Commentary: Hebephilia—A Would-be Paraphilia Caught in the Twilight Zone Between Prepubescence and Adulthood

Hebephilia

The term ephebophile, referring to attraction to adolescents in the age range of 15 to 19, was coined by Krafft-Ebing.² The current term, hebephile, apparently was first used by Bernard Glueck³ in his “Final Report for the New York State Department of Hygiene” on the treatment of individuals with “sexual aberrations.” Glueck referred to those with victims in the age range of 12 to 15 as “hebephiles.”

Blanchard et al.⁴ examined age preference profiles in 881 men who had been referred for paraphilic, criminal, or otherwise problematic sexual behavior for phallometric testing. Within-group comparisons showed that men who verbally reported maximum sexual attraction to pubescent children had greater penile responses to depictions of pubescent children than to depictions of younger or older persons.

On the basis of these results, Blanchard and his colleagues⁴ went on to propose a revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of pedophilia that would embrace sexual interest in adolescents in the age range of 11 to 14. The downward age trend over the past half century simply reflects the younger age of onset of puberty. The average age of menarche for American Caucasian females is 13, and other indices of puberty (e.g., pubic hair) emerge earlier, at age 11 for both girls and boys.⁴ The newly proposed category, pedohebephilia, essentially crafts two diagnoses differentiated by the Tanner Stages of sexual development.⁵ Pedophilia remains restricted to Tanner Stage 1 (i.e., no evidence of the development of primary or secondary sexual characteristics). Hebephilia would now include children in Tanner Stages 2 and 3 (e.g., early development of pubic hair and breasts).

Publication of the Blanchard et al.⁴ article provoked a flurry of criticism (e.g. DeClue,⁶ Frances and First,⁷ Franklin,^8,9 Green,¹⁰ Janssen,¹¹ Kramer,¹² Moser,¹³ Tromovitch,¹⁴ and Zander¹⁵). Although the critics found a minor methodological flaw (noted by the authors themselves) in the omission in Blanchard et al. of stimuli depicting 15- to 18-year-olds, they did not disagree with the basic scientific phenomenon described by them—namely, that some individuals are maximally aroused by adolescents. The critics were unanimous in their conclusion, however, that the scientific phenomenon reported in their study did not justify the recommendation of Blanchard et al.⁴ that hebephilia be included as a paraphilia in the DSM-5. O'Donohue, who was clearly supportive of the proposed distinction between arousal in response to a child and arousal to pubescent minors, was sharply critical of the “many proposed alterations which are not useful and which actually may make the current diagnostic criteria even less adequate” (Ref. 16, p 587).

Significant concern has been expressed that pedohebephilia implies an empirically supported condition that underlies both pedophilia and hebephilia and that arousal to stimuli depicting adolescents is inherently deviant. Frances and First⁷ provide a detailed analysis of these twin concerns, concluding that “Hebephilia is not a legitimate DSM-IV-TR mental disorder….” and “Hebephilia is not a paraphilia” (Ref. 7, p 84). A practical concern has been raised as well: the anticipated misuse of such a diagnosis in court involving civil commitment proceedings for sex offenders.^7,9,11,15

Other commentators have questioned the role of phallometry as an adequate determinant of mental disorder.^11,15 Green noted that, “A cornerstone of the argument for bundling hebephilia with pedophilia is the overlap between interest in prepubertals and pubertals. What of the overlap between hebephiles and teleiophiles (adultophiles)? What of the 50 percent hebephile/50 percent teleiophile?” (Ref. 10, p 586). Indeed, one of the earlier studies found precisely that. Barbaree and Marshall¹⁷ examined phallometric responses to pictures of nude females ranging in age from 3 to 24 in 61 child molesters (21 of whom were incest offenders) and a matched group of 22 nonoffenders. Barbaree and Marshall found five distinct phallometric profiles, none of which reflected a unique and distinct preference for adolescents. One of the profiles was characterized by responses to both adolescent and adult stimuli.

At present, the DSM-IV-TR¹⁸ includes only a category for pedophilia. Hebephilia, when diagnosed, must be NOS (paraphilia NOS, hebephilia). Although numerous other paraphilias, unspecified in the DSM, must also be diagnosed using NOS, hebephilia in particular has become a lightning rod for criticism, as noted above. At heart, the key is not operationalization. Presumably, hebephilia would be operationalized as adequately, or inadequately as the case may be, as pedophilia. Criterion A of Pedophilia 302.2 (Ref. 18, p 572) would remain the same, with the exception of the parenthetic age reference. Instead of generally age 13 years or younger, the age range for hebephilia would be generally 11 to 14, per Blanchard et al.⁴ Criterion B would remain the same.

What underlies the passion coloring this matter is the very legitimacy of hebephilia as a true paraphilia. The argument, quite simply stated, is that sexual interest in, and arousal in response to, pubescent teenagers is normative, or, at the very least, not deviant. Stated otherwise, if men are hard wired to respond sexually to young pubescent females, can sexual interest in adolescents in the age range of 11 to 14 be reasonably construed as a true mental disorder?

Normative Sexualization of Children and Adolescents

As Durham¹⁹ documents very well in her book on the ubiquitous media sexualization of young girls, the marketing and advertising industries take full advantage of very young teenage girls to sell products to adults. In a review of Durham's book, Wollek stated, moreover, that: Little girls are now being seen as part of the sex culture in the United States. Girls as young as the age of 7 are being involved in activities that originated for adults. An example of this is the fact that some health clubs are beginning to teach pole-dancing classes to young children…. Movie directors are casting girls as young as 10 years old as prostitutes or objects for men to admire sexually. Models on the catwalk in some events are as young as 12. Not only are young girls being used for sexual objects, grown women are also being portrayed doing things that are childlike but “sexy.” Women are shown sucking on lollipops with pig tails in their hair or wearing childish clothes [Ref. 20, p 123]. Brooke Shields was only 12 years old when she played a child prostitute in Pretty Baby, three years before she modeled Calvin Klein jeans, asking, “Want to know what gets between me and my Calvin's? Nothing.” Klein's young teenage models were so provocative that the Justice Department investigated whether the ads violated federal child pornography and child exploitation laws. Penelope Cruz was only 13 years old when she played a child prostitute in the French soap opera Série Rose. Jodie Foster was 14 years old when she played a child prostitute in Taxi Driver. The model Maddison Gabriel, the official “face” of Australia's Gold Coast Fashion Week in 2007, was only 12 years old. Highly sexualized young girls would not be used in advertising, in movies, and on catwalks unless a great many adult males were paying close attention. It appears that heterosexual human males are hard wired to respond sexually to young females with secondary sexual characteristics. This fact, of course, does not justify adult sexual involvement with individuals below the age of consent. Such behavior is a criminal offense, and most men who find young adolescent females sexually appealing exhibit appropriate control over their arousal and their subsequent behavior.

Nexus of Criminal Code and Diagnosis

Legitimizing hebephilia as a mental disorder is particularly controversial for legal reasons.^7,9,11,15 Fabian¹ alludes to the pivotal role hebephilia plays in the civil commitment of sex offenders. If hebephilia is granted the imprimatur of the American Psychiatric Association through inclusion in its DSM-5, it will, in some cases, satisfy the second prong, the mental abnormality element for civilly committing sex offenders whose victims are wholly or predominantly adolescent.⁸ Hence, for self-serving reasons, it is applauded by those who generally work for the prosecution and criticized by those who generally work for the defense. This is an admittedly cynical, if unfortunately accurate, commentary on the influence of adversarial litigation on clinical deliberation. The coincidental use, or abuse, of the DSM in court should, in an ideal world, have no bearing on deliberations over the extant clinical and empirical support for hebephilia. The American Psychiatric Association should not be influenced to adopt, or not adopt, a diagnosis based on who will be helped or hindered in court. Although we appreciate the naivete of this statement and are well aware of the similarly highly controversial adoption of another paraphilia (paraphilia coercive disorder) that would be used to civilly commit rapists,^21,–,25 the DSM was never designed or intended to be a tool of the criminal justice system.

This “secondary legal agenda” of the paraphilias is not new. Professor Money commented: In DSM-III-R only eight paraphilias are separately categorized with a named and numbered entry of their own…. The classificatory rationale for separating these eight from all other paraphilias is historically legal and, for the most part, criminological, not scientific, logical, or systematic. They represent the medicalization of behavior that in an earlier era was, and in some cases still is, criminal [Ref. 25, p 41]. The “law/psychiatry blur” described by Green¹⁰ was mentioned by Blanchard et al.⁴

The bright line in the sand should be the clinical and empirical integrity of the proposed diagnosis. We say this with full knowledge that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is routinely misused in court, resulting in inappropriate civil commitment of sex offenders. On this matter, we could not agree more strongly with Frances and First.⁷ If the authors of the DSM are so inclined, they can include a stern caveat, similar to the general one that presently appears at the beginning of the DSM-IV-TR, regarding the limitations of, and the appropriate use of, paraphilic diagnoses. Below, we offer an objective appraisal of hebephilia as a psychiatric diagnosis, independent of the justifiable concerns about its misuse in court.

Hebephilia as a Mental Disorder? The Putative Importance of Criterion B

Thirty-six years ago, Spitzer and Wilson provided the following three criteria for defining mental disorder: conditions that “are primarily psychological and involve alteration in behavior”; that, in their “full blown state are regularly and intrinsically associated with subjective distress, generalized impairment in social effectiveness or functioning, or voluntary behavior that the subject wishes he could stop…”; and that are “distinct from other conditions in terms of the clinical picture …” (Ref. 26, p 829). The current definition is quite similar: … a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, or disability, or an important loss of freedom…. Neither deviant behavior nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual … [Ref. 18, pp xxi–xxii].

There appears to be temporally consistent agreement that mental disorders are conditions that are associated with some degree of distress and/or impairment in functioning or disability. The question of distress and impairment was pointedly made with respect to the paraphilias. According to the newly proposed criteria, we can ascertain a paraphilia from self-report and behavior, but we can diagnose a paraphilia only from evidence of distress and impairment. Stated otherwise, although one may have a paraphilia based only on criterion A, a diagnosable paraphilic disorder requires that both criteria A and B are met. This new distinction was discussed critically by O'Donohue.¹⁶

Evaluating the presence of distress in paraphilias can be problematic, with the exception of those paraphilias that bring the individual in conflict with the law. The consequences of violating the law may then be inferred to be a primary source of distress, although one could certainly envision instances in which distress from legal sanctions transferred to the behavior itself (i.e., the behavior elicits anxiety due to the potentially severe sanctions associated with it). Otherwise, distress would not seem to be a common feature of paraphilias. All paraphilias, by definition, are forms of sexual gratification, be they deviant or not, and thus are highly reinforcing. One would not expect that a chosen vehicle for experiencing erotic pleasure would bring the level of distress commonly found in other mental disorders, such as depression, anxiety, and major mental illness.

The more germane question, one might argue, is whether that sexual interest precludes sexual interest in age-appropriate partners and reflects a serious deficit in adult psychosexual adaptation. Stated otherwise, for all the men who find the young teenage models and actresses to be sexy, how many would not only select those youngsters as partners in relationships but choose those youngsters as the preferred sexual partner? For men who have a preference for those youngsters, to the exclusion of interest in adult, age-appropriate partners, one could defend the argument that they have clinically significant deficits in social and interpersonal skills. Thus, for some men for whom these youngsters are the preferred object choice, it may be plausible to conclude that there is a disability or impairment in functioning.