introduction to the DSM-IV-TR, although not in the language of set theory. The definition of mental disorder has been debated for several decades without any final resolution, and the writer will not attempt to resolve it here. It is the writer’s position that, if pedophilia is a mental disorder, then hebephilia is a mental disorder. Both involve sexual attractions to persons who are physically quite immature. There is no evidence that the difference between the two conditions is a matter of kind (Blanchard et al., 2009), whereas there is evidence that it is a matter of degree (Blanchard et al., 2007).

There is evidence that men with an erotic preference for early pubescents do experience subjective distress and psychosocial impairment as a result of their age orientation and thus satisfy our Criterion B for Pedophilic Disorder. This research came out of the Prevention Project Dunkelfeld, which was initiated in 2004 in Berlin, Germany. (Dunkelfeld, literally “dark field,” refers to the portion of the pedo- and hebephilic population who are not visible because they have never been reported to the authorities.) This project was designed to reach out to pedophiles and hebephiles who are emotionally distressed because of their paraphilia and to offer such individuals psychotherapeutic help before they have committed any hands-on offenses against children. The project was launched with a large-scale media campaign using the slogan, “lieben sie kinder mehr als ihnen lieb ist?” This constitutes a deliberate word-play in German because of the lack of normal capitalization and can mean “Do you like children more than you like?” or “Do you like children more than they like?”

Beier et al. (2009) reported on the respondents during the first 38 months of the study: “Of the 358 interviewees who were fully assessed, 12.3% (n = 44) neither met the diagnostic criteria of pedophilia nor hebephilia; 60.1% met the diagnostic criteria for pedophilia, and 27.7% for hebephilia” (p. 547). (Beier et al., 2009, did not employ a pedohebephilic category, and it is unclear how they would have classified subjects who reported strong sexual attraction to both prepubescent and early pubescent children.) The main point is that a substantial proportion of persons who would satisfy our Criterion B because of their distress or worry over their attraction to children are predominantly (or exclusively) attracted to early pubescents, not to prepubescents. These individuals would be diagnosed with Pedophilic Disorder, Hebephilic Type according to our proposed criteria; they could not be diagnosed with a Paraphilic Disorder under DSM-IV-TR criteria. It is not clear how their exclusion from this diagnosis is in the patient’s interest or in the interest of society.

Some theorists have attempted to distinguish between pedophilia and hebephilia on Darwinian grounds. The argument may be summarized as follows: In the environment of evolutionary adaptedness, men with an erotic preference for pubescent females had greater reproductive success, either because they acquired female mates near the onset of their fecundity and thus prevented them from being impregnated by other men, or because they had more years in which to impregnate their mates themselves, or both. Since hebephilia is of evolutionary design, it cannot be a mental disorder.

There are three or four separate arguments against the reproductive fitness argument. In the first place, empirical research indicates that (heterosexual) hebephiles produce fewer offspring, not more. Blanchard (2010) compared the mean numbers of biological children reported by 818 heterosexual teleiophiles (men most attracted to physically mature women), 622 heterosexual hebephiles, and 129 heterosexual pedophiles. The teleiophiles had significantly more children than the hebephiles, and the hebephiles had significantly more children than the pedophiles.

In the second place, the use of reproductive fitness (essentially, fertility) as a criterion for mental disorder would argue for the reinstatement of homosexuality into the DSM. In the third place, a distinction between pedophilia and hebephilia on the grounds of reproduction makes no sense when applied to homosexual pedophilia and hebephilia, since neither pubescent nor prepubescent boys can become pregnant. Lastly, there is no evidence that the arrival of menarche abruptly demarcates girls’ attractiveness to heterosexual pedophiles vs. hebephiles (Blanchard et al., 2009).

Another common argument against the expansion of the Pedophilia diagnosis to encompass hebephilic and pedohebephilic types is that “normal” men respond sexually to pubescents. This argument is muddleheaded at best, disingenuous at worst. “Normal” men, as a group, can even be shown to respond to prepubescent children in the laboratory to some degree (Lykins et al., 2010). The issue is not whether normal men respond sexually to early pubescents. The issue is whether it is normal for an adult to respond as much or more to early pubescents than to physically mature individuals. In other words, would it be normal for an adult, given a free and unencumbered choice of sexual interaction with an attractive 12-year-old or an attractive 20-year-old, to take the 12-year-old every time?

Although “mental disorders” may be a fuzzy set, “disorders listed in the DSM” is not. Conditions are in or out; the decision is binary. The DSM-5 Task Force and the APA Board of Trustees may decide against including hebephilic and pedohebephilic types in the diagnosis of Pedophilic Disorder in DSM-5, but that is not the same as taking no action. That is an assertion that men who find early pubescents more sexually attractive than physically mature persons (and whose condition leads to psychological distress, psychosocial impairment, or harm or risk of harm to others) do not have a psychiatric disorder. That might seem, to some stakeholders, the correct decision. If that is the decision taken, however, then the description of prepubescent children in the diagnostic criteria for pedophilia as “generally age 13 years or younger” should be amended to something less misleading. “Generally age 10 or younger” would be closer to the mark for contemporary children.

The Paraphilias Subworkgroup has proposed to differentiate hebephilia as a subtype of Pedophilic Disorder rather than as a separate diagnosis because a non-trivial proportion of men do not distinguish much or at all between prepubescent and pubescent children, are strongly sexually attracted to both, and sexually approach both prepubescent and early pubescent children. Framing separate diagnoses of Pedophilic Disorder and Hebephilic Disorder would thus lead to many unnecessary comorbid diagnoses. Framing classic pedophilia and hebephilia as types of a superordinate category of Pedophilic Disorder makes it possible to include patients attracted to both prepubescent and pubescent children as a third type (“Pedohebephilic Type”) instead of giving them two different diagnoses.

Net-Widening—Results of Independent (Non-APA-Funded) Field Trials

The main reason for amending the diagnosis of Pedophilia to specifically include and identify hebephilic and pedohebephilic types is not to diagnose more people, but rather to diagnose more accurately. Indeed, the maximum age of children for whom an erotic preference is deemed pathological is raised only one year, from “generally age 13 years or younger” to age 14 years or younger. Nevertheless, one valid question that might be posed is whether the proposed diagnostic criteria would significantly increase the pool of persons eligible for DSM diagnosis. This question has been addressed by field trials conducted at sites in three states: Wisconsin, California, and Florida.

Although the American Psychiatric Association was not able to include the diagnostic criteria sets for paraphilias in the field trials for DSM-5, three research teams who had formally applied to be part of the field trials decided to carry out such field trials without APA funding, using their own resources. The subjects were inpatients from the Sand Ridge Secure Treatment Center in Wisconsin, inpatients from the Florida Civil Commitment Center, and outpatients from clinics in California.

The field trial at the Sand Ridge Secure Treatment Center included 64 adult male residents from a Wisconsin inpatient SVP (sexually violent predator) program, who were involved in the later stages of sexual offender treatment. The average age of the subjects was 48 years (SD = 10.8). The field trial at the Florida Civil Commitment Center included 296 adult male residents from an inpatient SVP program, who were involved in psychoeducational or therapeutic programming. Their average age was 47 years (SD = 10.26). The California outpatient samples consisted of 103 adult males treated or assessed at four independent outpatient clinics. The subjects’ average age was 40 years (SD = 12.82).

The field trials used the versions of the proposed diagnostic criteria posted on the APA’s DSM-5 Website in October 2010. The Paraphilias Subworkgroup has subsequently amended the proposed diagnostic criteria, partly because of feedback from the field trials investigators. The main differences between the versions used in the field trials and the current versions are that minimum numbers of victims needed to diagnose certain paraphilias in uncooperative patients have been removed from the diagnostic criteria, and the reference to pornography depicting prepubescent or pubescent children has been removed from the diagnostic criteria for Pedophilic Disorder. It should also be noted that the Paraphilias Subworkgroup originally used the diagnostic label “Pedohebephilic Disorder” to refer to men preferentially attracted to prepubescent children, pubescent children, or both. This has since been changed to “Pedophilic Disorder” on the grounds that the word “pedohebephilic” is unfamiliar and too long. In earlier documents and in the field trials, the term “Pedohebephilic Disorder” was used to denote the erotic preference for prepubertal or early pubertal children. The writer will use the diagnostic label used by the field trials investigators, Pedohebephilic Disorder, when talking about the results of the field trials.

The analyses of the data from the CA, WI, and FL field trials are still going on and will probably not be fully finalized for some months, because the researchers are conducting this work using their own resources and their own time. Some preliminary results, however, were recently presented at the annual meeting of the Association for the Treatment of Sexual Abusers (D’Orazio, Wilson, & Thornton, 2011). The available data appear to be quite sufficient to answer the question of whether the alteration of Pedophilia to specifically include and identify hebephilic and pedohebephilic types would result in more persons receiving a DSM diagnosis.

The results showed that there was no increase in the number of patients diagnosed with Pedohebephilic Disorder compared with DSM-IV-TR Pedophilia in the sample from the Sand Ridge Secure Treatment Center. The overall rate of agreement was 89% of cases (57/64). The breakdown of agreements and disagreements was as follows: 32 cases were diagnosed positively by both DSM-IV-TR and DSM-5 criteria, 25 cases were diagnosed negatively by both DSM-IV-TR and DSM-5 criteria, 6 cases were diagnosed positively by DSM-IV-TR but not by DSM-5 criteria, and 1 case was diagnosed positively by DSM-5 but not by DSM-IV-TR criteria. The 6 cases who were diagnosed positively by DSM-IV-TR but not by DSM-5 did not meet the latter’s criteria because they were only 16 or 17 years of age at the time of their sexual offenses against children. The 1 case who was diagnosed positively by DSM-5 but not by DSM-IV-TR did not meet the latter’s criteria because the patient had offended against 14-year-old children but not against younger children.

In the sample from the Florida Civil Commitment Center, there was no increase in diagnoses when one considers the number of patients who had been originally diagnosed with DSM-IV-TR Pedophilia or DSM-IV-TR Paraphilia NOS—Adolescent Victims. A diagnosis of DSM-IV-TR Pedophilia was made in 49.0% of cases (145/296) by Florida SVP (Sexually Violent Predator) evaluators, and a diagnosis of either DSM-IV-TR Pedophilia or DSM-IV-TR Paraphilia NOS—Adolescent Victims was made in 62.2% cases (184/296). A diagnosis of DSM-5 Pedohebephilic Disorder was made in 59.1% of cases (175/296) by the research team. Further information on diagnostic agreement on these cases is not available at this writing. Thus, the number of cases positively diagnosed under the two systems is similar (62.2% vs. 59.1%), but it is not yet clear to what extend these were the same cases.

It should be noted that the diagnosis of Paraphilia NOS—Adolescent Victims is used with some regularity in Florida; 39 of the 296 civilly committed subjects in the Florida sample had received this diagnosis from SVP evaluators prior to the field trials. Of those 39, 25 were diagnosed with DSM-5 Pedohebephilic Disorder by the research team. It therefore appears that only 64.1% of the men diagnosed with Paraphilia NOS—Adolescent Victims under DSM-IV-TR criteria would be diagnosed with Pedohebephilic Disorder under the proposed DSM-5 criteria.

Finally, there was no increase in the number of diagnoses among the California outpatient sex offenders. The overall rate of agreement was 97% of cases (100/103). The breakdown of agreements and disagreements was as follows: 34 cases were diagnosed positively by both DSM-IV-TR and DSM-5 criteria, 66 cases were diagnosed negatively by both DSM-IV-TR and DSM-5 criteria, 2 cases were diagnosed positively by DSM-IV-TR but not by DSM-5 criteria, and 1 case was diagnosed positively by DSM-5 but not by DSM-IV-TR criteria. The 2 cases who were diagnosed positively by DSM-IV-TR but not by DSM-5 did not meet the latter’s criteria because they had only one victim. The 1 case who was diagnosed positively by DSM-5 but not by DSM-IV-TR did not meet the latter’s criteria because the person had pubescent victims only.

The field trials investigators concluded that “There is no evidence to indicate more [patients] would be diagnosed with Pedohebephilic Disorder than are currently with Pedophilia.” It therefore appears that the Paraphilias Subworkgroup’s goal of diagnosing more accurately rather than diagnosing more frequently was met by the version of the diagnostic criteria used in the field trials.

References

Beier, K. M., Neutze, J., Mundt, I. A., Ahlers, C. J., Goecker, D., Konrad, A., & Schaefer, G. A. (2009). Encouraging self-identified pedophiles and hebephiles to seek professional help: First results of the Prevention Project Dunkelfeld (PPD). Child Abuse & Neglect, 33, 545–549.

Blanchard, R. (2010). The fertility of hebephiles and the adaptationist argument against including hebephilia in DSM-5 [Letter to the Editor]. Archives of Sexual Behavior, 39, 817–818.

Blanchard, R., Kolla, N. J., Cantor, J. M., Klassen, P. E., Dickey, R., Kuban, M. E., & Blak, T. (2007). IQ, handedness, and pedophilia in adult male patients stratified by referral source. Sexual Abuse: A Journal of Research and Treatment, 19, 285–309.

Blanchard, R., Lykins, A. D., Wherrett, D., Kuban, M. E., Cantor, J. M., Blak, T., Dickey, R., & Klassen, P. E. (2009). Pedophilia, hebephilia, and the DSM-V. Archives of Sexual Behavior, 38, 335–350.

D’Orazio, D. M., Wilson, R. J., & Thornton, D. (2011, November). Prevalence of Pedohebephilia, Paraphilic Coercive Disorder, and Sexual Sadism diagnoses with the proposed DSM-5 criterion sets. Paper presented at the 30th annual meeting of the Association for the Treatment of Sexual Abusers, Toronto, Ontario, Canada.

Glueck, B. C., Jr. (1955). Final report: Research project for the study and treatment of persons convicted of crimes involving sexual aberrations, June 1952 to June 1955. New York: New York State Department of Mental Hygiene.

Lykins, A. D., Cantor, J. M., Kuban, M. E., Blak, T., Dickey, R., Klassen, P. E., & Blanchard, R. (2010). Sexual arousal to female children in gynephilic men. Sexual Abuse: A Journal of Research and Treatment, 22, 279–289.