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.

A guest blog from Jon Brandt regarding SVP programs...

This blog post features commentary by ATSA member and Minnesota resident/clinician Jon Brandt.

Doubts about SVP Programs

Jon Brandt, MSW, LICSW

St. Paul, MN

Recently there have been some excellent commentaries on the ATSA LIST about the state of sexual offender civil commitment (SOCC) and SVP programs in the US and Canada. With the pending discharge from SOCC in Minnesota of only the second guy in 20 years, this is a hot issue here. Not surprisingly, some state legislators are already trying to figure out how to block the release of 64-year-old Clarence Opheim.
For 20 years, Minnesota’s SOCC program has been a one-way door, with releases determined by political fiat rather than by therapists or judicial review. The SDP threshold into SOCC in Minnesota (MN Stat 253B.02 (18c)) is frighteningly low and the obstacles out are impossibly high. The current census at Minnesota’s SOCC facilities, the Minnesota Sex Offender Program (MSOP) is about 640. By 2020, MN DHS projects 1,100 clients.

At least in Minnesota, my experience is that most of the professional, competent staff at MSOP are trying to provide effective treatment to clients. However, it is not lost on either clients or staff that there is an intellectual dishonesty about treatment goals that no one has ever completed. When treatment is unending, can we expect clients to maintain endless motivation? MSOP reports an 80% treatment participation rate; evidence that dedicated staff and hopeful clients are trying to make the best of current circumstances. I do not think it is a moral abdication for clinical staff to provide services to clients while supporting and encouraging reforms and participating in the academic debates about SOCC.

Just a year ago, in March 2011, The Minnesota Office of the Legislative Auditor released an evaluation on the Civil Commitment of Sex Offenders in Minnesota. Like a similar 2011 legislative report just released in Virginia, it offers a review and critique of how MSOP is operating, relative to legislative intent. Needless to say, it is difficult to have outcome data without any “outs.”

The Minnesota report is over 100 pages, but there is a summary of recommendations starting on page 93. The summary, however, does not do justice to the narrative, which actually has a candid discussion about some of the problems and weaknesses in the MSOP program. The authors did not sidestep the issue of morale and client motivation for a program that operates like the Eagles' Hotel California – “you can never leave.”

I appreciate the insightful commentaries on SVP programs recently posted by Merrill Main and David Thornton on the ATSA-LIST. There was much to agree with, but I disagree with Dr. Thornton that, "you can only work with sexual offenders in the USA if you are prepared to work as part of a system that is substantially less just and less effective than it should be. Your choice then is whether you either withdraw from that system as a whole or work within it trying to incrementally shift it in the direction of becoming less unjust and less ineffective."

Thornton has expressed his views often enough on the ATSA-LIST and in other professional forums to leave no doubt that he is an advocate for the better management of sexual offenders, but I think it is BECAUSE we know that we are working in a broken system that we should neither withdraw from the system nor acquiesce to "incremental” changes.

Per capita, Minnesota has the highest SOCC rate in the world, and has had only one provisional discharge in its 20-year history. It was unsuccessful, his release was revoked, and he died at MSOP. If Mr. Opheim is able to avoid revocation of his discharge, he will be the first-ever MSOP client to not leave SOCC in a body bag. SOCC in Minnesota and elsewhere is badly broken and needs more than incremental change.

In January of this year, MN DHS and the William Mitchell Law School co-sponsored a symposium on SOCC, comparing systems in four states (MN, WI, TX, NY). There was no consensus on whether Minnesota should look at "more successful" models of SOCC, or whether we should consider the possibility that the 30 states in the US and almost all other countries around the world who do not have SOCC might be the model to follow. Every state/country has dangerous offenders; how are they managed without SOCC? With all due consideration for the dangerousness of those men on the morally depraved end of the scale, how many guys at the other end of the continuum should not be under SOCC?

Prior to SOCC, the last widespread use of preventive detention in the USA was when all three branches of our federal government approved the roundup of Japanese-Americans during WWII. After Pearl Harbor, “internment” was popular with the public and, with roots in anger, fear, and misinformation, it was legally justified on concerns for public safety. At the time, there were undoubtedly a lot more discussions about who qualified as “Japanese” and the logistics of mass incarceration, than there likely were about triage for risk or concerns about social injustice. Surely, anyone who spoke to the idea that preventive detention might be a misguided reaction to overblown fear had a small audience. While, perhaps, some argued for incremental changes to the living conditions at internment camps, the existence of the camps themselves were challenged by too few.

Internment was wrong, and most educated, informed people knew it. Nevertheless, leadership caved and public policy was driven by widespread hysteria. If Japanese internment is an unflattering comparison, that does not make the analogy invalid; in fact it makes the point stronger. If we will use preventive detention without considerations for efficacy or social injustice with Japanese-Americans who did not do anything to warrant detention, is it any wonder that the public seems entirely “comfortable" with using preventive detention for sexual offenders? If hindsight is 20/20, when we look back at SOCC many years in the future, will we be proud of the roles that we had today?

William Mitchell Law School Dean Eric Janus warned 20 years ago that SOCC was both deceptively enticing and deeply flawed. He predicted that SOCC would over-reach, compromise legal integrity, and foster misguided solutions to complicated social problems. Professor Janus wrote about this in his 2006 book, "Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State." Some of his arguments were laid out in a 2008 journal article. Janus appears to be correct in his prophesy of “build it and they will come.” At the symposium last month Janus issued another warning, that SOCC is an "impending train wreck."

Washington became the first state with SOCC in 1990. Like in Minnesota, the impetus was a couple of high-profile heinous sex crimes. SOCC has now been enacted, in some form, in 20 states. The US Supreme Court had doubts about sexual civil commitment in 1997 when justices approved it, in concept, by a narrow 5-4 vote in Kansas v. Hendricks. Kansas v. Crane, decided in 2002 by a 7-2 vote, clarified the Hendricks decision in regard to volition. A read of the opinions in these cases reveals how fluid the legal underpinnings of civil commitment are. It is noteworthy that Justice Breyer, in his dissenting opinion in the Hendricks decision, refers to an Amicus Brief filed by ATSA, attesting to the treatability of sexual offenders. If one justice in the majority on the Hendricks decision had joined the dissenting justices, SOCC would not exist as we know it today. If the courts, upon further review, find SOCC in practice to effectively be prison in disguise, the courts may find SOCC to be unconstitutional. Indeed, we should have doubts about SVP programs, and as a profession be prepared to offer viable, effective alternatives.

If professionals who work with sexual offenders do not challenge the politics, misinformation, and misguided management of SOCC, where is a more credible voice going to come from? In an area of public policy where reason is often eclipsed by emotion, ATSA members may be in the best position to know the research, understand competing principles, and advocate for sound rationales. If forensic psychology with sexual offenders is being dominated more by forensics than psychology, I would suggest that the tail might be wagging the dog.

A 2012 report just released on Sex Offender Recidivism in Connecticut confirms that recidivism for sexual offenders continues to be extraordinarily low. In a five-year review of 14,400 men released from prison in 2005, of the 746 parolees who had served a prison term for a sex crime, only 27, or 3.6 percent were arrested and charged with a new sex crime; 20, or 2.7 percent were convicted; and 13, or 1.7 percent were returned to prison with a sentence for a new sex crime. (Incidentally, the report has excellent demographic data.)

In contrast, the report indicates that overall recidivism for general parolees in the same period was 78.6 percent arrested, 69.3 percent convicted, and 49.8 percent returned to prison with new sentences. It is noteworthy that the report also reveals that a large number of paroled sexual offenders reoffended in other ways, but not sexually, which is what sexual offender management and SOCC is targeting. Still this report supports the conclusions of other research—that sexual recidivism is exceptionally low and there is something materially different between most sexual offenders and most “common criminals”.

Consider the data in the CT report in the context of actuarial risk tools. Only 3.6% of 746 paroled sex offenders were charged with a new sex crime. Is it any wonder that actuarial risk tools are having a difficult time determining which 27 guys out of 746 parolees will sexually re-offend? The report offers some clues, but they are not likely to be statistically significant. It is widely believed that most actuarial tools, in practice, are over-reaching the underlying science. How does this affect the rate of SOCC?

Furthermore, consider the implications of this CT report for SO registration. Add these new Connecticut findings to a 2008 New York State review of 170,000 arrest records for sexual offenses over a 20-year period. The review determined that 95% were first time sex offenders. As a matter of good public policy, does a reoffense rate of 4-5% justify the registration and tracking of the other 95% of sexual offenders?

A growing body of national research is beginning to arrive at a consensus similar to findings in New Jersey, that SORNA is at best a misguided solution; at worst contributing to the “social death” of sexual offenders, not cost effective, and by missing 95% of sexual offending not effectively making society safer. If sexual offender registration is severely over-reaching in the management of low-risk sexual offenders, is it not likely that the same risk management system might also be over-reaching in SOCC?

How many men with sexual offenses are getting caught in the SVP nets, not because they are actually dangerous, but because what they did is exceptionally offensive? What level of false positives is acceptable? The cost to taxpayers, lost productivity, and social injustice cannot be quantified.

If Clarence Opheim is provisionally discharged from MN SOCC next month, morale at MSOP will rise and scores of clients will reinvest in treatment. Hundreds of MSOP staff and 639 other clients are pinning their hopes on one man’s success. Every day that Mr. Opheim remains offense-free, survives the public wrath, holds up to the scrutiny of the media, and professionals do not overreact to minor violations, will build success. Stakeholders on both sides of the razor-wire will be watching to see if he is able to put 20 years of sex offender specific treatment into practice in a “real social environment,” or if he has forgotten how to function in the real world.

The state might indefinitely have to provide housing and facilitate employment. “Ex-con” or “Sex Offender” is a tough enough label but being tagged the “worst of the worst” might be a deal-breaker on a resume or a housing application. While I’m intending to be only a little bit cynical, without significant reforms, most adjudicated or convicted sexual offenders today, no matter how successful their efforts in the future, will never escape their past. That will be especially true for every guy coming out of SOCC.

It is not just in everyone’s interest that Mr. Opheim succeeds; it is imperative. Consider the alternative: If the second of only two discharges in MSOP history fails, for any reason, both failures will be seen as a malfunction of both MSOP and SOCC. A second unsuccessful discharge is not only likely to have far-reaching consequences for sexual offender management in Minnesota; a seismic “thud” may well be heard at ATSA listening posts across the country. In addition, it would be hard for the courts to ignore.

SOCC in Minnesota may now be painted into a corner. In the interest of public safety we may have compromised Constitutional protections beyond integrity. Perhaps Ben Franklin’s quote is apt, that “those who would give up essential liberty to purchase a little safety deserve neither liberty nor safety.” This might be part of the “train wreck” scenario envisioned by Janus.

The successful release of Mr. Opheim and other men under SOCC will be something to celebrate by all of us in this field that believe in effective treatment, the power of redemption, and the principles of social justice. But, going forward, if we are going to effectively manage sexual offenders, we need a significant paradigm shift.

We have very solid empirical evidence to challenge current misguided public policies. We need to get good research to the right folks. We need to infuse policy makers with the necessary information for bureaucracies to champion productive recommendations into meaningful change. Many ATSA members are doing the “heavy lifting” of trying to bring good research, balanced perspectives, and reasoned initiatives by writing and speaking to the media and at public hearings in the US and Canada.

We should all push past some inherent reticence that interferes with our ability to professionally speak up, take a stand, or find a place at the table with other stakeholders who share our common goals of making society safer. If we use our knowledge and expertise to educate the public, inform our colleagues, and persuade policymakers that best practices should emanate from good science, we might not have to settle for incremental changes. We can help create new paradigms.

A postscript:  There is a sobering caveat contained in the Connecticut report. The data was based on offenders released from prison during 2005. In 2007 was the horrible home invasion murder of the Petit family by two CT parolees. In the months following, the state’s parole system stopped functioning, the prison system grew by almost 1,000 inmates, and remand rates soared. This is similar to what happened in Minnesota in 2003 when Dru Sjodin was murdered by a Minnesota parolee. The following year, the referral rate for SOCC in Minnesota went from an average annual rate of 26, to 235. Since then, SOCC referrals have remained at an average annual rate of 140. Horrendous events resulted in Adam Walsh, Jacob Wetterling, Megan Kanka, Dru Sjodin, and too many other murdered individuals becoming the namesakes of Congressional Acts. This should remind us of the urgent and ongoing need to do much, much more on the prevention side.

JonBrandt@aol.com

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.