Two recent votes suggest that professional consensus is running strongly against controversial proposals to add new paraphilias to the Diagnostic and Statistical Manual, Edition 5 (DSM-5). The votes are symbolic, but should send a strong message to the developers of the manual, due out in 2013.
The most recent vote came at the end of a spirited debate at the annual American Academy of Psychiatry and the Law conference, in Arizona, in October 2010. The assemblage of seasoned forensic psychiatrists voted overwhelmingly against paraphilic coercive disorder, pedohebephilia, and hypersexuality. The votes were 31 to 2, 31 to 2, and 29 to 2, respectively.
The rejection followed a similarly resounding vote at the International Association for the Treatment of Sexual Offenders meeting in Oslo, Norway, in September, 2010. Europeans voted 100 to 1 against pedohebephilia after psychiatrist Richard Green warned that adding the condition to the DSM would “compromise the scientific credibility of psychiatry.”1 Green served on the Gender Identity Disorders subcommittee for DSM-IV.
The controversial proposals have stimulated more than a dozen published rebuttals. At the AAPL conference, the three-member “con” team focused on the dearth of scientific reliability or validity for these proposed diagnoses. They also stressed the potential for misuse by partisan advocates in the forensic arena, especially in civil commitment proceedings.
This is the third time that paraphilic coercive disorder has been considered as a diagnosis for rapists. It was rejected as a DSM-III-R diagnosis on the basis of inadequate scientific foundation and lack of acceptance among psychiatrists, according to a review article by Thomas Zander,2 who took the con position.
Arguing against hypersexual disorder, APA Distinguished Fellow and AAPL Past President John Bradford wondered how clinicians could reliably determine the point at which sexual interest becomes excessive. He expressed worry that the label would be disproportionately applied to gay men.
Opposing pedophilia's expansion was this letter writer, who has authored a historical review in Behavioral Sciences and the Law3 pointing to problems with hebephilia's validity and reliability, especially in adversarial contexts.
The pro team consisted of Columbia University professor Richard Krueger, a member of the paraphilias work group for DSM-5; forensic psychiatrist Douglas Tucker; and David Thornton, Treatment Director at Wisconsin's detention center for civilly committed sex offenders. The debate was organized by forensic psychiatrist Lynn Maskel, a clinical professor at the University of California-San Diego.
Since the debate, Martin Kafka of the DSM-5 paraphilias work group has acknowledged in writing that the scientific literature supporting the three proposals is “quite modest.” He has also said publicly that he would consider it a victory if the proposals even made it into the appendix as conditions meriting further study. It is to be hoped that, given their lack of adequate scientific basis, they won't even make it that far.
Disclosures of financial or other potential conflicts of interest: The author was one of the debate panelists, on the “con” team.
- American Academy of Psychiatry and the Law