Monday, May 7, 2012

Civility, Accuracy, and Noise: It’s Time to Get Past the Pandemonium Surrounding the DSM-5 Paraphilias Subworkgroup

David Prescott & Robin J. Wilson

Almost every discussion regarding sexual violence ultimately involves some element of emotion. We understand this. The sexual abuse of children and other vulnerable persons is going to cause a variety of responses—many of them quite visceral. Presumably, how any one individual perceives and responds to this issue will be at least partly determined by the level of knowledge they have of sexual violence.

In a recent survey, the Center for Sex Offender Management (CSOM) asked Americans a number of questions about sexual violence. One area of questioning pertained to knowledge of the dynamics of sexual offending and sexual offender management. Interestingly, a majority of those asked reported that information about these issues should come from “experts” (i.e., researchers and practitioners). Not surprisingly, a majority of those asked stated that their main source of information was the popular media. So, here we have a clear problem.

The origins of that problem are interesting. For some time now, researchers and practitioners have been amassing expert knowledge in how to identify at-risk offenders, offer evidence-based treatment, and how to promote community safety, offender accountability, and reasonable practice. However, that knowledge and expertise is shared mostly with peers—a veritable preaching to the choir scenario. Truth is, many scientist-practitioners are reticent to enter the public forum regarding sexual violence precisely because of the aforementioned emotionality associated with it. An unfortunate consequence is that the popular media and, by extension, the public at large is left to speculate, emotionally, in the absence of the objectivity of science.

This suggests that a call to arms is required if the broader dissemination of the science is in any way going to assist the public in dealing with their fear and anger. At the very least, those of us with the ability to share expert knowledge and perspective with the greater public need to do so more often. And, of those who do, there is a need to provide clear, unbiased, and defensible information to a public that has clearly stated that they are waiting for us to do so.

In that vein, we recently reviewed a blog post by former DSM Chair Dr. Allen Frances. Dr. Frances is a frequent commentator on issues related to psychodiagnostics, as one might expect given his history. In the recent past, Dr. Frances has issued several scathing commentaries regarding proposed changes to the diagnostic criteria for the Paraphilias. Responses to those pieces have been the subject of earlier blog posts here at The current blog post addresses elements of Dr. Frances’ most recent issuance.

In his post, Dr. Frances waits until the concluding sentence to acknowledge “the confusion we caused by the poorly written section in DSM IV”. While we applaud this apparent accountability on Dr. Frances’ part, we find it ironic that the blog post itself does more to confuse the issues than clarify them. Here is what we mean:

Dr. Frances first describes hypersexuality as “sex addiction”, the latter being a largely undefined term of questionable validity or utility in clinical settings. Its use is spreading without the help of the DSM. He next likens the proposed Hebephilic subtype of Pedophilia to statutory rape. Neither of these diagnostic descriptions is accurate. In fact, the proposed categories are attempts to bring to heel the very diagnostic uncertainty that many among us have seen cause genuine human suffering. Here, we would suggest that Dr. Frances has strayed from his role as a scientist/practitioner and expert commentator. Of particular concern is the cavalier and inflammatory manner in which he characterizes what we believe to be quite serious behavioral problems. To use it again as an example, Dr. Frances’ equating of hebephilia with statutory rape causes us to question what he actually knows of sexual violence, the paraphilias, and their manifestations. His analogy is quite simply ludicrous, and we find it difficult to discern how he came to see persistent or preferential sexual interest in early adolescents as being the same as coercing a young person to engage in sexual activity when they are underage. (Actually, date rape includes a number of possible scenarios outside of anything to do with the sexual abuse of young persons.) We encourage readers to read the actual research and proposed categories; the conceptual confusion surrounding Hebephilia is precisely why empirically supported diagnostic clarification is needed.

At the core of Dr. Frances’ arguments is the fact that current sexual disorders are being used in the civil commitment of people who have sexually abused. However, Wilson, Pake, & Duffee (2011, email for a copy of the presentation) found that 36% of civilly committed people diagnosed with Paraphilia NOS (adolescent victims) using DSM-IV-TR criteria did not meet the proposed DSM-5 criteria for Pedohebephilia. Whatever one’s opinion of sexual offender civil commitment might be, DSM-IV-TR diagnoses have resulted in a wider diagnostic net. This needs to change. To put a finer point on this element of Dr. Frances’ claims, well-known sexual offender public policy expert Dr. Jill Levenson of Lynn University in Boca Raton tells us that civilly committed sexual offenders comprise approximately one percent of all sexual offenders. Dr. Frances centers much of his criticism of the proposed paraphilia criteria on the possibility that they may inflate civil commitment. On the other hand, we wonder whether failing to clean up the current difficulties in diagnosing the paraphilias might cause even more harm for the other 99 percent.

Dr. Frances, as always, makes a number of interesting points. However, the overall tone of his post calls his message into question. He refers to the proposed categories as “remarkably offbeat” and vulnerable to “serious forensic mischief”. He claims “universal opposition” from those in the field while making exhortations such as “come on, guys”. All the while, he provides no evidence for his statements and claims that the members of the Subworkgroup recognize that the “jig is up”. This approach strikes us as being more of the same thing that regular citizens say they typically get (popular media), and not what they say they want (information from experts).

Further still, Dr. Frances’ messages carry a certain weight because of his former role—to the extent that he has a duty to present reasoned, scientifically informed perspective to his readers, including other experts. As one might expect, Dr. Frances’ blog post has made the rounds of listserv discussions, arguably much more so than the actual scientific evidence. This, too, reflects poorly on Dr. Frances and on our field (with which Dr. Frances apparently has little experience). Even that venerable manual, Strunk and White’s Elements of Style cautions writers that, “when you overstate, readers will be instantly on guard, and everything that has preceded your overstatement as well as everything that follows it will be suspect in their minds because they have lost confidence in your judgment or your poise”.

Sexual violence can cause genuine human suffering for those who are victimized as well as those who perpetrate it. While the blogosphere can be an easy way to influence others, we believe that all professionals have an obligation to familiarize themselves with the actual thinking and research behind the proposed categories and not simply evocative assumptions. The field of understanding and rehabilitating people who have sexually abused deserves meaningful, respectful dialog that does not cause greater confusion in the minds of readers. We urge readers to study the proposed categories and the science underpinning them.

Tuesday, May 1, 2012

Sex Offender Registration and Notification: Who's driving the bus?

On Friday and Saturday April 20-21, 2012, the Florida chapter of the Association for the Treatment of Sexual Abusers held its annual conference. Our keynote speaker was Jennifer Dritt, Executive Director of the Florida Council Against Sexual Violence (representing all of the rape crisis centers in FL). During her talk, Ms. Dritt said clearly that she and her associates (victims' advocates) were unhappy with the state of the registration and notification laws in FL. During ad hoc discussions on the matter, we agreed that we could generally extrapolate that perspective to much of the same legislation in other states, federally, or even internationally.

In general, these pieces of legislation have public safety in mind, and I believe that the politicians and policymakers who enact them truly do have the intent to increase public safety. However, those of us who work specifically in the worlds of sexual abuse prevention, offender treatment, or services to those who have been victimized know that the empirical literature has not generally supported these laws, at least not insofar as there are obvious direct benefits, such as reduced reoffending.

Actually, we have seen from research published by ATSA members, like Jill Levenson of Lynn University in Florida (also a participant in the recent FL ATSA conference) and Elizabeth Letourneau (now of Johns Hopkins University) and Mike Miner of the University of Minnesota (dealing with juveniles who commit sexual offenses), that get tough on crime or get tough on offenders might not be the evidence-based way to go. Specifically regarding adult offenders, residency restrictions, public notification, and sexual offender registration appear to be more the result of political rhetoric than science. The alarming trend regarding juveniles appears to be a prevailing view that these youth are just "little adults" who must be managed in more or less the same manner as their adult counterparts. The evidence to date appears to strongly suggest that this is unlikely to be true.

Interestingly, when we look at some of the dynamic risk prediction schemes (e.g., Hanson et al.'s Dynamic Supervision Protocol) that are available to clinicians and probation/parole supervisors--at least on the adult side of the risk management house--it seems that many of the very factors linked to reoffending (e.g., social isolation/rejection, negative emotionality, lack of prosocial influences, inability to establish links to or a place in society, inability to comply with terms of re-entry) are the sorts of things that are realistic consequences of current residency restriction/public notification/registration practices. In short, by implementing such policies and legislation, we might actually make things worse by leading to destabilization of released offenders. Those who might counter that the answer is to simply stop releasing sexual offenders should consider that such a practice would ultimately cost taxpayers even more in terms of unnecessary incarceration and other associated costs for a group of offenders who, as a group, appear to reoffend at a rate of approximately 10-15% over 5 years or longer of follow-up (actually, many states are now reporting rates considerably lower--see Jon Brandt's blog post of February 22, 2012).

Certainly, there are subsets of the sexual offender population who pose a greater degree of risk than the 10-15% noted above, but the key is to appropriately identify these individuals and use our most stringent and resource-intensive measures (incarceration, supervision, treatment) with them. When we uniformly apply all measures to all offenders, we wash out their potential benefits by expending too many of our services in over-managing the low risk offenders at the expense of having enough time and resources (both human and financial) to appropriately manage the high risk offenders.

But, to get back to where we started...

I'm sure there are points on which Ms. Dritt and I might disagree, but this is not one of them: If the victims' advocates don't like these policies and those who work with offenders don't like these policies and the research suggests they do little, if anything, to reduce risk in their present incarnation, why do we still have them in their present forms?