CoSA in the USA ... and Beyond

In some respects, this has been a big year for Circles of Support & Accountability. Internationally, the first UK projects celebrated their 10^th anniversary of offering Circles, in addition to completing a matched comparison design evaluation that mimics existing research in its findings (approximately 70% reductions in violent or sexual offending--these results are currently in peer-review). Under the direction of Executive Director Stephen Hanvey, Circles-UK also commissioned a cost-benefit analysis from researchers Ian Elliott and Tony Beech and published in SAJRT. When reviewing only tangible costs, CoSA costs no more than traditional probation supervision. However, when intangible costs are also factored in, the CBA reaches 3.52; meaning that for every British Pound spent on CoSA, taxpayers get £3.52 back in benefit.

Elsewhere, the European group, headed up by the Netherlands, has secured a grant from the European Union to sponsor CoSA development in Bulgaria, Catalonia, and Latvia. The Dutch group—led by Bas Vogelvang, Mechtild Hoing, and Jeanne Caspars—jumped right in and started adding their voice to the CoSA movement worldwide. Specifically, they contributed to a small but important revision to the graphic for CoSA—seen below—in adding specific reference to a coordinator role essential to ensuring ongoing dialog between the two levels of support and accountability. Their most noteable contribution has been the publication of a European CoSA Handbook.

Here in the United States, we have also seen some great strides forward in the CoSA movement. Colorado and Vermont have been ongoing recipients of Second Chance Act grants intended to assist (at least partly) with sexual offender reentry. Elsewhere, Circles projects continue to sprout up in various US locations. Towards the end of this year, the federal government (through the SMART Office) issued three CoSA-specific requests for proposals:

1.     To support three CoSA start-up projects (Oregon Department of Corrections and the Criminal Justice Resource Center in Durham, North Carolina were ultimately named by DOJ)

2.     To provide training and technical assistance to the OR and NC projects, as well as other CoSA projects on an ad hoc basis (with that DOJ contract going to a group led by yours truly and including Canadian CoSA expert Andrew McWhinnie)

3.     To conduct an evaluability study on CoSA projects in the USA (awarded by NIJ to the aforementioned Ian Elliott and his associate Gary Zajac at Penn State)

The move by SMART to fund CoSA-related projects is part of their ongoing attempts to encourage and support evidence-based practices in sexual offender risk management. CoSA projects are now underway or in progress in California, Colorado, Minnesota, Nebraska, North Carolina, Oregon, Pennsylvania, Washington, and Vermont. A first-ever all-USA CoSA symposium was held at last fall’s annual ATSA conference in Denver, with CA, CO, MN, and VT represented. Of particular interest during the symposium was the presentation by MnCoSA, which reported results from a recently published RCT evaluation of their project. Although the follow-up period was too short to show significant differences in sexual recidivism, significant reductions were noted for CoSA core members in regard to probation violations, incurring new charges, and return to custody. Last, MnCOSA researcher Grant Duwe was able to show a 1.82 cost benefit (also in SAJRT).

Finally, Canadian CoSA projects are embarking on a national evaluation, with funding provided by the National Crime Prevention Centre (an arm of Public Safety Canada). We hope to start seeing more extensive outcome data from Canada in about 18 months.

A big year, indeed.

Pornography and Contact Offending

Jon Brandt

David S. Prescott

Robin J. Wilson

Many people have grave concerns about the potential for a relationship between pornography and inappropriate sexual behavior. For obvious reasons, there are apprehensions about the sexual behaviors of those who have sexually abused. As a result, it is not uncommon for persons who have sexually abused to be restricted from certain activities that would have remained available to them had they not sexually offended. However, questions remain as to whether we are using our professional energy and resources wisely in trying to prevent persons convicted of sexual crimes from being sexually active. This point extends to whether persons who have sexually abused should have access to sexually explicit materials.

There are many reasons not to like pornography. Perhaps women, more than men, are objectified by pornography. Both women and men have raised questions about how pornography cheapens and depersonalizes sex. As men dedicated to sexual violence prevention, we are concerned about both the demeaning representation of women and the unflattering portrayal of men (e.g., piggish, self-absorbed, or uncaring) in much commercial pornography. There are also concerns about the effects of the depiction of unhealthy, violent, or potentially harmful sexual behaviors. There is an open question about the long-term effects of exposure to sexually explicit media. These are important considerations, but as offensive as pornography is to many people, extant research does not support a causal relationship between pornography and sexual offending.

Defining pornography remains a challenge. In our field, this is not simply an academic discussion. Sexual offenders are typically restricted from possessing any type of pornography, but there are no clear demarcation points between artistic expressions of the human form, sexually suggestive images, erotica, or hard core pornography. When the legal consequences for possession of any sexual media are so severe, defining pornography has never been more important.

In the US, numerous court decisions, presidential task forces, and various “think tanks” have been unable to produce an agreement or useful definition of “pornography.” With the need for greater precision within our profession than perhaps elsewhere in public discourse, our field would benefit from fine-tuning and distinguishing between various types of sexual media. Using "pornography" to describe all forms of sexual media is both imprecise and emotionally loaded. It can obscure treatment needs and interventions. Missed opportunities of therapeutically beneficial sexual imagery could inadvertently lead to more harm.

The historical perspective that sexually explicit images are offensive and therefore must be harmful is such a powerful narrative that it is difficult to close the gap between what we know about private sexual behavior and widespread public perceptions. We wonder whether some restrictions imposed on our clients are the considered application of good science or a default result of moral panic. If the latter is true, are therapists complicit in the unwarranted enforcement of social controls more than the healing arts of rehabilitation?

Gone are the days when pornography originated in adult bookstores or arrived discreetly in the mail. Most sexual media today is user-produced and shared through cell phones and the Internet. The use of sexual media by male teens and adults today is not just normative, it is pervasive. Science has yet to show any key differences between those who “sext” and those who do not, except for the behavior itself. Consumption of sexually explicit imagery has been explosive in the last decade. Sexual content in cyberspace may account for more than 30% of the data transfer of the entire Internet. Starting as teenagers, consumers are overwhelmingly male, but also include a significant percentage of women.

Though controversial and perhaps even counterintuitive, evidence of the adverse effects of sexual media has not been established. Other than child pornography, broad sexual media restrictions for most persons who have sexually abused does not appear to be supported by research. Frequently, restrictions on "pornography" for such clients include prohibition of every type of sexual media. Without knowing whether some level of exposure to some form of sexual media might have some adverse effects on human behavior, we use a "shotgun” approach to such restrictions. These squishy definitions and operatives also compromise research.

We each entered the field of treating sexual aggression at a time when professionals assumed that all persons who had sexually abused were at high risk to persist. Not only has this turned out to be untrue, but the rates of sexual aggression and re-offense have declined at the very same time as access to sexually explicit imagery has never been easier. Although we know of no interactive relationship between these co-occurring trends, they should each cause us to reconsider our attitudes and beliefs about what is important in the treatment and supervision of persons who have sexually abused.

There has been limited research involving pornography’s influence on sexual aggression. The strongest concerns in studies published in refereed journals include a potentially aggravating influence of routine pornography use by men already at high risk for re-offending (and/or higher in entrenched antisociality, sometimes referred to as psychopathy). Certain types of pornography with high-risk offenders may also increase risk. Researchers such as Drew Kingston and Neil Malamuth appear to support the cautious position that without more conclusive research we should evaluate higher risk situations on a case by case basis. To our knowledge, no studies have as yet produced a credible indictment of pornography usage among persons who have sexually abused.

Two additional facts are worthy of consideration. First, both biased and impartial groups have been funding research for more than 50 years to find a connection between pornography and sexual offending, and none have been able to find any definitive link. Second, despite the explosion of sexual media since the advent of the Internet and rapid transfer of visual imagery, there has been no increase in rates of sexual offending—everywhere it has been studied, around the world. Arguably, the same information superhighway that provides access to pornography has also brought attention to the numerous media outlets that remind us that true sexual violence is intolerable.

Several researchers have suggested that the correlation between pornography and sexual offending is either absent or inverse. A noteworthy advocate for this theory is sexologist Milton Diamond of the University of Hawaii. His published research on pornography and sexual offending in the US, Japan, and Europe persuasively argues that the relationship between pornography and sexual offending is negatively correlated. Diamond's research appears to also hold true for the relationship between child pornography and engagement in contact offenses. If validated, consider the implications of such findings in mitigating contact offenses against children, as offensive as it may seem. Perhaps adult pornography really is more offensive than actually harmful in the treatment and supervision of people who have sexually abused.

What might account for a negative correlation between pornography and contact offenses? Diamond and others have theorized that sexual media may provide a vicarious satisfaction of sexual curiosity and/or a cathartic venting effect for libido. If this theory turns out to be correct, restricting most sexual offenders from having sexual media might not just be overly cautious, it might, in individual circumstances, be counterproductive.

Kingston and Malamuth have challenged some of Diamond's research, but only to the extent that Diamond's aggregate data, while compelling, might not apply to certain individuals. Theirs is an important point for consideration. Michael Seto has raised similar concerns with respect to certain risk factors and child pornography. We can also see how this is an important aspect to consider. However, a ban on all sexual media for all persons who have sexually abused appears neither science-based nor justified.

At what point does research become conclusive? It may be that pornography currently remains too controversial and emotionally charged for effective public policy to emanate from good science. Nonetheless, our concern is that broad bans on sexual media may be squandering resources, at the expense of truly science-based treatment and supervision elsewhere.

These are not simply academic points. Revoking a person’s parole or violating their probation because of behaviors that are socially undesirable, rather than an established characteristic of risk or harm, can be costly to society as well as the individual. All too often, we implement public policies and impose restrictions on offenders because we feel better to believe we are doing something to help stop victimization. However, we should also consider that when we overreach with risk management, limited resources are stretched thin.

We are not suggesting that pornography use by clients should be ignored. Following the model of Risk-Needs-Responsivity, the risk and need principles may guide the formation of effective therapeutic and correctional interventions. To that end, clinicians would be wise to thoroughly assess the effects of sexual media on individual clients (see appendix). Professionals should avoid restricting clients’ access to sexual media based only on personal values, unsupported professional beliefs, or undocumented theories. Therapeutic efforts should be focused on managing abuse-related sexual interests (as opposed to all sexual interests). Therapists can provide clients with education about healthy sexuality, with the end goal of a safe, fulfilling, and non-exploitive sex life.

Given that science continues to better inform us about the psychological and social dynamics of sexual behavior, we should periodically review status quo. When scientific trending suggests current policies or practices might be unfounded, outdated, or perhaps even counterproductive, we should gather the professional courage to explore better pathways that might more effectively prevent or mitigate sexual offending.

Appendix

In assessing the effects of sexual media with individual clients, clinicians might explore:

1) The client’s history, current use, and experience with different types of sexual media.
2) The client’s use of sexual media compared to normative data.
3) Possible connections between certain sexual media and problematic sexual behavior.
4) Escalating or compulsive patterns of the use of sexual media.
5) The possible relationships of sexual media to the index offense(s).
6) The use of sexual media as socially or psychologically protective measures.
7) How sexual media could be interfering with relationships.
8) The use of sexual media to explore or satisfy sexuality curiosity.
9) How sexual media is an element of libido management.
10) Whether clients might benefit from a modified use of sexual media.
11) The possible therapeutic or conditioning benefits of proscriptive sexual media.
12) Sexual media that might be contraindicated therapeutically or socially.
13) The legal hazards or consequences for accessing certain types of sexual media.
14) Limitations on certain sexual media for specific higher-risk offenders.
15) The various risk factors involved in client’s access to sexual media via the Internet, cell phones, digital cameras, Wi-Fi communication devices, and social networking websites.
16) The degree to which clients can exercise internal controls in managing sexual media or to what level external controls might be beneficial to aid in risk management.
17) How clients can move from external controls to internal controls prior to discharge from treatment or supervision in anticipation of independent management.

References

Andrews, D.A., & Bonta, J. (2010). The psychology of criminal conduct. 5th Ed. Cincinnati, OH: Anderson.

Bensimon, P. (2007). The role of pornography in sexual offending. Sexual Addiction & Compulsivity, 14.

Burton, D. (2010). Comparison by crime type of juvenile delinquents on pornography exposure: The absence of relationships between exposure to pornography and sexual offense characteristics. Journal of Forensic Nursing, 6.

D’Amato, A. (2006). Porn up, rape down. Northwestern Public Law Research Paper No. 913013.

Diamond, M. (1999). The effects of pornography: An international perspective. International Journal of Law and Psychiatry.

Diamond, M. (2009). Pornography, public acceptance and sex related crime: A review. International Journal of Law and Psychiatry.

Diamond, M., et al. (2010). Pornography and sex crimes in the Czech Republic. Archives of Sexual Behavior, 40, 1037-1043.

Diamond, M., et al. (2011) Rejoinder to Kingston and Malamuth. Archives of Sexual Behavior, 40, 1049-50.

Ferguson, C.J. & Hartley, R.D. (2009). The pleasure is momentary… the expense damnable?: The influence of pornography on rape and sexual assault. Aggression and Violent Behavior, 14, 323-329.

Kingston, D. & Fedoroff, P. (2008). Pornography use and sexual aggression: The impact of frequency and type of pornography use on recidivism among sexual offenders. Aggressive Behavior, 34, 1-11.

Kingston, D. & Malamuth, N. (2009). The importance of individual differences in pornography use: Theoretical perspectives and implications for treating sexual offenders. Journal of Sex Research, 46, 216-232.

Kingston, D.A. & Malamuth, N.M. (2011). Problems with aggregate data and the importance of individual differences in the study of pornography and sexual aggression: Comment on Diamond, Jozikova, and Weiss (2010). Archives of Sexual Behavior, 40.

Seto, M.C., et al. (2010). Contact sexual offending by men with online sexual offenses. Sexual Abuse: A Journal of Research and Treatment, Vol. 23.

Williams, K.M., et al. (2009). Inferring sexually deviant behavior from corresponding fantasies: The role of personality and pornography consumption. Criminal Justice and Behavior, Vol. 36, 198-222.

Winick, C. & Evans, J.T. (1996). The relationship between non-enforcement of state pornography laws and rates of sex crime arrests. Archives of Sexual Behavior, 25.

Brian Patrick McKegney 1950 - 2012

McKEGNEY, Brian Patrick - born June 23rd 1950 died unexpectedly September 2nd, 2012 of complications following surgery at Kingston General Hospital. Cherished husband of Cindy McKegney. Devoted Dad to Kate (Krin Mann) and Neal McKegney.



Sometime in the summer of 1992, I met Brian McKegney. I was a newly hired psychologist for the Central Ontario District (essentially, the Greater Toronto Area, or GTA) of the Correctional Service of Canada. He was the staff training coordinator for the District. Brian’s personality was as big as a house and often preceded him, as he was often heard exclaiming, “Holy Doodle” in response to colleagues who shared events and stories with him. The relationship we developed was one of the most important in my career.

Brian was a Parole Officer by trade, but he truly found his calling in staff training—a field in which he excelled like few others. In fact, I believe to this day that Brian was good at his job because he was propelled into it by life experience and he was driven by a need to ensure that he made a difference.

As the new kid on the block—the District’s first community based sex offender specialist—I had knowledge and expertise that would ultimately prove helpful to Brian as he attempted to develop a sex offender risk management training curriculum for parole officers and other staff in the District. We became quite a team. In fact, if you were a PO working in the Ontario Region in the 1990s, there was a good chance that you got your training in working with sex offenders from the one-two punch of McKegney and Wilson. He did the supervision side and I covered the clinical side.

Over the span of eight or so years, we got to meet many CSC staff and community partners (including police and agency staff) as we offered our 5-day course throughout the province, with many interesting and wonderful (if not colourful) extra-curricular moments in the hours outside of the classroom. We clicked. Indeed, before Brian, I had never really done much public speaking. As a lifelong stutterer, I eschewed such responsibilities. Brian taught me how to be a good presenter and encouraged me to be better with each opportunity. I now spend most of my professional life standing in front of crowds of people of various sizes, engaging in knowledge transfer, and trying to do it as well as my buddy Brian did.

However, the learning didn’t stop at the end of the training day. As I worked with this powerful educator, I discovered a bit about the man, the father, and the friend, and why he was so passionate about this particular element of his job—sex offender risk management. In many ways, Brian was working out his personal trauma.

The early 1990s saw many sweeping changes to the way in which sex offenders were managed by CSC in the community. In the span of a few short years in the late 1980s, three particularly troubling sexually motivated murders were perpetrated by offenders on conditional release in the Ontario Region. These events would cause CSC to completely rethink and revamp its methods of treating and supervising conditionally released sex offenders. Indeed, a good part of the reason for my being hired was to increase the likelihood that comprehensive aftercare and treatment services would be available to parolee sex offenders in the GTA.

Perhaps the most troubling of these crimes was that perpetrated on young Christopher Stephenson—by all accounts, a wonderful 11-year-old boy who was abducted from a suburban shopping mall in Brampton on Father’s Day weekend in 1988, sexually assaulted over a day and a half, and murdered. The Coroner’s Jury of the ensuing Stephenson Inquest would level some damning criticisms at the way in which sex offenders were managed in the community, and their recommendations forever changed sex offender risk management policy and practice in Canada. Canada’s first sex offender registry—Christopher’s Law—was named in honour of this young boy.

Brian was a Parole Officer when Christopher died, and he had some degree of involvement in the case. I came to learn that his participation in the case and, ultimately, the inquest, fundamentally changed him as a civil servant and human being. Brian set about becoming as knowledgeable as he possibly could about sex offender risk management, I think, in good part because of a burning desire to make sure that this never happened again on his watch. He took it personally. Brian needed to know that the staff he was responsible for training would have the best training and tools available to assist him in his personal quest for No More Victims.

Ultimately, Brian moved on to be a Staff Training Officer at the Regional Correctional Staff College in Kingston and I took a job in Florida. We didn’t speak often but, from time to time, one of us would call the other to check in. In hindsight, I didn’t do this often enough.

During my time training with him, Brian astounded me with his voracious appetite for new science and literature—evidence-based practice and perspective—in addition to new and improved ways of getting the message across that we (the Correctional Service of Canada and its staff) needed to do a better job to protect the citizens of Toronto and elsewhere. Brian’s breadth of knowledge and understanding was driven by a passion for and dedication to community service that was sincerely greater than that demonstrated by most other professionals with whom I have had the occasion to work. He never stopped being that way, as is clearly apparent in the many messages of condolence posted online after his death by those he trained and worked with. Those who knew him will miss him dearly; those who didn’t are poorer for the missed opportunity. For me, Brian set the bar. I will always be encouraged to work harder in what I do because of the example he set.

Rest peacefully, Doodle Man.

London Calling: Circles South-East Marks 10 Years of COSA in the UK

In June 2000, I was privileged to be one of five Canadians invited by the Quakers and the UK Home Office to discuss what was then a relatively new innovation in re-entry for persons who have sexually offended. Circles of Support and Accountability was just starting to take hold in Canada, and we had had the opportunity to present preliminary research findings at ATSA, ACA, ICCA, and other research and treatment conferences—apparently catching the attention of our British compatriots.

Robin Wilson, Evan Heise, Det. Wendy Leaver, Gerry Minard, Rev. Hugh Kirkegaard

The "Canadian Connection" at Friends House, Euston Square, June 2000

Within two years of our visit and discussions, Circles projects were established by the Lucy Faithfull Foundation (under the direction of Donald Findlater) and the Hampshire and Thames Valley Probation Offices (with Becky Saunders and Chris Wilson leading the way). COSA has since flourished in the UK, with projects found in various communities. In the summer of 2008, a national charity was rolled out under the name “Circles-UK”. As the COSA model moves forward into Europe, Circles-UK continues to play an important role in supporting similar endeavours in such countries as the Netherlands, Belgium, and France, among others.

Meanwhile, back in the UK, celebrations are afoot, and not just because this is a big Jubilee year for the Queen or because the Olympics are about to begin …

On July 6, 2012, Circles of Support and Accountability celebrated 10 years in the United Kingdom. At a very well attended event at Friends House in the Euston Square area of London, British and international delegates met to hear about the successes of the Circles South-East group (formerly Hampshire and Thames Valley Circles, but now including Kent—hence the new name). Keynote speakers at the conference included desistance expert Fergus McNeill of the University of Glasgow and Probation Service psychologist Andrew Bates (who has written or collaborated on the bulk of the UK COSA evaluation research, see here and here).

Andrew Bates presents outcome data from
Circles South-East's new study.

In a document entitled “Ten Years One Hundred Circles: Community Safety – What Can Be Done”, the Circles South-East folks recount the long road from project inception to their current status as the largest COSA project outside of Canada. The booklet includes information and perspective on the UK version of COSA, with inspirational stories from volunteers and core members. There is also a final chapter in which an updated outcome evaluation of the project is presented.

The evaluation, entitled “Circles South-East: The First Ten Years 2002-2012”, co-authored by Andrew Bates, Rebekah Saunders, Dominic Williams, Chris Wilson, and yours truly, marks the first time that our UK compatriots have been able to include a comparison group. This comparison group is comprised of persons who were referred for a COSA but who, for some reason, were never taken into one. Care was exercised not to include those who would never have been placed anyhow, for reasons such as no impending release or a lack of motivation to be involved in a COSA. Fortunately, Risk Matrix 2000 scores were available on these control subjects and the study’s authors were able to identify a similar risk distribution; however, on average the comparison sample (N = 71) was at somewhat lesser risk to reoffend than their COSA-involved peers (N = 71).

The study is currently being prepped for submission for peer-review; however, let me share some of the outcome data with you here. Although the comparison group was of somewhat lower risk, their rates of reoffending (contact sexual or violent reconviction) were significantly higher (see table below). They also had a tendency to higher rates of failure to comply with registration requirements. Indeed, in the COSA group, there were no reconvictions for contact sexual or violent reoffenses. In regard to non-contact sexual offenses, there were three in the COSA group and two in the comparison. Adding the contact and non-contact sexual and violent offenses resulted in a difference of 3 vs. 12, a finding that is also statistically significant (χ2 = 4.77, p < .05). Average length of follow-up was approximately 4.5 years for both groups.

The research findings supporting the COSA model continue to grow. Indeed, I have it on good authority that the outcome study completed by Grant Duwe of the Minnesota DOC’s COSA project (MnCOSA) has been accepted for publication by SAJRT. What makes this particularly exciting is that Grant used a Randomized Clinical Trial (RCT) design – by far the most elegant yet in COSA research. I won’t steal Grant’s thunder by publishing his results here; take it from me that they are strongly supportive of a perspective that COSA not only assists Canadian and British core members, it is also helpful in reducing post-release difficulties for American core members. Once Grant’s study is released "online first", I will be sure to blog about it here.

RJW

Getting the Message Right:

Compassion and Media Responses to Sexual Abuse

A guest blog by:

David S. Prescott, LICSW

Readers of this blog are no doubt familiar with James Cantor. A scientist and editor of Sexual Abuse: A Journal of Research & Treatment (ATSA’s journal), James has spent his career seeking out ways to understand and prevent sexual abuse. With the Jerry Sandusky trial in the media spotlight, CNN recently asked James to write a piece for the opinion section of its web site. His submission carried the title “The Science of Pedophilia and the Prevention of Child Molestation”. Typical of news media outlets, James had control over his text, but CNN elected to use the catchiest possible headline: “Do Pedophiles Deserve Sympathy?”

The good news is that James’ article is excellent and garnered enough attention to warrant an on-air interview on CNN’s “Newsroom” with Don Lemon. It is encouraging to see reasonable, science-based information available to the public. My concern is with the messaging of CNN’s headline (“Do Pedophiles Deserve Sympathy”), which horrifies even as it draws readers in. It is worth examining the words themselves, and our susceptibility to media influence. This is not simply an academic exercise; at least one listserv for the discussion of sex-related topics has seen considerable discussion on minor points, such as whether there is enough brain research to warrant “sympathy for rampant pedophiles”. It seems that some of us have let language get the best of us.

First, CNN uses the word “pedophiles” even though the article makes clear that not all who molest children are pedophiles and many people who are sexually attracted to children who do not molest them. Terms such as “child molester” and “pedophile”, while potentially useful in some professional contexts, are implicitly misleading in others.

“Pedophile” implies identity. Although research is unclear on the extent to which people can change their sexual interests, it is clear that not all people who sexually abuse are equally dangerous, that the majority of them are not known to re-offend, and that they re-offend less as they get older. More recently, we have also learned that reports of sexual crimes have declined in recent years. As a treatment provider, I’m concerned that the word “pedophile” can mislead others. Treatment is about people living different, better lives; it is not about changing somebody’s fundamental identity. Approaching treatment from an identity perspective can also make it seem insurmountable. Which would you choose: Changing the way you live or changing who you actually are?

“Pedophile” implies that a person is destined to have sex with children unless specifically prevented from doing so. One can argue that the belief in the inevitability of re-offense was central to the establishment of our field’s first programs, prior to adequate studies of re-offense rates. Simply put, when the field of treating people who had abused began, professionals typically thought their clients were all at high risk.

“Pedophile” has many negative connotations. It is hard for lay people to hear the word without associating it with “evil” and/or “monsters”. One typically sees it in the same paragraph as words such as “predator”. Rational discussion about resource allocation and science-based public policy become even more difficult under these circumstances. The Medical Director of a civil commitment program who asked why no one had been released from a program, expressed the relevance of this point succinctly: How do you release somebody after building them up as monsters? (Oaks, 2008).

Similarly, the word “deserves” raises many questions: Do pedophiles deserve sympathy? Compared to whom? What does anyone actually deserve? To some degree, don’t all human beings deserve more than they have in their life? What do any of us deserve? In some cases, our clients have considered these questions more than we have. In 2009, the staff members of a civil commitment program heard from three clients who were nearing the end of treatment. The format was akin to a town hall meeting, in which 100 or more staff asked questions of clients housed in another facility:

Staff: Tell us why you deserve to be released into the community after all the harm you’ve done.

Client: (after some thought): I don’t know that I deserve anything… but I’m grateful for the opportunity.

Finally, there is the word “sympathy”. Research has found that empathic treatment providers can produce better outcomes than those who adopt a harsh, confrontational style (Marshall, 2005), but most of us shrink away from the idea of sympathy, which implies a deeper emotional congruence. Again, language matters. Let’s have a look at other places where this word appears in our lives.

First, those of us who are fathers have heard about sympathy pain and weight gain when our partners are pregnant. Then, as parents, we might display super-human strength to defend our children. This aspect of the fight-or-flight response is known as sympathetic arousal. Many of us remember the 1953 play “Tea and Sympathy”. If not, we will remember that the Rolling Stones’ “Sympathy for the Devil” became famous due to its shock value. Sympathy ultimately connotes closeness, often bordering on intimacy.

Having read up to this point, take a moment to consider: Under what conditions would you answer “yes” if someone asked you if pedophiles deserve sympathy?

On the other hand, one might also ask: Assuming that our clients have consented to treatment (and knowing that punishment alone does not reduce risk), do they also not deserve our best rehabilitative efforts? Do they not deserve humane and compassionate treatment providers? Do they not deserve the most empirically sound management in the community?

Another way to look at this is to consider those who would experience victimization at some point in the future if professionals did not intervene. Do they not deserve our best efforts at maintaining the highest standards of care, including maintaining an empirically supported treatment approach? If the answer is yes, we have to conclude that people who abuse and are at risk to molest children may indeed “deserve” our most compassionate response in order to involve them meaningfully in interventions.

These questions and comments do not arise out of any desire to hug thugs or defend deviance. Rather, it is becoming clearer in the research that people can stay safer in our communities when they receive the same compassionate concern as any other people seeking to lead better lives. For example, Wilson, Cortoni, Picheca, Stirpe, & Nunes (2009) found that compassion-based programming can yield very impressive results in community aftercare services.

We are now at a point in our field’s development where we have effective means for helping people change and stay changed. The good news is that articles such as James Cantor’s show that we can provide helpful, needed information to the public. The challenge now is to make sure that we are all asking the right questions.

References

Marshall , W. L. (2005). Therapist style in sexual offender treatment: Influence on indices of change. Sexual Abuse: A Journal of Research & Treatment, 17, 109-116.

Oaks, L. (2008, June 7). Locked in Limbo. Minneapolis Star Tribune. Retrieved June 23, 2012 from http://www.startribune.com/projects/19529344.html.

Wilson, R.J., Cortoni, F., Picheca, J.E., Stirpe, T.S., & Nunes, K. (2009). Community-based sexual offender maintenance treatment programming: An evaluation. [Research Report R-188]Ottawa, ON: Correctional Service of Canada.

Point-Counterpoint Regarding Proposed Changes to the Diagnostic Criteria for Paraphilias in the DSM-5

It has been more than 17 years since any substantive changes were made to the diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders, currently in its fourth edition (with a text revision having occurred in 2000). The American Psychiatric Association (APA) is presently working towards a new edition (DSM-5), scheduled to be released sometime in 2013.

It is not particularly surprising that proposed revisions to diagnostic criteria suggested for DSM-5 have resulted in considerable debate. For our readership—persons who work with persons affected by sexual violence (either as victims or as offenders)—the proposed changes to the criteria for diagnosing Paraphilias have drawn both strong support and strong opposition.

In this unique entry to http://sajrt.blogspot.com/, we hope to give you something of a point-counterpoint experience. Two letters to the President of the APA have been drafted:

1. A letter outlining concerns with the proposed changes to the Paraphilias diagnostic criteria, written by Drs. Richard Wollert and Thomas Zander.
2. A letter outlining support for the proposed changes to the Paraphilias diagnostic criteria, written by Drs. Robin J. Wilson, Jill Levenson, Richard Packard, and Mr. David Prescott.

Regardless of their positions regarding the proposed changes, the authors of the letters are prominent members of the ATSA community—persons who are frequently adding perspective to the collective debate/progress regarding evidence-based practice and defensible diagnostics. That these two camps disagree is good for our field—it promotes debate and collegial discourse.

In this blog, we will present the two letters and allow readers to make comments. In a subsequent blog, we will present additional commentary by each group on the other’s perspective. We hope you find this point-counterpoint exercise to be both intellectually stimulating and of importance to the ongoing work all of us engage in attempting to better understand the difficult phenomenon of sexual violence.

For those who are interested, the APA has reopened its DSM-5 website for general comments. The link is http://www.dsm5.org/Pages/Default.aspx.

Each of the letters below is addressed to the new President of the American Psychiatric Association, Dr. Dilip V. Jeste. For those who are interested, Dr. Jeste’s contact details are as follows:

Dilip V. Jeste, M.D.
President, American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
Telephone: 703.907.7300
Fax: 703.907.1085
E-mail: apa@psych.org

An Open Letter Urging the APA to Exclude

Unreliable Paraphilic Proposals from DSM-5

Dear Dr. Jeste:

As mental health professionals, sex educators, and researchers we are writing to you to encourage the American Psychiatric Association to leave invalid sexual disorders out of DSM-5.

In 1999, the Dangerous Sex Offender Task Force of the American Psychiatric Association issued a strongly worded statement about psychiatry’s failed efforts to meaningfully define and classify sexual deviance. In contrast to the cautious approach advised by the Task Force, a ParaphiliasSubwork Group of the DSM-5 is vigorously lobbying for the adoption of three highly controversial expansions of sexual disorders (Hebephilia, Paraphilic Coercive Disorder, and Hypersexual Disorder). The expansions would be a major mistake, due to poor reliability, unproven validity and – most of all – the potential for vast and harmful unintended consequences.

The Subwork Group is now proposing to add the equivalent of a “Hebephilic” type to Pedophilia, extending the diagnosis of Pedophilia from covering those with sexual attractions to prepubescent children to those with sexual attractions to pubescent children under age 15. It also proposes to add new diagnoses of “Paraphilic Coercive Disorder” and “Hypersexual Disorder” to the Appendix as “Criteria Sets for Further Study.” We are dismayed by each of these recommendations for the following reasons.

Hebephilia lacks conceptual coherence. Most men are attracted to sexually maturing 14-year-olds, as reflected in the large number of industrialized countries where the age of sexual consent is 14 (Green, 2010). Normative attractions may be criminal when acted upon, but they should not be labeled as mental disorders. “Hebephilia” is an archaic term that languished in psychiatric obscurity until the passage of modern civil commitment laws in the United States (Franklin, 2010). Since then, some evaluators who confuse statutory rape with mental disorder have invoked Hebephilia as a condition that justifies civil commitment (Ewing, 2011). Such usages do not provide a cogent explanation for behavior that is illegal in the United States but legal in other countries being classified as a mental disorder. Finally, Hebephilia lacks adequate diagnostic reliability (Wollert & Cramer, 2011). Most of the research has been conducted by a single Canadian research team that is overly represented on the Paraphilias Subwork Group. Although the DSM-5 Task Force has indicated that final decisions about proposed revisions will be made on the basis of field trial data, a November 2011 change in the proposed criteria for the diagnosis rules out the application of even this meager safeguard.

Paraphilic Coercive Disorder (PCD) was initially proposed for inclusion in DSM-5 as a diagnosis that would be limited to men who preferred rape over consensual sex. Because only a very small percentage of rapists prefer rape over consensual intercourse (American Psychiatric Association, 1999), clinicians are unable to reliably apply this label (Wollert, 2011). This is one reason for the American Psychiatric Association’s consistent rejection of rape-based paraphilias in three previous editions of the DSM (Zander, 2008). In the face of overwhelming opposition, the Subwork Group has taken the fallback position of recommending PCD only for inclusion in the Appendix as a condition meriting “further study.” However, this would confer an undeserved back-door legitimacy to the invalid construct. Rather than a mental disorder, rape is a crime for which the proper placement is prison.

The proposed criteria for Hypersexual Disorder (HD) are the product of a recent ad hoc literature review by Martin Kafka, a member of the Subwork Group. His review indicated their validity has not been empirically confirmed. Given the inherent difficulty in determining at what point a normal human drive becomes abnormal, it is not surprising that the proposed diagnosis is marred by conceptual confusion and vague verbal anchors (Moser, 2011). Its poor reliability and validity will translate to a high rate of false positives in both civil commitment trials and outpatient clinics that serve the community in general. With the proposal becoming a magnet for ridicule both by academic scholars and the popular press, it too has been relegated to the Appendix. However, the Appendix was not intended as a storage site for criteria sets that, like Hypersexuality Disorder, have never been tested.

These three proposals all lack adequate empirical support. They will increase false positive diagnoses by labeling behaviors that are normative, developmental, or criminal as mental disorders. Promoting the misclassification of juveniles and other vulnerable populations as dangerous sex offenders, they will undermine the reputation of forensic practitioners and those who study sexual behavior. Collectively, professions that endorse the use of unreliable diagnoses run the risk of losing their credibility.

The British Psychological Society, the American Counseling Association, and the Society for Humanistic Psychology and many other divisions of the American Psychological Association have all submitted petitions or letters of concern to the American Psychiatric Association regarding revisions proposed for the DSM-5. These documents expressed concerns about the lack of empirical support for many DSM-5 proposals, the likelihood of “false-positive epidemics” flowing from decreased diagnostic thresholds, and the negative effects of “over-medicalizing” human behavior. They also pointed out that the prevention of false-positive epidemics should take precedence over “nomenclatural exploration” and that the temptation to adopt new diagnoses should be tempered by the recognition that diagnostic labels tend to be confounded with normative social expectations.

We share these concerns as they apply to sexual disorders. We further support the adoption of sexual disorder criteria sets only after they have been established to have high true positive rates and acceptable false positive rates. Therefore, we urge the DSM Task Force to remove the Hebephilia qualifier from the proposed diagnosis of Pedophilia, and to eliminate Paraphilic Coercive Disorder and Hypersexual Disorder from any inclusion in the DSM-5.

Sincerely yours,

Richard Wollert, Ph.D.                       Thomas K. Zander, Psy.D., J.D., ABPP
Clinical Psychologist                           Clinical & Forensic Psychologist
Vancouver, WA                                 Indian Rocks Beach, FL

References

American Psychiatric Association (1999). Dangerous sex offenders: A task force report of the American Psychiatric Association. Washington DC: American Psychiatric Association.

Ewing, C. P. (2011). Justice perverted: Sex offense law, psychology, and public policy. New York: Oxford University Press.

Franklin, K. (2010). Hebephilia: Quintessence of diagnostic pretextuality. Behavioral Sciences and the Law, 28, 751-768.

Green, R. (2010). Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! [letter to the editor]. Archives of Sexual Behavior, 39, 585-586.

Moser, C. (2011). Hypersexual Disorder: Just more muddled thinking [letter to the editor]. Archives of Sexual Behavior, 40, 227-229.

Wollert, R. (2011). Paraphilic Coercive Disorder does not belong in DSM-5 for statistical, historical, conceptual, and practical reasons [letter to the editor]. Archives of Sexual Behavior, 40, 1097-1098.

Wollert, R. & Cramer, E. (2011). Sampling extreme groups invalidates research on the Paraphilias.Behavioral Sciences and the Law, 29,554-565.

Zander, T. (2008). Commentary: Inventing diagnosis for civil commitment of rapists. The Journal of the American Academy of Psychiatry and the Law, 36, 459-469.

An Open Letter to the APA in support

of Proposed Revisions to DSM-5 Paraphilia Disorders

Dear Dr. Jeste:

As a scientists and practitioners, we believe that the sexual disorders in the DSM-5 must be evidence-based. We are writing to express our support for the inclusion of the proposed revisions for the Paraphilic disorders. We believe the revisions provide a more precise taxonomy for diagnostic decision-making that will benefit clinicians and clients.

The Paraphilias Subworkgroup of the DSM-5, made up of some of the world's leading experts in the area of pathological sexual behaviors, has developed a set of thoughtful and empirically based revisions to the existing schema. These refined and revised disorders (Pedophilic Disorder, Paraphilic Coercive Disorder, and Hypersexual Disorder) have shown acceptable validity and reliability in recent field trials, and represent the consensus of clinicians in the field. The Subworkgroup, chosen specifically for their vast experience and expertise, is aware of concerns expressed by other parties and has considered the potential for overuse and misuse of DSM diagnoses in forensic cases. With these concerns in mind, they have carefully crafted a set of criteria designed to improve the precision of the application of these diagnoses to individuals.

The Subworkgroup is proposing to add a "Hebephilic" subtype to Pedophilia, which would assist in the clinical conceptualization of individuals with persistent, exclusive, or primary sexual attractions to early pubescent children, generally ages 11 to 14, as opposed to older, more physically mature adolescents. It also proposes to add new diagnoses of "Paraphilic Coercive Disorder" and "Hypersexual Disorder" to the Appendix as "Criteria Sets for Further Study." We believe that these recommendations represent improvements in the taxonomy of Paraphilias for the following reasons.

Some regard Hebephilia as a conceptually complex and confusing construct. This is exactly why refinements in the DSM criteria are necessary. Although research indicates that some men find themselves attracted to sexually maturing 14-year-olds (Green, 2010), these attractions are not normative when they represent an enduring, primary, or exclusive attraction to young pubescent individuals and lead to distress or impairment in functioning. An erotic preference for, or orientation toward, children in the early stages of puberty (Tanner stages 2 and 3, generally ages 11 through 14) is not normative. In fact, the proposed change would bring the DSM in line with the World Health Organization’s definition of Pedophilia in the International Classification of Diseases (ICD-10): “A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age” (World Health Organization, 2007).

Heeding concerns about potential misuse of the Pedohebephilia subtype as a justification for sexual offender civil commitment in the U.S. (Ewing, 2011), a field trial investigated this question using cases from the Florida Civil Commitment Center (Wilson, Pake, & Duffee, 2011). Results indicated that 36% of the clients diagnosed with Paraphilia NOS (adolescent victims) using the DSM-IV-TR did not in fact meet the proposed DSM-5 criteria for Pedohebephilia. In other words, whatever one’s opinion of sexual offender civil commitment might be, DSM-IV-TR diagnoses offer little guidance to evaluators and have resulted in a wider diagnostic net. Despite claims to the contrary, the proposed empirically based revisions would actually serve to narrow the group of individuals who meet criteria for designation as a sexually violent predator. The revisions are long overdue, and without them, clinicians are left with the current, less precise classifications that perpetuate exactly the type of problem identified by opponents of the revisions. When inter-rater reliability was tested in Florida, kappa coefficients were significant for the proposed diagnostic schemes for Pedophilic Disorder (.71; Wilson et al., 2010). A second field trial in Wisconsin obtained similar results (kappa = .66; Thornton, Palmer, & Ramsey, 2011).

Paraphilic Coercive Disorder (PCD) has been proposed for inclusion in the DSM-5 Appendix as a diagnosis for future research. The disorder would apply only to men with established preferences for sexual coercion over consensual sex. Previous editions of the DSM have rejected coercion manifested in rape as a disorder for a variety of political and clinical reasons (Zander, 2008). Currently, the Subworkgroup is recommending PCD only for inclusion in the Appendix as a condition meriting "further study." Regardless of how state legislatures address the criminal aspects of sexually coercive behavior, clinical and empirical evidence suggest that a small group of men prefer non-consensual sex and that this desire represents a pathological and deviant sexual interest. In DSM-5 field trials, many civilly committed sexual offenders who had been given the frequently utilized Paraphilia NOS (nonconsent) diagnosis did not meet criteria for PCD using the proposed diagnostic scheme (D’Orazio, Wilson, & Thornton, 2011). Inter-rater reliability for PCD from the aforementioned field trials in FL and WI were k = .66 and k = .50, respectively.

With the vast volume, variety, availability, accessibility, and affordability of sexual material on the Internet, the past twenty years have brought new manifestations of what some have called "sexual addiction." Though consensus for such a construct does not yet exist, clinicians reveal an increase in requests for therapy services related to sexual self-regulation and its potential consequences. Hypersexual Disorder (HD), proposed for the DSM-5 Appendix, would be helpful for clinicians to be able to refine the conceptualization of harmfully excessive sexual behavior and the parameters by which it deviates from normal sexual patterns. The proposed diagnostic criteria are explicitly descriptive and atheoretical and do not depend on models of “addiction” or “compulsion” (Kafka, 2010).

In summary, for those who express legitimate concern about overuse or misuse of Paraphilia NOS diagnoses in sexual offender civil commitment cases, field trials revealed that DSM-5 proposals resulted in a significantly lower proportion of potential candidates who would meet criteria for commitment. It is also important to note that while opponents of civil commitment are among the most vociferous challengers to the proposed DSM-5 revisions, civil commitment is far from the only clinical application of these diagnoses. In fact, less than 1% of the 739,000 registered sex offenders in the U.S. are civilly committed (Ackerman, Harris, Levenson, & Zgoba, 2011).

It is unclear what constitutes "adequate empirical support" for inclusion in the DSM, and all mental health disciplines have grappled with this question for decades. It is noteworthy that few field trials of any disorders took place prior to the publication of the DSM-IV, and no field trials of the Paraphilias occurred. Valid concerns exist regarding problems of false positive diagnoses, and clinicians should avoid labeling as mental disorders those behaviors that are normative, developmental, or criminal. On the other hand, labeling has been noted as a general concern with many DSM categories since its inception. As science and knowledge evolve, evidence should be folded into our diagnostic systems and our clinical understanding of the patients we serve.

In the end, the integrity of the DSM-5 demands that scientific evidence weigh most heavily in determining and refining diagnoses. Research findings and clinical utility should take precedence over debates about civil commitment policy. We are sure we all agree that clients and clinicians alike deserve no less.

Sincerely yours,

Robin J. Wilson, Ph.D., ABPP                                Jill Levenson, Ph.D.

Clinical Psychologist                                                Clinical Social Worker
Sarasota, FL                                                           Boca Raton, FL

Richard Packard, Ph.D.                                           David Prescott, LICSW
Clinical Psychologist                                                Clinical Social Worker
Bainbridge Island, WA                                            Falmouth, ME

References

Ackerman, Harris, Levenson, & Zgoba, (2011). Who are the people in your neighborhood? A descriptive analysis of individuals on public sex offender registries, International Journal of Law and Psychiatry. doi:10.1016/j.ijlp.2011.04.001

D’Orazio, D., Wilson, R.J., & Thornton, D. (2011, November). Prevalence of Pedohebephilia, Paraphilic Coercive Disorder, and Sadism Diagnoses Produced with the Proposed DSM-5 Criterion Sets. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.

Ewing, C.P. (2011). Justice perverted: Sex offender law, psychology, and public policy. New York: Oxford.

Green, R. (2010). Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! Archives of Sexual Behavior, 39, 585-586.

Kafka, M.P. (2010). Hypersexual Disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377-400.

Thornton, D., Palmer, S., & Ramsay, R.K. (2011). DSM-5 Pedohebephilia, PCD, and Sadism diagnoses: Reliability in WI. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.

Wilson, R.J., Pake, D.R., & Duffee, S. (2011, November). DSM-5 Pedohebephilia, PCD, and Sadism diagnoses: Reliability in Florida. Paper presented at the 30th Annual Conference of the Association for the Treatment of Sexual Abusers, Toronto, ON.

World Health Organization. (2007). International statistical classificationof diseases and related health problems (10th rev., version for 2007). Retrieved from: http://apps.who.int/classifications/apps/icd/icd10online/index.htm?gf60.htm

Zander, T. K. (2008). Inventing diagnosis for civil commitment of rapists. Journal of the American Academy of Psychiatry and Law, 36, 459–469.

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 sajrt.blogspot.com. 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.

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?

RJW

Second Guest Blog on Proposed Criteria for Paraphilic Disorders by DSM-5 Paraphilias Subworkgroup Chair Dr. Ray Blanchard

NOTE: This guest blog was written 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.

Proposed Changes for DSM-5 Diagnostic Criteria

Affecting Several or All Paraphilic Disorders

Ray Blanchard, Ph.D.

Toronto, ON Canada

The changes proposed by the DSM-5 Paraphilias Subworkgroup regarding the diagnostic criteria for Paraphilic Disorders may be divided into two categories: those that affect the diagnostic criteria for a single Paraphilic Disorder and those that affect the diagnostic criteria for all Paraphilic Disorders. This essay concerns proposed changes in the latter category.

Proposed Definitions, Labels, and Distinction between Paraphilias and Paraphilic Disorders

The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting human partners between the ages of physical maturity and physical decline. In some circumstances, the criteria “intense and persistent” may be difficult to apply; these include the assessment of persons who are very old or medically ill, and who may not have “intense” sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests (Blanchard et al., 2009).

Some paraphilias primarily concern the individual’s erotic activities, and others primarily concern the individual’s erotic targets (Cantor, Blanchard, & Barbaree, 2009). Examples of the former would include intense and persistent interests in spanking, whipping, cutting, immobilizing, or strangulating another person, or an interest in these activities that equals or exceeds the individual’s interest in copulation or equivalent interaction with another person. Examples of the latter would include intense or preferential sexual interest in children, the elderly, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber.

One of the first questions addressed by the Paraphilias Subworkgroup was whether all paraphilias are ipso facto mental disorders. We took the position that they are not. We therefore proposed that the DSM-5 make a distinction between paraphilias and Paraphilic Disorders, as described below.

A Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.

It was possible to implement the distinction between paraphilias and Paraphilic Disorders without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diagnostic criteria set for each of the listed Paraphilic Disorders, Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of harm—to others). This format is exemplified by the proposed diagnostic criteria for Sexual Sadism Disorder:

A. Over a period of at least six months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.

B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.

The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a Paraphilic Disorder. The word diagnosis would not be used in regard to individuals who meet Criterion A but not Criterion B, that is, individuals who have a paraphilia but not a Paraphilic Disorder. If an individual meets only Criterion A for a particular paraphilia—a circumstance that might arise when a benign paraphilia is discovered during the clinical investigation of some other condition—then the act of noting or reporting that the individual acknowledges the paraphilia should be referred to as ascertainment rather than diagnosis. Usage of the term ascertainment does not mean that an additional or a special step has been added to clinical assessment. It is simply a convenient way of avoiding the inappropriate word diagnosis when the individual has a paraphilia but not a Paraphilic Disorder.

The distinction between paraphilias and Paraphilic Disorders is one of the changes from DSM-IV-TR that applies to all atypical erotic interests. This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. An additional advantage of this approach is eliminating certain logical absurdities in the DSM-IV-TR. In that version, for example, a man could not be identified as having transvestism—however much he cross-dressed and however sexually exciting that was to him—unless he was unhappy about this activity or impaired by it (Blanchard, 2010b). This change in viewpoint is reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, DSM-IV-TR Fetishism becomes DSM-5 Fetishistic Disorder, Voyeurism becomes Voyeuristic Disorder, and so on.

Addition of Course Specifiers

The second overarching change from DSM-IV-TR is the addition of the course specifiers, “In a Controlled Environment” and “In Remission,” to the diagnostic criteria sets for all the Paraphilic Disorders. These specifiers were added in response to clinicians’ complaints that the DSM-IV-TR and earlier versions provided no mechanism for indicating important changes in the individual’s status. There is no expert consensus about whether a longstanding paraphilia can disappear spontaneously or be removed by therapy. There is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be ameliorated by therapy or reduced to acceptable levels. Therefore, the “In Remission” course specifier was written so as to indicate remission from a Paraphilic Disorder. It is silent in regard to changes in the presence of the paraphilic interest per se. The intended meaning of remission is clarified in each of the diagnostic criteria sets with a parenthetical expression: “In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment).” The other course specifier, “In a Controlled Environment,” was included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges.

Changes and Continuities in Criterion A

The DSM-IV and DSM-IV-TR used the identical wording format in Criterion A for all Paraphilias: “Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving [the paraphilic focus].” Only the specification of the paraphilic focus varied from one paraphilia to another, for example, “nonliving objects” (Fetishism) and “exposure of one’s genitals” (Exhibitionism).

The wording format proposed for Criterion A for all DSM-5 paraphilias is essentially similar: “Over a period of at least six months, recurrent and intense sexual arousal from [the paraphilic focus], as manifested by fantasies, urges, or behaviors.” The purpose of this change was to clarify the relations of sexual fantasies, urges, and behaviors to each other and to the corresponding, underlying paraphilia. Fantasies, urges, and behaviors are (directly or indirectly) observable indicators of a psychological trait—a paraphilia—that cannot itself be observed using present technologies and perhaps cannot be observed in principle. The writer has previously expressed this conceptualization of paraphilias in somewhat different language: “I regard paraphilias . . . as erotic preferences or orientations that inhere in the individual and that have some existence independent of specific, observable actions” (Blanchard, 2010a, p. 310).

Changes and Continuities in Criterion B

In comparison with Criterion A, Criterion B (the distress and impairment criterion) has had a rather variable history. DSM-III-R used the identical wording format in Criterion B for all Paraphilias: “The person has acted on these urges, or is markedly distressed by them.” DSM-IV also used the identical format for all paraphilias, but it was completely different from the one applied in DSM-III-R: “The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

DSM-IV-TR used two different formats: One for Paraphilias whose satisfaction does not entail the involvement of nonconsenting others and one for Paraphilias that do involve nonconsenting others. Criterion B for Fetishism, Sexual Masochism, and Transvestic Fetishism remained exactly as it had been in DSM-IV. Criterion B for Exhibitionism, Frotteurism, Pedophilia, and Voyeurism reinstated a clause about acting on the basis of the paraphilia and thus returned to a formula very similar to that used in DSM-III-R: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.” Criterion B for Sadism was the same statement with an additional qualifier: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.”

The B criteria proposed for DSM-5 follow the two-version pattern established in DSM-IV-TR. The version of Criterion B for Fetishistic Disorder, Sexual Masochism Disorder, and Transvestic Disorder reads: “The fantasies, sexual urges, or behaviors cause marked distress or impairment in social, occupational, or other important areas of functioning.” The version of Criterion B for Exhibitionistic Disorder, Frotteuristic Disorder, Sexual Sadism Disorder, and Voyeuristic Disorder reads: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.” There is a slight variation of Criterion B for Pedophilic Disorder, because a nonconsenting person (in the common-language sense of unaware, unwilling, or resisting) is not inherent to the sexual objective. Thus: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.”

The crucial point of this section is that the proposed diagnostic criteria for DSM-5, exactly like the diagnostic criteria for DSM-IV-TR, make it possible to diagnose a patient with a specific paraphilia on the sole grounds that he has offended against multiple victims in a way characteristic of that paraphilia, whether he acknowledges that paraphilia or not. The recurrent behavior constitutes clinical grounds for inferring that the paraphilia is present (satisfying Criterion A) and, at the same time, it demonstrates that the paraphilically motivated behavior is causing distress, harm, or risk of harm to others (satisfying Criterion B).

The question of how much sexually offending behavior of the same type is necessary to diagnose the corresponding Paraphilic Disorder in a patient who verbally denies that disorder has traditionally been left to clinical judgment. The available research indicates that a threshold of three or more different victims age 14 or younger can be used to diagnose Pedophilic Disorder with a high degree of specificity, that is, 90% or more (Blanchard, 2010c, 2011). The writer knows of no published research investigating a diagnostic threshold based on a patient’s total number of sexual interactions with the same child or on the length of time (in weeks, months, or years) during which a patient interacted sexually with the same child.

References

Blanchard, R. (2010a). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior, 39, 304–316.

Blanchard, R. (2010b). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior, 39, 363–372.

Blanchard, R. (2010c). The specificity of victim count as a diagnostic indicator of pedohebephilia [Letter to the Editor]. Archives of Sexual Behavior, 39, 1245–1252.

Blanchard, R. (2011). Misdiagnoses of pedohebephilia using victim count: A reply to Wollert and Cramer (2011) paraphilias [Letter to the Editor]. Archives of Sexual Behavior, 40, 1081–1088.

Blanchard, R., Kuban, M. E., Blak, T., Cantor, J. M., Klassen, P. E., & Dickey, R. (2009). Absolute versus relative ascertainment of pedophilia in men. Sexual Abuse: A Journal of Research and Treatment, 21, 431–441.

Cantor, J. M., Blanchard, R., & Barbaree, H. E. (2009). Sexual disorders. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psychopathology (2nd ed., pp. 527–548). New York: Oxford University Press.