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

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

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

Ray Blanchard, Ph.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

A guest blog from Dr. Deirdre D'Orazio on Dr. Allen Frances and SVP/Paraphilias

The following blog by Deirdre D'Orazio is in reply to an article by DSM-IV editor Dr. Allen Frances in the Psychiatric Times, published January 4, 2012. Dr. D’Orazio is a psychologist in private practice and Chairperson of the California Coalition on Sexual Offending, Civil Commitment Committee. Among her professional endeavors, she maintains a contract with the CA DMH conducting SVP evaluations. It is important to note that her opinions stated above are her own. She is not speaking on behalf of CA DMH.


------------------------------


In a recent article written in the Psychiatric Times (January 4, 2012), entitled California DMH Instructs SVP Evaluators on Proper DSM-IV-TR Diagnosis (1), DSM-IV editor Dr. Allen Frances reviewed a training session offered to California state evaluators conducting evaluations of potential sexually violent predators (SVPs). Readers interested in learning more about the California SVP statute are referred to the California Coalition on Sexual Offending information paper referenced at the end of this article (2). Dr. Frances’ article commences:

By far the most important event in the sad history of the Sexually Violent Predator (SVP) statutes occurred in Sacramento between September 9 and September 11, 2011. The California Department of Mental Health (DMH) conducted a 3-day workshop to educate its evaluators on proper procedures in diagnosing DSM-IV mental disorders. This could be a turning point in solving what has been the most vexing problem at the delicate interface between psychiatry and the law.

(Frances, 1/4/12)

Dr. Frances is a frequent commentator on issues related to Paraphilia diagnosis, DSM-5, and sexual offender civil commitment (SOCC). In reading Dr. Frances’ posts about Paraphilia diagnosis, DSM-5, and SOCC laws, I get the notion that he is a man deeply possessed—possessed by the idea of doing whatever it takes to undermine all three. His published works on the topics swarm with passion, allure by acrimony and, in my opinion, are built on a rational foundation of sand. The sharp realization of this latter point brings me to the uncomfortable position of writing this post.

On the one hand, I ask myself, “Why would you ever want to get involved in this mess?” Surely, rationality is not a key player in this arena, why attempt to bring some to the forefront? Anything I might have to offer will likely be twisted and misused as fuel for the cauldron. On the other hand, having read Dr. Frances’ most recent piece involving his interpretation of the recent training for California evaluators—which I attended—I cannot dismiss my experience. My experience of the meeting is vastly discrepant from that which Dr. Frances portrays.

So, why am I getting involved in this “mess”? There is a vocation in the work that we do as professionals that necessitates a response. It is out of this internal imperative that I seek to clarify Dr. Frances’ distorted interpretations.

It is one thing to have an opinion and state it. But, it is another thing entirely to embark on a veritable witch hunt against people and ideas. After all, my colleagues and I who work conducting SVP evaluations are professionals, just like those that treat the less than one percent of these men eventually committed as SVPs in California, as well as the researchers and academics who join us in a shared goal of helping alleviate the societal problem of sexual abuse. We put ourselves on the front line of a psychic battlefield every day to help men convicted of sexual crimes. We, sexual offenders included, all share the most fundamental of human qualities. However, there is a feature of humans possessed that contributes to a splitting-off that leads to thinking that some other group of persons—“them”—has no resemblance to the rest of “us”. Unfortunately, in this case, I am in Dr. Frances’ ousted “them” group.

At this point, I hope readers will infer the point that our endeavors to diagnose illness in this particular domain engender an “us versus them” attitude, which ultimately fuels diagnostic and Sex Offender Civil Commitment debates, but does not serve our collective goal—our vocation—of healing.

How disturbing then that some SVP evaluators remain ignorant of DSM-IV, leading them to provide supposedly “expert” testimony that is simply incompetent. They blithely write reports filled with idiosyncratic and incorrect diagnostic opinions that can result in the unjustified psychiatric hospitalization of simple criminals who have already served their apportioned prison terms.

(Frances, 1/4/12)

The “idiosyncratic evaluators” here in California, to whom Dr. Frances refers, are extensively trained professionals who have many years’ experience in the area of severe sexual abuse. For myself, I worked for several years for the California DMH program that treats men committed as SVPs. This is the same DMH Dr. Frances lauds as “rescuing proper diagnostic practice” and “redeeming forensic psychology.” Paradoxically, he also notes it as an agency providing “unjustified psychiatric hospitalization of simple criminals.”

So, I seem to get discredited twice by Dr. Frances, once for treating people within the civil commitment context, and another for being an “idiosyncratic evaluator”—a resistant member of a “hard corps of stubborn dead-enders” that is “mistaken and incompetent” by exercising “independent clinical judgment of any given case.” It seems the real grievance Dr. Frances has is not that evaluators are “ignorant” or “incompetent”, but that we are not sufficiently deferential to him. In truth, many of us have heard Dr. Frances’ arguments many times and simply do not find him convincing.

The great news is that the California (DMH) has taken upon itself the responsibility to improve diagnostic practice in SVP cases. It sponsored a landmark workshop for its evaluators...

(Frances, 1/4/12)

Having attended the training to which Dr. Frances refers, my opinion—and I believe the opinion of the others in attendance—is that the training was not “landmark” as Dr. Frances described. Further, it did not occur as Dr. Frances purports. It was not implemented to correct aberrant diagnostic practices. Rather, its intent was to train a new group of California SVP evaluators with no prior experience conducting SVP evaluations, and only few having significant experience working with high risk sexual offenders. In an interesting corollary, the trainer—although a long-time practitioner working for DMH administration in the Mentally Disordered Offender unit—had been recently asked to assume additional responsibilities by leading the Sex Offender Commitment Program SVP evaluation services. By his own admission, this trainer has little experience working with SVPs specifically, but he does have a lot of experience in the forensic assessment of other types of mentally ill offenders.

Rather than a landmark event, the training was a laudable endeavor of the newly established leader to train a group of new evaluators within the unique context of both parties being relatively new to the subject. A secondary purpose was to provide a refresher to those of us already experienced evaluators currently doing the work. The training did not focus exclusively on “proper procedures in diagnosing DSM-IV mental disorder,” as Dr. Frances states. It was a beginner training and overview seeking to ensure that certain minimum standards are routinely applied in conducting SVP evaluations for DMH in California

I have specific concerns about several interpretations made about this training session in the article by Dr. Frances. The first point Dr. Frances interprets from the training is that the trainer instructed evaluators to:

1) NOT carelessly confuse the relatively common crime of rape with the very infrequent mental disorder of paraphilia.

(Frances, 1/4/12)

It is my opinion that the trainer did, indeed, underscore this point. He instructed the new evaluators not to equate the act of rape with Paraphilia Not Otherwise Specified (NOS). In doing so, the trainer restated the obvious to the experienced evaluators regarding the utilization of Paraphilia NOS as a predisposing mental disorder in SVP evaluations. The message was, "All rapists do not suffer from a Paraphilia." The message was NOT that there is no such thing as a paraphilia involving sexual arousal to coercion. It was NOT that evaluators should not diagnose that paraphilic proclivity via use of Paraphilia NOS when they determine it is present. The trainer noted a general rule that if a diagnosis is outside the contemporary DSM, it is out of bounds for DMH SVP reports, but he also reminded those in attendance that Paraphilia NOS is a DSM-listed disorder.

The most egregious error is the creative misuse of the designation “Paraphilia NOS.” Many SVP evaluators incorrectly assume that rape by itself is grounds for diagnosing paraphilia—ignoring the fact that this notion has been explicitly rejected by DSM-III, DSM-IIIR, DSM-IV, and DSM-5.

(Frances, 1/4/12)

This is not the first time Dr. Frances has written about California DMH and Paraphilia NOS. After his first article (3) about the same California DMH SVP evaluator training, I was asked while testifying whether the DMH had instructed evaluators, as Dr. Frances alleged, not to employ Paraphilia NOS as a potential qualifying disorder in SVP evaluations. Afterwards, in personal correspondence with the trainer, I double-checked DMH’s intention in this regard. The trainer confirmed that my understanding was correct—that CA DMH is not advising its evaluators against the use of Paraphilia NOS as a potentially qualifying mental disorder.

It is also worthy to note that in a more recent training attended by many of the California SVP evaluators that occurred in December 2011 (at which the trainer of the September event was present), Dr. David Thornton (4) provided compelling scientific evidence to support the notion that such a disorder (i.e., Paraphilic Coercive Disorder) does actually exist. During that training, there was general consensus among California evaluators that a disorder of sexual deviancy involving sexual arousal to non-consent themes exists. Participants expressed an appreciation for Dr. Thornton’s empirical analysis and lack of bombastic rhetoric. Most agreed that the current DSM lacks a proper place for paraphilic coercion; however, this does not apparently dissuade them from utilizing the NOS category to compensate for DSM-IV’s failings.

In contrast to his stated opinion, in the current article Dr. Frances seems to come very close to acknowledging that there may be some offenders for whom the “act of rape” may be a “precondition” for attaining sexual arousal. He seems to allow that this may be a bona fide expression of Paraphilia NOS—one that others have sought to define as Paraphilic Coercive Disorder.

Any diagnosis of “Paraphilia NOS, nonconsent” should contain both affirmative evidence that the act of rape was a precondition for attaining sexual arousal and a complete differential diagnosis that rules out the much more common contexts of rape.

(Frances, 1/4/12)

It is also valuable to note that in addressing the process of assessing for an SVP qualifying mental disorder, the DMH trainer cautioned against a practice of automatically disqualifying Antisocial Personality Disorder as a potential predisposing mental disorder. The trainer noted that California statutes do not exclude such and stated that a personality disorder may very well predispose a given sexual offender to perpetrate sexual offenses. This opinion is consistent with data presented by Dr. Thornton at the December 2011 training—illustrating that a high density of non-sexual criminality, along with a low density of sexual deviance among sex offenders, is generally as predictive of sexual re-offense as a high density of sexual deviance paired with a low density of non-sexual criminality among sex offenders.

The second point Dr. Frances perceived as having been underscored at the September 2011 CA DMH training is:

2) (evaluators should) NOT use “hebephilia” as an excuse for making a “Paraphilia NOS” diagnosis because having sex with pubescent youngsters is not a DSM-IV mental disorder.

(Frances, 1/4/12)

With respect to this issue, I cannot comment regarding its veracity as a point made in the training. This is because I can find no mention of the word “hebephilia” or any related topic in the workshop’s PowerPoint handouts, nor did I make any personal notes to the effect.

Last, Dr. Frances opined that the trainer instructed evaluators to:

3) NOT confuse the violence inherent in all rapes with the sexually arousing use of violence that specifically defines the extremely rare DSM disorder of Sexual Sadism…Sexual Sadism requires that the violence be inflicted specifically because causing pain and humiliation is necessary for sexual arousal.

(Frances, 1/4/12)

In my recollection and opinion, the trainer did, indeed, underscore the importance of not automatically inferring that a person suffers from Sexual Sadism simply because of the presence of violent behavior. My experience is that evaluators do not automatically infer such but, rather, they strive to disinter factors that illustrate an underlying sexual arousal pattern. A problem with Sexual Sadism as a diagnostic option absent a diagnostic option for a paraphilia of sexual coercion is that it sets up a serious challenge to accurate diagnosis. Conceptualizing Sexual Sadism as an “all or none” diagnosis, without appreciation of the oft-observed presence of arousal to coercion, leaves many evaluators without a route to diagnostic precision. In his quest to denigrate PCD, Dr. Frances continues to leave us with no direction whatsoever in regard to those offenders who demonstrate what others in the literature have referred to as the paraphilic rape pattern, biastophilia, or paraphilic coercion.

Dr. Frances concluded his article with a unique packaging and sales attempt of his agenda, using as wrapping his twists on the California DMH training combined with DSM-5 developments. He exalted California DMH by declaring that the training “was brilliantly conducted and under the powerful auspices of California DMH” while prophesying that the training will not “solve the SVP problem for California.” This statement would surely lead any naïve reader to speculate there must be a serious problem in the way SVP evaluations are conducted in California or, at least, that there were serious problems with those evaluations conducted prior to the training. He noted that we, as independent contractors, are free to exercise independent clinical judgment in any given case. He graciously gave us permission to choose to continue our diagnostic practices in a mistaken, incompetent, and careless manner.

But the tide has definitively turned against careless SVP diagnosis. The combination of the DSM-5 rejection of “coercive paraphilia” and the California DMH’s reigning in of idiosyncratic evaluators should together presage the beginning of the end for the misuse of DSM in SVP cases.

(Frances, 1/4/12)

In this final note, Dr. Frances combines his misrepresentation of California’s recent DMH training points with the rejection of the DSM-5 proposal for Paraphilic Coercive Disorder in an effort to propagandize that no such disorder involving sexual arousal to coercion exists. Here, he seems to allow personal umbrage to predominate his arguments against the DSM-5—a committee he has not been asked to be a part of this time around. Dr. Frances reiterates his opinion that to persist to acknowledge the presence of paraphilias involving coercion or pubescent victims means that evaluators are misusing the DSM, implying that the book itself dictates the reality of mental disorder. However, this is not consistent with the experience of professionals that actually work with severe sexual abusers who do not doubt these conditions exist among the sub-group of severe sex offenders. The combination of harsh language and misrepresentation of facts that has come to characterize Dr. Frances’ work is of little assistance to those tasked with accurately characterizing the mental disorders of severe sexual abusers. We deserve better from leaders in the field.

References:

1 - Frances, Allen. (1/4/12). California DMH Instructs SVP Evaluators on Proper DSM-IV-TR Diagnosis. Psychiatric Times.

2 - D’Orazio, D., Arkowitz, S., Adams, J., & Maram, W. (2009). The California sexually violent predator statute: History, description, and areas of improvement. San Jose, CA: CCOSO.

3 - Frances, Allen. (10/10/11). Another step toward ending the Paraphilia NOS fad: The California DMH takes a stand. Psychiatric Times.

4 - Thornton, David. (12/12 & 12/13/2011). Advanced training in sexual offender assessment. Paper presented at workshop hosted by Central Coast Clinical and Forensic Psychology Services, Atascadero, CA.

Could Pedophilia Be Considered a Disability?

In a recent couple of posts on both the ATSA-list and SEXNET, list members discussed the issue of whether or not Pedophilia could or should be considered a "disability", entitling those so-diagnosed to receive social benefits.

These discussions were spurred by two newspaper articles, the first of which reported that benefits would be extended to persons diagnosed with Pedophilia in Greece—which was apparently incorrect. The second article, essentially a clarification, stated that Pedophilia would be listed by the social service sector, but not for the purposes of assigning benefits.

The possibility that a pedophilic person might somehow receive financial benefit for being that way seems to have struck a chord in many persons, judging by both the news reports and some of the email traffic I read. However, the question remains (at least) in my mind. Might there be circumstances in which we could/would/should consider Pedophilia to be a disability?

Before anyone starts getting offended or angry about the prospect of giving social benefits to a person who has sexually abused children, just follow along for a couple of paragraphs—I am asking readers to think outside the box for a moment.

Over the past couple of decades, an ever-increasing number of legislative attempts have been made to control the behavior of sexual offenders in the community; a good number of these persons being diagnosable as pedophilic. If we assume, for the moment, that the majority of higher risk or more intractable persons who offend are also those who have a preference for (or really strong sexual interest in) children, then at least some of these laws and policies will have a marked effect on how well a pedophilic person might be able to function in the community.

In many contemporary communities, persons who have sexually offended are, among other things, subject to:

• public notification (sometimes including photos and other personal details)
• registration (sometimes including publicly accessible records)
• residency restrictions
• employment restrictions (including mandatory reporting of status as a sex offender/predator)
• 1000/2000/2500 foot rules as to where they can be
• GPS tracking, or other means of electronic monitoring

Used judiciously, any of these measures may be useful in managing the risk of a specific offender. However, we tend to apply most or all of them to most or all of the offenders. And, whenever we hear the diagnosis "Pedophilia", we are immediately caused to think high-risk, incorrigible, etc. Professionals working with persons who have sexually offended know that all clients are unique and that each brings his/her own set of risk factors and social issues to the table.

The first point I suppose I would make is that, taken together, many of these legislated attempts at risk management have resulted in poor social reintegration prospects for some or even many offenders. Finding a place to live, finding a place to work, and finding people upon whom the person might rely for social support can be particularly difficult for anyone returning to the community after incarceration. It appears that these difficulties are heightened when the person trying to reintegrate is a sexual offender. Everyone will likely remember the famous "sex offenders under the bridge". The majority of these issues would appear to stem from, first, identification as a sexual offender/predator and, second, the notoriety that sometimes comes along with that designation.

So, could being identified as a pedophile be a determining factor in a person being unable to function appropriately in the social domain? Could that be considered a disability?

The second point I would like to make is that all these risk management measures cost money. As a society we already dedicate a lot of money to trying to make people with Pedophilia “better” by providing treatment in civil commitment centers and prisons, so why would we not consider the judicious use of funds to provide a “hand-up” (as opposed to a “hand-out”)? We provide community supervision, but people often see this as “management” rather than as the support of efforts at rehabilitation that it really ought to be.

As an example, let me share a personal experience. Some 10 years ago in Toronto, I was the psychologist-of-record for a particularly notorious "pedophile" who had recently been released from prison. Although he had apparently not offended in nearly two decades, the system was still clearing-off many of the complaints against him from the many instances of offending he engaged in while younger. Hence, the reason for the recent release.

Anyhow, when he was released, his picture was front page news. He was the subject of television and radio reports, and he soon became a particularly recognizable person. He had difficulty finding a place to live, and even more difficulty finding work. During our counseling sessions, we brainstormed as to how he might make ends meet and get off the street, as it were. In the end, I suggested that we attempt to get him social benefits, even though both of us were convinced that he would be denied.

After completing the necessary paperwork and providing a rationale that was akin to identifying his diagnosis and the subsequent notoriety as a "disability", we mailed it in and the waiting began. To both our surprise, he received a letter from the benefits office some six weeks later stating that he had been approved.

This fellow eventually did find some work and was able to find accommodations with a family member, which led to his coming off the social benefits roll. However, without those initial funds of assistance, his community reintegration picture would have been considerably more grim. While I am hesitant to state that he would have returned to reoffending—I think he was pretty much past that—I do wonder what other ills might have befallen him. In this particular instance, I continue to believe that our application for disability benefits was the right way to go.

Whether or not this is a bona fide example of Pedophilia as a qualifying diagnosis for receiving disability benefits, I don't know. I do know that it helped my client immeasurably and I can imagine that there might be others in the same boat in other communities. The bigger question may very well be in regard to whether or not our legislative efforts have created another problem entirely. In our haste to manage the "dark spectre" of pedophilic risk, have we sometimes made it nearly impossible for these persons to get better and move on?
 
(RJW, with a little help from my friends)

A Jerry Sandusky flight of fancy...

Caveat: In reading this post, I would ask that you allow me a “flight of fancy”, as it were. Under normal conditions, risk assessments are made of persons before the court and are conducted using validated tools and procedures in a standard fashion. Attention to detail and precision are important goals in risk assessment. The following pays attention to those prescriptions in spirit; however, I’m not suggesting that my process below would be acceptable if we were actually attempting to assess risk posed for true judicial or case management purposes.

So, here goes…

Best as I can figure, the score Jerry Sandusky would get on the Static-99R is -1. Based on what has been reported in the media (admittedly, this is not a formal risk assessment, but you’ll see where I’m going with this), that’s what you get. Negative one.

According to the reports: Mr. Sandusky has been married for a long time and has no other criminal history; the alleged victims are all persons he appears to have known for a while; and there is apparently no violence other than that directly associated with sexual offending. So, no points for “ever lived with a lover…”, “index non-sexual violence”, “prior non-sexual violence”, “prior sexual offenses”, “non-contact sexual offenses”, “prior sentencing dates”, or “any stranger victims”.

That leaves one point for “any unrelated victims” and one point for “any male victims”. Then, of course, you have to consider his age. Sandusky is in his sixties, which means that his score on the age item would be -3. Total it up and you get -1. If you follow the nominal risk category labels suggested by the Static-99R’s developers (Karl Hanson and David Thornton), this score would put Sandusky in the low risk group according to static (life history, or unchangeable) factors.

Then, there’s the issue of the appropriate normative sample against which to compare him. Since 2008, Hanson, Thornton, and others associated with Static-99R have suggested that it would be inappropriate to simply use a one-size-fits-all normative group against which to compare individual offenders. Options for comparative samples include “routine”, “non-routine”, “preselected for treatment need”, and “preselected for risk and need”. The intent is to ensure that we really do compare apples with apples and oranges with oranges. Meta-analytic data suggest that using a normative group that includes all offenders amounts to a veritable “fruit salad” in which the heterogeneity of the sample leads to possible over- or under-estimation of risk for some individual offenders.

In a short paper originally published in the CCOSO Newsletter (republished in The Forum of the Association for the Treatment of Sexual Abusers ATSA), Thornton, Hanson, and Helmus suggested that the we might be able to use scores on measures of dynamic risk to help us choose an appropriate normative group for better interpreting an offender’s risk as scored on Static-99R. Stable dynamic risk factors are those that assist us in measuring risk according to factors related to personality or other longstanding aspects of someone’s make-up—but which are theoretically amenable to change with treatment or other interventions. Using the Stable-2007, Thornton et al. suggested that, among persons with the same Static-99R score, higher scores on the Stable-2007 would indicate higher levels of criminogenic need and an attendant increase in overall risk to reoffend.

Lacking any clinical interview with Mr. Sandusky, it is difficult to speculate what his exact score might be on any risk measure but, again, if we simply infer from information presented in the media, we can get a rough idea of what stable dynamic risk factors might be pertinent.

Of course, we have to emphasize that the reported offenses are all still allegations. For this exercise, one must assume that what’s been reported in the media is correct. So, for sake of argument, it appears reasonable to assume at least some degree of marital strife. It also seems reasonable to strongly suspect deviant sexual preferences and to presume the presence of emotional identification with children. Last, it seems likely to me that sexual pre-occupation and some degree of poor cognitive problem-solving and impulsivity might also be reasonably assumed.

Putting all this together, Mr. Sandusky would very plausibly be assessed as being of at least moderate risk to reoffend based on Stable-2007. Thornton et al. would suggest that this is indicative of a need for participation in a formal treatment program aimed at addressing risk for sexual reoffending and other aspects of lifestyle instability and dysfunction. This is to be contrasted with psychoeducational or short-term counseling programs usually offered to lower risk offenders (in keeping with the tenets of the Risk-Need-Responsivity Model).

At this point, it is likely worthwhile to briefly revisit the punishment vs. treatment issue. I’ve expounded on this much more precisely in previous posts, but it bears reiterating that there is little if any research showing that punishment alone reduces recidivism. The meta-analytic data suggests that this relation actually may work in reverse to what many might assume, in that it appears that punishment without programming leads to increased reoffending. Whatever we might think of individual studies supporting (or not) the benefits of providing treatment and other human service interventions, some really large meta-analytic studies show a strong effect of lower risk as a consequence of cognitive-behavioral programs, including treatment for sexual offenders. Bottom line, however much we might want to punish the Sanduskys of the world, punishment will not get us nearly as much bang for our risk reduction buck as will treatment. It’s fine to want to sanction someone for their actions, but we shouldn’t kid ourselves that that will eliminate risk to reoffend.

Back to our flight of fancy risk assessment exercise…

Referring to the Static-99R Evaluators’ Workbook, persons in the “Preselected for Treatment Need” normative sample have a roughly 3.1% chance of sexually reoffending within five years, or a 5.4% chance of doing so within 10 years of release. Pretty low, eh? I bet that the majority of the public would be shocked to learn that Sandusky’s putative risk for reoffense is so low; especially, given the degree of media attention and public outcry this case has garnered to date.

However, this is an excellent example of how the process of risk assessment doesn’t always line up with public perception. We sometimes let our emotional impulses determine how we think about the risk posed by the offender. If he actually committed the offenses, it is very reasonable to assume that Mr. Sandusky did an awful lot of harm to a large number of boys and young men. Such offenses naturally evoke some degree of anger, disgust, and denunciation. However, none of those responses necessarily makes for good risk assessment or, ultimately, good risk management.

Should he be found guilty of the offenses, Mr. Sandusky will be subject to punishment for his actions. It is also possible that he will attend a treatment program for persons who have sexually offended. Depending on the length of the sentence, his health, and the release practices of the state in which he is incarcerated, it is also possible that he may someday be released back to the community. That brings us back to his Static-99R score and the consideration of Stable-2007 variables.

Should he be released at some point in the future, it would be scientifically defensible to consider the risk Sandusky poses for reoffense to be low. One of the salient risk factors to be considered here is age-related desistance. Of course, Sandusky is alleged to have been offending as recently as only a few years ago, when he was already of advanced age. Some might be inclined to say that this negates age-related desistance as a modifier of risk potential—I disagree. The data I’ve seen so far on the age-related desistance issue do not suggest that age is a dichotomous factor. Rather, it is incremental or continuous. What that indicates is that all persons are likely to “slow down” in most areas of life as they age, but not necessarily in the same exact fashion. All in all, advancing age WOULD BE a risk-reducing factor for Sandusky, just like it is for every sexual offender—it might just not be as much of a risk-reducing factor for him as it might be for his peers.

In closing, the intent of this blog post is not to garner sympathy for offenders nor somehow to excuse their actions. Rather, my intent was to highlight the apparent disconnect between our emotions about offending and our knowledge about scientifically defensible risk assessment processes. Concluding that Jerry Sandusky would be in the low risk range for sexual reoffending is not the same thing as concluding that his actions are acceptable or mitigating the harm done to the putative victims. Neither does that rating suggest that Mr. Sandusky should be exempted from criminal prosecution, criminal sanction, or eventual evidence-based risk management processes should he ever be released.

Hopefully, as this case goes forward, Sandusky will be properly assessed by a trained professional and a scientifically defensible plan of action will be developed that assists him in addressing whatever risk factors are actually present. All of this would be intended to reduce the level of risk he might pose to others in the community. Ultimately, that’s the dilemma of people who sexually abuse. We can reduce risk among the most reviled of our citizens, but only through compassionate rehabilitation and sensible community supervision.


RJW

Denial, Minimization, and Polygraphy

This blog comes to you jointly authored by David Prescott and your resident blogger.

There has been much talk of late about polygraphy and sexual offender risk management in a number of forums. Recent issues of The Forum of the Association for the Treatment of Sexual Abusers have included both articles and reviews of books about the polygraph. Similarly, the list-serve of the same organization has seen a number of recent threads on this topic, with heated debate from both sides. Further, at a couple of recent trainings conducted in New York State (by RJW), the topic also came up, with equally spirited discussion. From our observations (and, perhaps, participations in those discussions), it is pretty clear that this topic includes a significant degree of passion and has the potential to polarize (alienate?) persons who, by our estimation, are all similarly inclined towards public safety.

Overall, the debate seems to progress along a number of lines:

1. How do denial and minimization affect recidivism?


2. How much “truth” is necessary in order to provide effective treatment or risk management?


3. Do we need to “honor” the victims of sexual abuse by making sure that offenders take full responsibility for their actions?


4. What does the research tell us about the overall utility of the polygraph itself as a tool for use in sexual offender risk management?

First, many of us appreciate that the polygraph can produce disclosure/confession very quickly, but there is a very real question of whether short-term confession equates to someone who can be honest with others in the long term. How much is our thinking influenced by a moral judgment rather than opinions based on science? As the fathers of former and current teenagers, we are very aware that they lie to us every so often. All teenagers do. However, we are more concerned that they learn to live a balanced and self-determined life than we are in accounting for each time they’re not completely honest with us. Indeed, we are sometimes caused to consider whether there isn’t a certain degree of denial or minimization that adaptively functions as legitimate ego defense.

The meta-analytic data suggest that neither denial nor minimization are particularly fruitful as indicators of reoffense risk, but we are aware that other data seek to clarify that global perspective. As clinicians, we find it interesting that full disclosure is a prerequisite for treatment entry or continued participation for sexual offenders, and sexual offenders only. In no other aspect of mental health or impulse control do we compel clients to enunciate in painstaking detail the particulars of every instance in which they either did or might experience the negative symptoms or manifestations of their difficulties. Think what might happen if we held schizophrenics or drug addicts to the same standard? Would anyone ever get better?

Third, while many of us feel that the rapid accountability that polygraphy provides is part of a victim-centered approach, we are unfamiliar with any research showing that survivors of sexual abuse want compelled disclosure. If it were us, we would prefer that someone who hurt us had demonstrated meaningful change rather than confess merely because he/she was compelled to do so by representatives of the legal system. Admission does not equal understanding. Most of the survivors with whom we’ve worked have simply said they just wanted the behavior to stop. It is clear that sexual offender treatment can be of assistance to victims; however, we question by what authority we presume to speak for survivors.

Last, there seems to be no research showing that the polygraph is directly beneficial to clients’ treatment progress in the long term. The available data (from McGrath and crew in Vermont), scant as they are, would seem to suggest either the opposite or simply no effect. Nonetheless, many of us believe that the polygraph is an important part of the equation for various reasons, such as the fact that it produces more information. What is less clear is that more information is necessarily better information. How much of “the truth, the whole truth, and nothing but the truth” is required for offenders to appreciate the harm caused by their behavior and to make genuine and real efforts to stop? Similar to our questions above, if we were providing treatment for other kinds of crime, would it be necessary to account for every instance of criminal behavior? Or, is it that we feel compelled to account for every hurtful sexual behavior because of the high stakes?

As noted above, the current data underscoring the reliability and validity of polygraphy as used with sexual offenders are scant or questionable. That is not to say that polygraph assessment doesn’t assist some clients some of the time, and we get that. Rather, we believe that, as a field of inquiry and practice, we owe it to our clients, victims, and the community-at-large to employ methods supported by sound science. Perhaps, this is the reason why many courts have qualms about accepting polygraph results? For us, we’re all about the data. Show us the data and we’re good to go. Otherwise, we likely ought to be more circumspect.

We also wonder why a tool used so extensively in common practice has not been the subject of more research? Other technologies—actuarial risk assessment scales, PPG, and VRT measures—all routinely used in sexual offender risk management have been subject to extensive inquiry as to their relative utility in our cause. Why not polygraphy? As one ATSA list-serve poster noted, we don’t need extensive research to accept that parachutes are an important preventive measure when jumping out of a plane. However, is this degree of face validity appropriate regarding the polygraph? In this regard, we are very mindful of Marshall’s research on the deleterious effects of confrontation in treatment and means by which to offer effective treatment to “deniers”. Perhaps, the issue is more about how we use polygraph and for what purpose. This brings us back to our questions about how much “truth” is required and what methods of eliciting those truths are most likely to get us what we want—increased public safety?

Perhaps, we need to be more honest with ourselves: Our field uses the polygraph to meet our needs more than those of our clients. Whether that is good or bad depends on one’s orientation and definition of what sexual offender treatment actually is. However, it might also be time to address an irony in this discussion: An essential part of the polygraph examinations involves being certain of the technology and the results. When our field is as uncertain as it is, where does our own credibility start to come into question?