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.

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