Saturday, May 15, 2010

Commenting on the Paraphilias Subworkgroup

Most of us have learned to be wary of reading the comments on the internet, but for the Psychiatric Times, I have found some of the comments that people have left regarding the DSM-5 Sexual and Gender Identity Disorders Workgroup (and especially the Paraphilias Subworkgroup) are quite interesting. There are people with very serious concerns about how this process has been going who have been using that as a platform to get their voices heard.

A while ago, I reported on an article that Allen Frances (chair of the DSM-IV Taskforce) wrote, a response that Ken Zucker (chair of the DSM-5 Sexual and Gender Identity Disorders Workgroup) made, and Frances response to that. It seem that there are two versions of this.

In the recent version Rory Houghtalen (Google tells me he's a forensic psychaitrist) provides an interesting anecdote:
[There was] a session held at the at the American Academy of Psychiatry and the Law annual meeting this past October in Baltimore where the recommendations of the DSM 5 workgroup was presented then critiqued by an expert panel and the audience. I cannot recall more than a handful of comments from either the panel or the audience that supported the recommendations for changes to the paraphilic disorders criteria sets or the inclusion of new diagnoses related to hypersexuality or paraphilic coercive disorder. Rather there was a loud and consistent plea for the workgroup to return to the drawing board. The level of defensiveness Dr. Krueger displayed in the face of negative feedback was disappointing and surprising. Discussion spilled into the hallway after where a straw poll indicated that many left the session with the impression that the workgroup would hunker down and ride out the criticism rather than listen to the thoughtful critique of experts and practicing professionals who expressed grave concerns about its recommendations.

On the earlier version of the article, a fascinating comment was made by Richard Kramer (who explains who he is in his comment):
One of the issues that has yet to be addressed is the fact that in regards to "pedohebephilia,"the DSM is currently being revised in the absence of data from representative samples of those people under consideration. If experts are right, there are hundreds of thousands of people (most experts estimate over a million) in the general population who are preferentially attracted to children or adolescents (emotionally and sexually). Yet, DSM revisions are being based on limited data only from unrepresentative correctional populations who cannot be honest with researchers. It is well-known among social scientists that data from such populations are highly biased and misleading. Such limited data hardly lead to "diverse perspectives" or to "a thorough, balanced review of scientific data" as specified by APA Statements regarding DSM revisions.

In fact, Dr. Blanchard writes that his proposed diagnostic criteria are based on the assumption that patients will be dishonest. Do other subworkgroups base their criteria on such assumptions? If one is interested in accurate diagnostic criteria, it would seem to be more effective to find solutions to this problem than to be content with misleading information and a situation where the only subjects are those who are encouraged to be dishonest while clinicians must outsmart them. It seems hard to believe that such an adversarial approach would result in accurate diagnosis or effective treatment.

This approach, along with the lack of accurate information, breeds fear both in society and among people who are attracted to minors. In my work with a non-profit organization (B4U-ACT) in Maryland, I have met many minor-attracted people not under the supervision of the correctional system, some of whom seek mental health services but are extremely feaful of condemnation solely for their feelings of attraction. I have also been contacted by teenagers who have engaged in cutting or attempted suicide due to their attraction to children. They do not feel safe contacting professionals or suicide hotlines. Fear forces minor-attracted people into hiding, making the gathering of accurate information even more difficult. Perpetuating this vicious cycle does not lead to reliable diagnostic criteria (nor to effective child protection policies). It renders the APA powerless to gather and disseminate accurate information.

There is a solution to this otherwise intractable problem. Our organization has facilitated communication and cooperation between mental health professionals and minor-attracted adults, and has proposed to establish in-person dialog with the paraphilias subworkgroup for the purpose of obtaining more accurate information. The ultimate goal is to reduce barriers between professionals and people who are attracted to minors for their benefit as well as the benefit of children and society in general.

So far, Dr. Blanchard has replied as follows:

1. He stated that members of the subworkgroup are too geographically scattered to meet with us. We replied by offering to meet with only one or two members.

2. He responded by saying that for the reason already given, the subworkgroup would not meet with us. He did not acknowledge the need for accurate information.

3. He wrote that his subworkgroup would never discourage minor-attracted people from seeking clinical assistance. We replied by noting that failing to include representation from patient and family groups as stipulated by APA policy seriously discourages them from receiving mental health care. The need to promote a cooperative relationship with clients is well known in the mental health field.

4. He wrote that to "ensure fair and equal treatment of all advocacy groups," APA policy precludes his subworkgroup from meeting with us. We replied that this was puzzling since the APA held a symposium at its 2009 Annual Meeting to "bring together transgender advocates and DSM-V group members," thus it was unclear how meeting with transgender advocates but not with us was fair and equal treatment. We also did not see how such a policy could be reconciled with the following APA statement: "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, patient and family groups..." We wonder how minor-attracted patients or their families had been represented in his workgroup.

We fully support the APA's stated positions as cited above, but see evidence that the paraphilias subworkgroup may be reluctant to adhere to them.


Recently, Allen Frances has written a letter to the APA board of Trustees, which is posted in the Psychiatric Times. In the comments there, Richard Green leaves serious critique of the Paraphilias Subworkgroup:
For the past 15 years I have been in Europe, having retired from a professorship at UCLA. My specialty has been gender and sexual behavior. The DSM5 is making a major error in the sections on paraphilias. Including paraphilias along with paraphilic disorders stigmatizes persons with no mental disorder. They only practice an atypical pattern of sexual behavior. The inclusion of hebephilia is especially inappropriate here in Europe. The age of sexual consent is 14 in many countries. The DSM 5 will pathologize those who prefer sex with 14 year olds. The old cry of psychiatry as an agent of social control returns. This must not happen, Richard Green MD, JD, FRCPsych
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It certainly will be interesting to see how things continue to develop.

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