DSM5 in Distress

The DSM's impact on mental health practice and research

Sneaking Hebephilia Into DSM 5

Statutory rape is not a diagnostic criterion.

Dr. Ray Blanchard, of the DSM 5 sexual disorders work group, has written a misleading blog that portrays the introduction of 'Hebephilia' into DSM 5 as no more than a minor change. In his rendering, DSM IV already permits the diagnosis of pedophilia if victims are 13 or younger and DSM 5 is just raising the age threshold to 14. No big deal. 

http://sajrt.blogspot.com/2012/01/guest-blog-by-dsm-5-paraphilias...

This is yet another step in a stealth campaign to progressively repackage 'Hebephilia' so unobtrusively that it can somehow fly below the radar and sneak into DSM 5. Originally, 'Hebephilia' was offered as a free standing diagnosis—but this was so roundly criticized by the vast majority of experts (in both forensics and sexual disorders) that it had to be dropped. Then the DSM 5 work group tried to bury the name (but not the concept) of 'Hebephilia' by slipping it within an omnibus 'Pedohebephila'—but this didn't fool anyone and criticism continued unabated.

In the work groups latest attempt, the word 'Hebephilia' now disappears altogether as a title of a diagnosis, but the concept is cloaked as a qualifier within a radical and unrecognizably broad redefinition of DSM 5 'Pedophilia.' It makes no sense to place 'Hebephilia' as a specifier under the diagnosis Pedophilia—yet another sly way to shoehorn it into DSM 5, but it just doesn't fit.

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The term Pedophilia has always been exclusively reserved for preferential attraction to prepubescent children and it is ridiculous to suggest otherwise. However cleverly it is disguised, 'Hebephilia' is a turkey that just won't fly.

Dr Blanchard's stratagem is based upon a fundamental misunderstanding of the DSM IV definition of 'Pedophilia'. The 'A' criterion reads: "Over a period of at least six months, recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubuscent child or children (generally under 13 years or younger)."

The reader should note (as Dr Blanchard has not) that the words "(generally under 13 years or younger)" appear in parentheses and are clearly meant to be merely illustrative, not definitive. The defining feature of Pedophilia is the preferential and intense interest in PREPUBESCENT children, not the specific age of the child. The parenthetical "(generally under 13 years or younger)" indicated only that most kids over thirteen would have attained puberty and should not be considered. The ruling issue is always the presence or absence of puberty, not age.

When this criterion was written more than 20 years ago, puberty occurred much later than it does now and age 13 seemed an appropriate upper suggested limit, provided only for illustrative purposes. In the interval, the average age of onset has dropped so substantially that age 13 has become meaningless. This large drop in age of onset has in no way affected the current diagnosis of 'Pedophilia' precisely because it has always been the presence or absence of puberty that counts, not the age of the victim. If an illustrative age is kept at all in DSM 5, it should be lowered to reflect the current earlier onset of puberty- not raised upward in a futile attempt to sneak in 'Hebephilia'.

Dr Blanchard misstates in two ways when he claims that it is only a small change to raise the age requirement for victims of 'Pedophilia' from age 13 to age 14. First, there never has been (and should not be) an age requirement. Second, given the current early onsets of puberty, arbitrarily introducing an age requirement and setting it as high as age 14 will, by definitional fiat, magically turn much of the newly broadened 'Pedophilia' into 'Hebephilia'. As Richard Green puts it, "Several European nations where the age of consent is 14 will suddenly become hotbeds of Pedophilia."

So, quite contrary to Dr Blanchard's reassurance, DSM 5 is in fact suggesting a major and radical qualitative expansion in the DSM conception of Paraphilia, not a minor and quantitative one.

Why shouldn't there be an age requirement? First off, the onset of puberty is highly variable from one person to the next and its median age differs dramatically with time and place. Setting any arbitrary age limit for diagnosing 'Pedophilia' is simply meaningless. But even more important, 'Hebephilia' is a very bad idea almost completely unsupported by evidence and vigorously opposed by the field.

The literature on 'Hebephilia' is remarkably thin and almost totally irrelevant. Most of the research has studied 'Hebephilia' only incidental to Pedophilia. We have no peer reviewed, published data on how it would best be defined; the performance characteristics and validity of the proposed criteria; and its impact on real world forensic practice. Dr Blanchard's 'field trials' really don't deserve the name- they were unfunded; informal; not peer reviewed; done in highly selected, rarified, and possibly biased sites; and report preliminary results that are simply not credible.

Remarkably, Dr Blanchard fails to mention (much less, take seriously) the harmful consequences that would follow the stealth inclusion of 'Hebephilia' in DSM 5. If a disorder is described in DSM, it can count in SVP cases. If not in DSM, it usually does not count. In my January 23 blog, Ron Mihordin MD JD of the California Department of Mental Health characterized 'Hebephilia' and other unrecognized disorders as "weed diagnoses." These are now facing an increasingly uphill struggle masquerading under the much overused rubric 'Paraphilia NOS'. But if Pedophilia is irresponsibly expanded to include 'Hebephilia,' the courts will have to treat this as evidence that 'Hebephilia' has attained widespread community acceptance- when most emphatically it has not. 'Hebephilia' will have become a qualifying diagnosis for SVP commitment -when certainly it should not be.

Any DSM 5 decision to greatly broaden the Paraphilia section would be arbitrary, radical, scientifically unsupported, and much opposed by the field. But once made, it would set the standard for diagnosis in SVP cases. A poorly thought through, minimally studied, and untested 'diagnosis' that was inserted into DSM 5 despite fierce opposition will nonetheless be empowered to trigger the most consequential decision in all of forensic psychiatry- the recommendation for civil commitment as a Sexually Violent Predator (SVP).

The integrity of SVP statutes is undermined when they are applied carelessly and based on questionable diagnostic practice. Recommending involuntary psychiatric commitment (often for life) makes sense only when the diagnosis can be counted on. Using a makeshift diagnosis (like 'Hebephilia') in SVP cases is not only an abridgment of individual civil rights, but also represents an abuse of psychiatric diagnosis and involuntary commitment to further a questionably constitutional form of preventive detention. The inclusion of 'Hebephilia' will bring shame on DSM 5 and the APA- which incidentally has taken a strong stand against the misuse of psychiatric diagnosis in SVP cases.

The DSM 5 sexual disorders work group is an inbred, idiosyncratic, and insulated outlier on the 'Hebephilia' question and should not attempt to impose its controversial views as if they were widely accepted by the field. DSM must be a 'consensus scholar' document that rejects any suggestion that is this controversial. An official diagnostic manual must include only the tried and true, not stretch itself to promote premature and untested research hypotheses.

So don't be fooled by DSM 5's misleading relabeling. Introducing 'Hebephilia' under any guise would be a reckless change with immediate and severely dire consequences. The 'Hebephilia' suggestion (like its equally unfortunate predecessors 'coercive paraphilia' and 'hypersexuality') never made any sense and should now finally receive the summary repudiation it richly deserves.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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