LETTER TO THE EDITOR

APA Guidelines Ignored in Development of Diagnostic Criteria for Pedohebephilia

Richard Kramer

 Springer Science+Business Media, LLC 2010

This Letter describes how the proposed DSM-5 criteria for pedohebephilia
have been developed without following four key guidelines specified by the American Psychiatric Association (APA) and to point out significant flaws that have resulted. It also proposes solutions.

First,
the paraphilias subworkgroup apparently ignored the DSM research agenda development process, which addressed developmental issues, questions of disability and impairment, potential contributions from neuroscience, and cross-cultural and gender considerations (American Psychiatric Association, 2010e).

Developmental issues are crucial for determining the ages at which pedohebephilic disorder can be diagnosed and the bases for diagnosis at various ages, since attraction to children develops during childhood (Farella, 2002; Freund & Kuban, 1993).

The other considerations would inform ongoing debates over impairment and distress in diagnosing pedophilia (e.g., Green, 2002; O’Donohue, Reger,& Hagstrom, 2000) and over whether pedohebephilic disorder is a genuine psychiatric disorder or solely a taboo in current Western culture (Bullough, 1990; Green, 2002).

Additionally, they might help us understand why pedohebephilia is rarely diagnosed among women. However, neither the literature review on pedohebephilia (Blanchard, 2010) nor the rationale on the DSM-5 website acknowledges these issues.

Second,
the paraphilias were ignored by the APA/NIH organized conference series designed to address problematic diagnostic questions in particular categories and

‘‘to stimulate the empirical research necessary to allow informed decision making’’(American PsychiatricAssociation, 2010f).

If any category is in need of such attention, surely it is the paraphilias.

There have been continuing controversies over conceptual validity, logical consistency, and terminology; in the absence of reliable scientific data, it has been easy for critics to claim that conceptualizations and criteria have been determined by law and morality rather than science (Franklin, 2009; Green, 2002; Moser & Kleinplatz, 2005).

The lack of research interest in pedohebephilia is breathtaking in light of the extreme societal concern over adults and adolescents who interact sexually with children, and considering that 5% or more of males (over 5 million adults and 600,000 teenagers in the U.S.) may be preferentially attracted to children (Abel & Harlow, 2001; Farella, 2002; Hall, Hirschman, & Oliver, 1995).

Yet, none of the 10 APA/NIH conferences or resulting white papers, which‘‘played
a key role in establishing the evidence base for DSM-V,’’ addressed pedohebephilia (American Psychiatric Association, 2010d).

Third,
the paraphilias subworkgroup ignored the APA’s statement that

‘‘to ensure that those involved in the revision process represent diverse perspectives, disciplines, and areas of expertise, the Task Force and work groups represent a variety of clinical and scientific disciplines…’’ (American Psychiatric Association, 2010a).

A full understanding of pedohebephilia would require consulting experts and research from psychology, sexology, evolutionary biology, ethology, anthropology, and sociology. But all four members of the paraphilia subworkgroup are specialists whose perspective on pedohebephilia is limited to that of controlling sex offenders.

Of the 34 studies cited in Blanchard’s (2010) literature review, 31 were from a sex
offender management perspective, including 10 co-authored by Blanchard himself.Although relevant literature from other fields is not plentiful, it does exist.

Fourth,
the subworkgroup failed to heed APA guidance that DSM work groups should represent ‘‘patient and family groups’’ (American Psychiatric Association, 2010a).

Researchers have long criticized research on pedophilia for its reliance on unrepresentative correctional samples (e.g., Okami & Goldberg, R. Kramer 1992).

Additionally, such subjects cannot be honest with researchers or clinicians about their sexual feelings. In fact, this is the rationale Blanchard (2010) used for relying on offense records for diagnosis,writing

‘‘they might experience even more severe consequences of their actions if they acknowledge being pedophiles.’’

Thus, he recognizes both the disadvantages of relying on correctional populations and the harm to the patient of accurate diagnosis. But instead of suggesting the usual scientific and therapeutic response — namely, developing collaborative relationships with patients and challenging the obvious injustice of increased punishment resulting from accurate diagnosis — he accepts this adversarial stance in which the clinician must outsmart the patient and contribute to his demise.

Involvement of minor-attracted people (not constrained by the correctional system) in research and collaborative efforts to dismantle adversarial relationships would increase understanding of pedohebephilia and lead to solutions to such ethical dilemmas.

However, contrary to APA guidelines, no patient or family groups have had any
representation in the workgroup regarding pedohebephilia.

The failures described above have resulted in serious flaws in the proposed diagnostic criteria:

1.  Without any understanding of the developmental course of pedohebephilia or any scientific rationale whatsoever, Criterion A arbitrarily specifies that feelings and behaviors be present for at least six months, and Criterion C arbitrarily specifies that patients be at least age 18, but only if their object of attraction is 5 or more years younger.
2. Criteria A and B rely on arrest records for diagnosis, ignoring the fact that cultural factors may have a large impact on who gets arrested.
3. Criteria A and B define sexual interaction with 13 and 14 year olds as a mental disorder based not on any scientific rationale but on the fact that Western culture sees it as wrong and that people are arrested and already diagnosed for it. 
    
   Most amazing is Blanchard’s rationale that arrests for it are more common than those for sexual activity with prepubescent children, citing a study finding that 14 is the modal age for sexual victimization (Snyder, 2000).
   He fails to mention that the very same study found that 14 is the modal age of those offending against prepubescent children!
   By his logic, Criterion C should be changed to include 14 year olds as diagnosable.
4. Due to the subworkgroup’s narrow perspective, Criteria A, B, and C exhibit a singular focus on sexual behavior and ‘‘urges,’’ ignoring the emotional and social aspects of pedophilia suggested by other research (Li,1990; Wilson& Cox, 1983).
   This reinforces an extraordinarily harmful and distorted stereotype of minor-attracted people as motivated only by their desire for sex with children.
5. Blanchard (2010) defines a paraphilic disorder as ‘‘a paraphilia that causes distress or impairment to the individual or harm to others,’’ ignoring the currently proposed definition of mental disorder requiring there be an ‘‘underlying psychobiological dysfunction’’(American Psychiatric Association,2010b).
    
   Furthermore, the actual proposed criteria do not require harm, but rather sexual activity by someone 18 or older with children or adolescents at least 5 years younger.
    
   Blanchard cites no scientific literature suggesting that these age requirements determine harmfulness, thus appealing to law rather than the work of the study group on impairment and distress, in direct contradiction to the APA’s statement that a mental disorder is ‘‘not primarily a result of social deviance or conflicts with society’’ (American Psychiatric Association, 2010b)

There are significant ethical consequences of the above failures.

Particularly egregious is the tendency for the criminal justice system to enthusiastically label people diagnosed with pedophilia and hebephilia as ‘‘sexually violent predators’’ in spite of overwhelming research (ignored by Blanchard’s literature review) showing that they rarely exhibit aggressive tendencies (Okami & Goldberg, 1992).

The paraphilias subworkgroup and the APA as a whole have an ethical obligation to disseminate this fact to policymakers, and to vigorously challenge the misuse of DSM to label non-violent people as ‘‘violent.’’

Failure to do so reinforces a culture in which it is obligatory to refer to minor-attracted people as animals (‘‘predators’’) and to call for their banishment or extermination. Youth who realize they are attracted to children find no encouraging information or help — only condemnation.

Goode (2009) gives a particularly haunting account of a 16-year-old boy attracted to children who decided that he would be a hero if he slit his wrists and bled to death. I have been contacted by teenagers who were contemplating suicide, and one 14-year-old who habitually cut himself and turned to drugs and alcohol.

Psychiatry is not a helping profession when it takes an adversarial stance toward
such patients and exacerbates rather than relieves psychiatric symptoms.

The APA must heed its claim that the new criteria

‘‘not only reflect new advances in the science and conceptualization of mental disorders, but also reflect the needs of our patients’’ (American Psychiatric Association, 2010c).

The APA and the paraphilias subworkgroup have an intellectual and ethical responsibility to promote valid research and to counter rather than reinforce false stereotypes.

There are steps they can take to fulfill this responsibility:

1. Researchers whose expertise lies outside the sex offender management perspective must be consulted, and their perspectives integrated into the work of the paraphilias subworkgroup.
2. A truly comprehensive literature review that includes research from a wide variety of applicable fields needs to be conducted.
3. Funding priorities and incentives must be put in place to encourage research and education regarding pedohebephilia.
4. Minor-attracted people not constrained by the correctional system must be involved as subjects in research and collaborators with psychiatrists and other professionals in setting the research and education agenda.
   B4U-ACT, a Maryland non-profit organization that promotes communication between mental health professionals and people attracted to minors, is ready to facilitate such collaboration.
5. Symposia must be held to promote the flow of ideas among minor-attracted people and researchers of diverse perspectives.

References

Abel, G.,&Harlow, N. (2001). The stop child molestation book. Xlibris.
American Psychiatric Association. (2010a).
Current activities: Report of the DSM-5 Task Force (March 2009).

American Psychiatric Association. (2010b). Definition of a mental disorder.

American Psychiatric Association. (2010c). DSM-5: The future of psychiatric
diagnosis. http://www.dsm5.org/Pages/Default.aspx .

American Psychiatric Association. (2010d). DSM-V planning conference
series monographs. http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/...

American Psychiatric Association. (2010e). Phase 1: A research agenda
for DSM-V: White paper monographs. http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/... .

American Psychiatric Association. (2010f). Phase 2: Refining the research
agenda for DSM-V: NIH conference series. http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/... .

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

Bullough, V. L. (1990). History in adult human sexual behavior with
children and adolescents in Western society. In J. Feierman (Ed.),
Pedophilia: Biosocial dimensions (pp. 69–90). New York: Springer-Verlag.

Farella, C. (2002, July 1). The unthinkable problem of pedophilia. Nursing Spectrum. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=70... .

Franklin, K. (2009). The public policy implications of ‘‘hebephilia’’: A
response to Blanchard et al. (2008) [Letter to the Editor]. Archives
of Sexual Behavior, 38, 319–320.

Freund, K., & Kuban, M. (1993). Toward a testable developmental
model of pedophilia: The development of erotic age preference.
Child Abuse and Neglect, 17, 315–324

Goode, S. D. (2009). Understanding and addressing adult sexual attraction
to children: A study of paedophiles in contemporary society.
New York: Routledge.

Green, R. (2002). Is pedophilia a mental disorder? Archives of Sexual
Behavior, 31, 467–471.

Hall, G., Hirschman, R., & Oliver, L. (1995). Sexual arousal and
arousability to pedophilic stimuli in a community sample of normal
men. Behavior Therapy, 26, 681–694.
< http://www.ipce.info/ipceweb/Library/97-048_article.html >

Li, C. K. (1990). Some case studies of adult sexual experiences with
children. Journal of Homosexuality, 20(1–2), 129–144.

Moser, C., & Kleinplatz, P. J. (2005). DSM-IV-TR and the paraphilias:
An argument for removal. In D. Karasic &J. Drescher (Eds.), Sexual
and gender diagnoses of the Diagnostic and Statistical Manual
(DSM): A reevaluation (pp. 91–110). Binghamton, NY: Haworth Press.

O’Donohue, W., Regev, L. G., & Hagstrom, A. (2000). Problems with
the DSM-IV diagnosis of pedophilia. Sexual Abuse: A Journal of
Research and Treatment, 12, 95–105

Okami, P.,& Goldberg, A. (1992). Personality correlates of pedophilia:
Are they reliable indicators? Journal of Sex Research, 29, 297–328.

Snyder, H. N. (2000). Sexual assault of young children as reported to
law enforcement: Victim, incident, and offender characteristics
(Report No. NCJ 18399). Washington, DC: U.S. Department of
Justice Bureau of Justice Statistics

Wilson, G.,& Cox, D. (1983). The child-lovers: A study of paedophiles
in society. London: Peter Owen Publishers.
< http://www.ipce.info/host/wilson_83/ >.