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Hebephilia Is Not a Mental Disorder in DSM-IV-TR and Should Not Become One in DSM-5

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Hebephilia Is Not a Mental Disorder in DSM-IV-TR and Should Not Become One in DSM-5 ANALYSIS AND COMMENTARY Hebephilia Is Not a Mental Disorder in DSM-IV-TR and Should Not Become One in DSM-5 Allen Frances, MD, and Michael B. First, MD The paraphilia section of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is being misinterpreted in the forensic evaluations of sexually violent offenders. The resulting misuse of the term paraphilia not otherwise specified, hebephilia, has justified the inappropriate involuntary commitment of individuals who do not in fact qualify for a DSM-IV-TR diagnosis of mental disorder. This article has two purposes: to clarify what the DSM-IV-TR was meant to convey and how it has been twisted in translation within the legal system, and to warn that the DSM-5 proposal to include pedohebephilia threatens to make the current bad situation very much worse in the future. J Am Acad Psychiatry Law 39:78–85, 2011 Twenty states and the federal government have carceration would clearly represent double jeopardy passed statutes that allow for the involuntary psychi- and a denial of due process. There is no constitu- atric commitment of sexually violent predators tional justification for continued preventive reten- (SVPs) to begin after their prison sentence has al- tion once a prison sentence has been served, unless ready been served. These statutes were passed as a dangerousness is specifically caused by mental public safety measure in response to egregious sexual abnormality. offenses committed shortly after release by former The Supreme Court ruling does not require that prisoners who had received relatively short sentences. the qualifying mental abnormality be a Diagnostic Central to all the statutes is a requirement that the and Statistical Manual of Mental Disorders (DSM)- SVP offender be diagnosed with a mental disorder or defined disorder, but in actual practice, evaluators abnormality. The five to four Supreme Court ruling invariably use one or another of the DSM categories 1 in Kansas v. Hendricks that narrowly supported the to justify their findings. Although it varies from state constitutionality of SVP statutes rests completely on to state, the two most commonly used DSM diagno- a presumed ability to distinguish individuals who are ses to justify involuntary commitment are generally mentally disordered from those who are common pedophilia and paraphilia NOS (most often NOS, criminals. Otherwise, the continued involuntary in- nonconsent, but more recently also NOS, hebe- philia).2,3 There has been some, but limited, contro- Dr. Frances is Professor Emeritus, Department of Psychiatry and Be- 4,5 havioral Science, Duke University, Durham, NC. Dr. First is Professor versy about the suitability of pedophilia, but it is of Clinical Psychiatry, Columbia University, and Research Psychia- generally accepted within the field as a qualifying trist, New York State Psychiatric Institute, New York, NY. Address DSM-IV-TR mental disorder. The grounds for ac- correspondence to: Allen Frances, MD, 1820 Avenida del Mundo, Coronado, CA 92118. E-mail: [email protected]. cepting paraphilia NOS as a qualifying mental disor- Disclosures of financial or other potential conflicts of interest: Dr. der are much shakier. Frances was chair of the DSM-IV Task Force and has provided testi- In the first half of this article, we discuss the cur- mony on behalf of the defense in SVP commitment cases. Dr. First was rent misuse of the concept paraphilia NOS, hebe- editor of text and criteria for DSM-IV and editor and co-chair of the DSM-IV-TR, and has performed forensic evaluations on behalf of the philia, in involuntary SVP commitments. In the sec- defense in SVP commitment cases. ond half, we discuss the weaknesses of the DSM-5 78 The Journal of the American Academy of Psychiatry and the Law Frances and First proposal for a new diagnosis of pedohebephilia and Sexual Deviations. The term Paraphilia is preferred its detrimental consequences. because it correctly emphasizes that the deviation (para) lies in that to which the person is attracted The Misuse of the Diagnosis Paraphilia (philia)” (Ref. 17, p 279). NOS, Hebephilia Those preparing DSM-III-R understandably Although it was first mentioned 100 years ago, did not anticipate that many years later their trun- hebephilia has sprung into sudden prominence only cated definition of paraphilia would be placed un- because of its recent use in forensic proceedings.6 der intense scrutiny and have such consequential The term hebephilia has been used to provide a men- impact in the context of sexually violent predator tal disorder diagnosis for those SVP offenders whose commitment hearings. The DSM-III-R listing of targeted victims are pubescent, not the prepubescent eight specific paraphilias, along with the inclusion targets of pedophilia. The numerous conceptual of seven other patently abnormal examples in the problems with the diagnosis of hebephilia and the NOS section (e.g., necrophilia (corpses), zoophilia extreme limitations of its research base have already (animals), and coprophilia (feces)), was thought to been well described by authorities in the sexual dis- be sufficient to communicate to clinicians the va- orders field.7–15 This background has not prevented riety of sexual arousal foci considered to be para- hebephilia (in the official sounding guise of para- philic. Subsequent editions have similarly failed to philia not otherwise specified, hebephilia) from be- provide a general and abstract definition of what ing misused as a qualifying diagnosis in legal pro- makes a particular sexual arousal pattern para- ceedings, to justify what often becomes a lifelong philic. Nonetheless, the underlying principle gov- involuntary psychiatric commitment. erning inclusion in this category is that a person’s We will attempt to correct the misunderstandings focus of sexual arousal be considered deviant, bi- that are shared among many SVP evaluators about zarre, and unusual. the DSM-IV-TR paraphilia section. These misun- In our roles as Chair of the DSM-IV Task Force derstandings result in part from the imprecise DSM- and its Editor of Text and Criteria, we must take IV-TR wording, which is best understood by review- 16 responsibility for its insufficiently clear wording that ing how paraphilia was defined in DSM-III and has allowed the misuse of the Paraphilia section in how and why the wording was changed in DSM-III- 17 18 19 SVP hearings. We did not anticipate the later foren- R, DSM-IV, and DSM-IV-TR. sic misuse of the section and dropped the ball by DSM-III, which first introduced the term para- retaining the vague DSM-III-R wording that did not philia, noted that “the essential feature of disorders in include anything approaching a clear and coherent this subclass is that unusual or bizarre imagery or acts are necessary for sexual excitement” (Ref. 16, p 266). definition of the overall concept of paraphilia. The The text then went on to offer some examples of boundaries of the term paraphilia are admittedly ex- what would constitute unusual or bizarre imagery or tremely difficult to define precisely, but in retrospect acts, explaining that they “generally involve either: we should have provided more guidance and less (1) preference for use of a nonhuman object for sex- room for the loose usage now found in SVP ual arousal, (2) repetitive sexual activity with humans proceedings. involving real or simulated suffering or humiliation We will annotate the wording of the three intro- or (3) repetitive sexual activity with nonconsenting ductory sentences in the DSM-IV-TR Paraphilia sec- partners” (Ref. 16, p 266). Because of concerns about tion, in an attempt to clarify the original intent of the subjectivity and unreliability of the terms un- DSM-III, DSM-III-R, and DSM-IV and reduce the usual and bizarre in the definition, these terms were confusion caused by the unfortunate ambiguity in omitted from DSM-III-R (Robert Spitzer, personal their wording. We chose these three sentences be- communication, July 8, 2010), leaving only the list cause they have been the most misinterpreted in fo- of examples that were modified to mention “chil- rensic settings to justify the inappropriate use of the dren” specifically, alongside “other nonconsenting paraphilia NOS category. We hope that this insider’s persons.” Notably, the sentences explaining the ety- parsing of the intended meanings will help to set the mology of the word paraphilia were retained: “In record straight and prevent their further misuse in other classifications these disorders are referred to as SVP proceedings. Volume 39, Number 1, 2011 79 Hebephilia Is Not a Mental Disorder Essential Features of a Paraphilia The underlying problem is that a satisfyingly pre- Much has been made in legal settings of the word- cise bright-line definition of paraphilia may not be ing of the opening sentence of the DSM-IV-TR possible, just as there is no satisfying bright-line def- Paraphilia section: “The essential features of a Para- inition of the more general concept of mental disor- philia are recurrent, intense, sexually arousing fanta- der in either psychiatry or the law. This ambiguity has led to the distressing situation of the defining of sies, sexual urges, or behaviors generally involving 1) paraphilia NOS by the idiosyncratic, unreliable, and nonhuman objects, 2) the suffering or humiliation of untrustworthy standard of “you know it when you oneself or one’s partner, or 3) children or other non- see it.” But one thing is clear about the DSM defini- consenting
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