Table Of ContentArchSexBehav(2010)39:585–586
DOI10.1007/s10508-010-9602-7
LETTER TO THE EDITOR
Sexual Preference for 14-Year-Olds as a Mental Disorder:
You Can’t Be Serious!!
RichardGreen
Publishedonline:4March2010
(cid:1)SpringerScience+BusinessMedia,LLC2010
ThisletteraddressestwopapersbytheDSM-VSexualand successful, becomes an agent of social control (Moser &
Gender Identity Disorders Workgroup member Ray Blan- Kleinplatz,2005).
chardpublishedinthisJournal(Blanchard,2009;Blanchard TheAmericanPsychiatricAssociation(APA)isanorga-
etal.,2009). nizationrepresentingaprofessionstillstrivingforscientific
Havingbeenactiveinthe1970sstruggletoremovehomo- respectability.Theparodyofsciencemasqueradingasdemoc-
sexualityfromtheDSM(Green,1972),asuccessthatcured racymadealaughingstockofpsychiatryandtheAPAwhenit
millionsoftheirmentaldisorder,Iamappalledthattheranks held a popular vote by its membership on whether homo-
of the disordered may swell, once more in consequence of sexuality should remain a mental disorder (Bayer, 1981).
sexualorientation. Decreeinginafewyearstimethat19-year-oldswhoprefer
As a psychiatry professor and graduate of Yale Law sex with 14-year-olds (5 years their junior) have a mental
School,IhopeIunderstandthedomainofbothdisciplines. disorder,asproposedforDSM-V(Blanchard,2009),willnot
TheDSMproposaltrespassestheirboundary. enhancepsychiatry’sscientificcredibility.
Concernisexpressedthat‘‘thecurrentdefinitionofpedo- A series of biased terms or logically frail arguments are
philiaisexcludingfromspecificdiagnosisaconsiderablepro- providedforincludinghebephiliaasamentaldisorder.First,the
portionofmenwhohaveapersistentpreferenceforhumans terminologystampedonyoungerparticipantsinsexualinter-
atanincompletestageofphysicaldevelopment’’(Blanchard actions loads the dice in favor of criminalizing (though not
etal.,2009).Whencethe11thcommandment,Thoushaltnot pathologizing)sexwithearlyteens.‘‘Themodalageofvictims
have sex with those not fully mature? The Commandment ofsexualoffencesintheUnitedStatesis14years;therefore,the
couldhavebeencarved:Thoushaltnothavesexwiththose modalageofvictims fallswithinthe timeframeofpuberty’’
before reproductive capacity. This would permit sex with (Blanchard,2009).Whatconstitutesvictimhood?Isavictima
some13-year-olds. personwhoexperiencedtraumaconsequenttoasexualinter-
InseveralEuropeancountries,theageoflegalconsentto actionorawillingparticipantwhodidnotexperienceanunto-
have sex falls within the range proposed for the DSM as wardreactionbutcouldnotconsentlegally?
signifyingmentaldisorderfortheolderparticipant.Theage Logicalslippageisdemonstrated:‘‘Inanonymoussurveys
of consent is 14 in Albania, Austria, Bulgaria, Croatia, ofsocialorganizationsofpersonswhoacknowledgehavingan
Estonia,Germany,Hungary,Italy,Lithuania,andSerbiaand eroticinterestinchildren,attractiontochildrenofpubescent
13inSpain(www.avert.org).Ifthegeneralcultureisaccept- agesismorefrequentlyreportedthanisattractiontothoseof
ing of participation by the younger party, but psychiatry prepubescentages’’(Blanchard,2009)So?Thisdoesnotshow
pathologizesparticipationbytheolderparty,thenthemental thattheattractionisamentaldisorder.Further,‘‘Insamplesof
health profession pronounces a moralistic standard and, if sexualoffendersrecruitedfromclinicsandcorrectionalfacili-
ties,menwhoseoffensehistoriesorassessmentresultssuggest
eroticinterestsinpubescentssometimesoutnumberthose
R.Green(&)
whosedatasuggesteroticinterestinprepubertalchildren’’
DepartmentofPsychologicalMedicine,ImperialCollege,
(Blanchard,2009).So?This,too,doesnotshowthattheattrac-
LondonW68RF,UK
e-mail:[email protected] tionsorinteractionsreflectmentaldisorder,thoughcontactisa
123
586 ArchSexBehav(2010)39:585–586
crime.And,‘‘…largescalesurveysthatsampledindividuals humansinmid-stagepubertytobecomparedtothoseattracted
fromthegeneralpopulationincludedquestionsregardingsex- to5-year-oldsor80-year-olds,orthoseofasimilaradultage
ualexperienceswitholderpersonswhentherespondentwas asthemselves.Buttheirstudydoesnotrequireinclusionin
underage…asubstantialproportion…reportedagesofoccur- theDSM.
rence… within the normal time frame of puberty. The data The international social and political significance of
therefore indicate that hebephilia may be as great a clinical decisionsbytheAPAanditsDSMworkgrouponsexualand
problemaspedophilia’’(Blanchard,2009).Whymustitbea genderidentitydisordersareeasilyunderestimated.Inthree
clinicalproblem? countriesinEurope,therehasalreadybeendelistingofsome
Another argument proposed for DSM inclusion of hebe- paraphiliasfromthatcountry’sversionoftheWHO’slistof
philiaengagessexualpredatorlaw:‘‘…practitionersevaluating sexual disorders (ICD-10) because of stigma attaching to
patientsforcivilcommitmentundersexuallyviolentpredator diagnosis(www.revisef65.org).Inconsequenceofitsimpact
statutestypicallydiagnosesuchpatientswith‘‘ParaphiliaNOS incontroversialareasofsexualexpression,APA/DSMmust
(Hebephilia)’’’’(Blanchard,2009).Again,alaw/psychiatryblur. avoid both the rock and the hard place: 19th century com-
Thankfully,noteveryhebephileisasexuallyviolentpredator. pulsivelistingofnearlyeverypatternofsexualexpressionas
Thosewhoarecouldbechainedindefinitelybythepenalsys- psychopathic sexuality (Krafft-Ebing, 1886) and the con-
tem.Thwartedsuicidebomberswhocontinuetoposeapublic demnationofnearlyallpatternswithamodernrepackaging
threatcanbecagedwithoutterrorismenteringtheDSM. of4thcenturysin(Augustine,398).
A cornerstone of the argument for bundling hebephilia
withpedophiliaistheoverlapbetweeninterestinprepuber-
talsandpubertals.Whatoftheoverlapbetweenhebephiles References
andteleiophiles(adultophiles)?Whatofthe50%hebephile/
Augustine.(398).Confessions(A.Outler,Trans.).GrandRapids,MI:
50%teleiophile?
ChristianClassicsEtherealLibrary.
The proposed diagnosis may not attach short of sexual
Bayer,R.(1981).HomosexualityandAmericanpsychiatry:Thepolitics
contactwithapubescentperson,evenwhenthereisintense ofdiagnosis.NewYork:BasicBooks.
attraction. If diagnosis requires action (Blanchard, 2009), Blanchard, R. (2009). The DSM diagnostic criteria for pedophilia.
ArchivesofSexualBehavior.doi:10.1007/s10508-009-9536-0.
then psychiatry, the scientific/medical discipline of the
Blanchard,R.,Lykins,A.D.,Wherrett,D.,Kuban,M.E.,Cantor,J.M.,
emotionsandthought,isturnedonitshead.Nomatterhow
Blak, T.,Klassen, P. E. (2009). Pedophilia, hebephilia, andthe
madthethought,itisnotadisorderunlessactedupon. DSM-V.ArchivesofSexualBehavior,38,335–350.
Protecting people from unwanted, unwilling, or uncom- Green, R. (1972). Homosexuality as a mental illness. International
JournalofPsychiatry,10,77–98.
prehendedsexualinteractioniscommendable.Solegislatures
Krafft-Ebing,R.(1886).Psychopathiasexualis.Stuttgart:Verlagvon
enact rape laws to protect older persons and age of consent
FerdinandEnke.
lawstoprotecttheyounger.Butcategorizingrapeasamental Moser,C.,&Kleinplatz,P.(2005).Doesheterosexualitybelonginthe
disordershouldnotbenecessaryforfurtherprotection. DSM?LesbianandGayPsychologyReview,3,261–267.
Iagreethatitisoftheoreticalandresearchinterestifthere
is a population of humans attracted equally or primarilyto
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ArchSexBehav(2010)39:587–590
DOI10.1007/s10508-010-9604-5
LETTER TO THE EDITOR
A Critique of the Proposed DSM-V Diagnosis of Pedophilia
WilliamO’Donohue
Publishedonline:5March2010
(cid:1)SpringerScience+BusinessMedia,LLC2010
Giventheirfoundationalrole,examiningtheadequacyofdiag- tinction between deviant arousal to a child (pedophilia) and
nosticcriteriaandattemptingtoimprovetheseisoneofthemost arousaltoapubescentminor(hebephilia)isausefuldistinction
importantactivitiesourprofessionundertakes.However,devis- and one that communicates important information to stake-
ingandimplementingsatisfactorydiagnosticcriteriaisavery holders.Thisproposalshouldbeadopted.
difficulttaskforseveralreasons:(1)thereisnoconsensualmeth- However,therearemanyproposedalterationswhicharenot
odologythatcanbeusedtoproducevaliddiagnosticcriteria;(2) usefulandwhichactuallymaymakethecurrentdiagnosticcri-
languageiscomplexandattachingwordstoclinicalphenomena teriaevenlessadequate.Iwillreviewthesenow.
givesrisetoawholehostofthornylinguisticsubproblems(e.g.,
themeaningofeachwordused);and(3)thereisoftenmissing
informationthatwouldbeusefulinrevisionsidentifyingwhat NumberofVictims
themajorproblemsareregardingthecurrentdiagnosticcriteria
(e.g.,sourcesofcurrentinter-raterreliability).However,despite TheproposedCriterionBstates:‘‘Thepersonisdistressedor
theseproblems,theprofessionandotherstakeholdersareinter- impairedbysucharousal,orthepersonhassoughtsexualstim-
estedinthequestionoftheextenttowhichthecurrentcriteria ulation,onseparateoccasions,fromthreeormorepubescentor
‘‘carvenatureatitsjoints’’andcanbesuccessfullyimplemented younger children (two if both are prepubescent), or has used
byclinicians. childpornographyforaperiodof6monthsorlonger.’’
Blanchard (2009) has made several specific proposals for Thenotionthatone—andoftennoteventwo—victim(s)is
significantrevisionsinboththegeneralcriteriaforaparaphilia notsufficientforthediagnosisisthemostseriousproblemwith
aswellasrevisionsforthediagnosisofPedohebephilicDisor- theproposednewdiagnosticcriteria.Diagnosesallowtreatment
der.AccordingtoBlanchard(2009),manyoftheserevisions tolegitimatelybegin(andthirdpartypaymenttobegin)bypoint-
wereinresponsetoconcernsraisedbyO’Donohue,Regev,and ingtotheexistenceofapathologicalcondition.Diagnosesallow
Hagstrom(2000).Duetospacelimitations,theseconcernsabout legalauthoritiestomakecertaindecisions(regardingsentencing,
clarity,consistency,andpsychometricsoftheDSM-IVcriteria custody, parole, etc.). Diagnoses allow stakeholders to under-
willnotberepeatedhere. stand their current situation—that they are disordered, among
First, a positive development should be recognized: the otherfunctions.Itisharmfultotheseprocessesifallstakeholders
inclusionofhebephilia—arousaltodevelopingbutstillminor needto(needlessly)waitforothervictimstoemergebeforea
adolescents—isadecidedimprovement.Diagnosticcategories diagnosiscanbemade,andthesefunctionstoinstantiate.
shouldbeinformativeandmakecriticaldistinctions.Thedis- Further,thisproposalisinsensitivetotheknown/unknown
victimsratio(see,forexample,Abeletal.,1987).Ifthediag-
nosticianknowsofonevictim,thenisn’titoftenthecasethatitis
reasonabletohypothesizethattherearealreadymanyothers?If
thediagnosticianmustwaitforthree knownvictims(andthe
W.O’Donohue(&)
clientwilloftennotdisclosethese),doesthatmean,inactuality,
DepartmentofPsychology,UniversityofNevada,Reno,
thediagnosticianhasoftenwaitedfor3timesx(wherexrep-
Reno,NV89557,USA
e-mail:[email protected] resents the multiple representing total victims) victims to be
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588 ArchSexBehav(2010)39:587–590
harmed?Abeletal.’sdatasuggestthatxcouldbeaslowas2and aphilia‘‘ascertained’’butnotaParaphiliaDisorderdiagnosed,
ashighas100(forboys). whatdoesthismeanforhim?Doesthismeanheneedstreatment
Moreover,theproposedmultiplevictimscriterionleavesunan- or is he‘‘normal’’? Does this‘‘ascertainment’’have any legal
sweredthequestionofwhyisn’titthecasethatsexuallyabusing relevance—implicationsforcustody,sentencing,andsoon?It
one child in and of itself is not pathognomonic of a disor- seemstocreateagrayzonethatwillunnecessarilycreatealotof
der.Inaddition,whyistheunitofanalysisavictim?Whynot puzzlinganddifficultsituations.Thus,itisnotatallclearthe
abusive incidences, forexample?Ifa personhasabused two costsbringanyresultantbenefit.
victimshundredsoftimeseach,thismassiveamountofabuse
anddeviantbehaviorwould(strangely)stillnotmeetthepro-
posed diagnostic criterion. Finally, the proposed equivalence PsychometricIssues
oftwopre-pubescentandthreepubescentvictimsispuzzling
andataminimumneedsjustification.Theseseemlikecounte- Therehavebeentoo few studies ofthepsychometrics of the
rexamplesthatshowthatthisproposaliswrongandoughttobe current criteria. Levenson (2004) does not mitigate concerns
withdrawn. aboutthecurrentinter-raterreliabilityoftheDSM-IVdiagnosis
Ahypothesisisthatthisrevisedcriterionisproposedtoestab- (thekappaswerebyherownomission‘‘fairtopoor’’—.23–.70).
lishthatthereisapatternintheindividual’sbehavior.However, Moreover,thesubjectswereincarceratedforsexualoffensesand
again,thisisill-advisedfortwomajorreasons:(1)asdescribed wereallundergoingevaluationsforsexoffendercivilcommitment
above,apatternmayalreadyexistduetothehiddennatureof (whichmakesthesampleanunusualsubsetofclients),andthe
abuse;(2)whatistherivalpathwaythatisbeingattemptedto raterswerealsosomewhatatypicalastheaverageclinicianisnot
beruledout—’’experimenting’’—insomesortofputativenon- involvedwithsexoffendercivilcommitment.Thus,theclients’
pathologicalsensewithonevictim?Thisisnotanactualworryas histories were unique, which gives the clinician unusual infor-
sucharivalpathwayisnotestablishedintheliterature;and(3) mation(e.g.,arrestrecords,courttranscripts,convictionsfor
finally,itdoesnotmakesensethat6monthsofchildpornography sexual offending) that in all likelihood led to increased reli-
useissufficienttomakethediagnosisbuttwovictimsdoesnot abilityoverclientsseenoutsideacorrectionalsettingwhodonot
(also‘‘use’’isaveryvagueword). havetheseextensivelegalhistories.Also,theratersmayhave
alsobeensomewhatunique(e.g.,moreforensicallyexperienced
thanthegeneralpractitioner).Ataminimum,thisstudymaybe
AscertainingaParaphiliaversusDiagnosing generalizedonlytoconvicted,incarceratedsexoffenderswith
aParaphilicDisorder specialized raters, not clients in the general population with
moregeneralpractitioners.Itwouldhavebeenusefultohave
Thenewcriteriamakethisdubiousdistinction:‘‘Aparaphilic morestudiesregardingtheinter-raterreliabilityandthatprovide
disorderisaparaphiliathatcausesdistressorimpairmenttothe informationconcerningwhatpartsofthecurrentdiagnosislead
individualorharmtoothers.Onewouldascertain(emphasisin tounreliability.Withoutthisinformation,thecurrentrevisions
theoriginal)aparaphilia(accordingtoactionsandself-report, areproposedrelativelyblindtoactualreliabilityproblems.This
e.g., sexual attraction to amputees or inanimate objects) but lackofdataneedstoberemedied.Thesubworkgroupshould
diagnose(emphasisintheoriginal)aparaphilicdisorder(onthe conductstudiestoevaluatetheproposedcriteriawithrespectto
basisofdistressandimpairment).Aparaphiliaisanecessarybut their psychometric properties using typical clinicians seeing
notasufficientconditionforhavingaparaphilicdisorder.Gen- typicalpatientsinbothforensicandnon-forensicenvironments.
erally,paraphiliasareascertainedaccordingtotheAcriteriaand Iftheproposedcriteriaarefoundtobeunreliable,itisnotclear
paraphiliasarediagnosedaccordingtotheAandBcriteria.’’ whatcanbedoneatthislatedate;butbettertoexposeaproblem
Again, it is not clear what existing problem this revision earlythannottoknowit.
attempts to resolve. If it is meant to minimize false positive
diagnoses,thenthisconcernissimplywrongheaded.Thereis
oftenatradeoffbetweenfalsepositivesandfalsenegativesin FalsePositivesversusFalseNegatives
diagnosis,andthereislittleevidencetosuggestthatthefield
shouldmakechangestoacceptmorefalsenegativestoattempt Itsimplyisnotthecasethatwehavedocumentedproblemswith
to‘‘correct’’somesortofragingproblemwithfalsepositives. falsepositiveswiththecurrentdiagnosticcriteria.Duetothe
Secondly,thisdistinctioncomesatahugepsychometriccost. wellknown problemswith denial and minimizationwith pe-
Thefieldnowhasdoubleditspsychometricproblemsand dophiles,andtherelianceononlyself-reportinsomeofthecurrent
tasks—itnowhastoaskquestionsaboutthereliabilitiesand and proposed diagnostic criteria (e.g., fantasies), it seems rea-
validitiesofthisascertainmenttask.Finally,whatsortoflimbo sonabletoconcludethattheproblemistheopposite—theprob-
doesthisplaceallstakeholdersin—ifanindividualhasapar- lemiswithfalsenegatives.Diagnosingpedophiliaismorelike
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ArchSexBehav(2010)39:587–590 589
diagnosingAntisocialPersonalityDisorderthandiagnosing PossibleUnderlyingAssumptionsintheDiagnosis
somethingmoresociallyacceptableandegosyntoniclikeAgo- ofParaphilia
raphobia.Theclientinthesituationathandwillmoreoftenbe
minimizing,lying,anduncooperativeinanattempttoavoidthe Do the diagnostic criteriacontain assumptionslike:(1)Most
diagnosis.However,thecurrentcriteriareversethisemphasis. individualshaveasexualorientation,andpedophiliaisasexual
Moreover,whetherthedeviantarousaldistressestheperson orientation;(2)Orientationsarestable,traitlikephenomena;(3)
islargelyirrelevant.WouldwerequireanAntisocialPersonality Orientationssharesimilarproperties,suchasaspecifiedrange
Disorderedindividualtobedistressedbyhisbehavior?Some ofinterests,afunctioninself-definition,andsoon?Thisisan
disordersaredisordersbecausetheyhavethepotentialtoorhave importantquestionasdiagnosesoughttohavepredictivevalid-
actuallyharmedothers.Thepointisthatpedophilia(likeAnti- ity,includingpredictivevalidityrelatedtotreatment.
socialPersonalityDisorder)isdistressingtoothersforthefact Onereasonwhythisquestionissointerestingisthatitgives
thatitdidharmothersorforitspotentialtocauseharmtoothers. risetoseveralimportantquandaries.ItseemsliketheDSMdoes
Diagnosticcriteriaforthiswouldbemoresoundwiththereal- appeartotakepedophiliaasastableorientation,inthatitstates
izationthatitistheharmtoothers,notthedistresstoself,thatis that‘‘thesedisorderstendtobechronicandlifelong’’(American
thecruxoftheabnormalnatureofpedophilia. PsychiatricAssociation,2000,p.568)andthat‘‘theessentialfea-
tures of a paraphilia are recurrent, intense sexually arousing
fantasies,sexualurgesorbehaviors’’(p.568)(whichsoundslike
ClinicalandTreatmentUtility afairlygooddefinitionofsexualorientation).Ifpedophiliaisa
sexual orientation, can orientations be changed? Is there any
Any proposal for diagnosis should adequately consider the goodevidenceofthis—orevidencetothecontrary(see,e.g.,
burdenplacedontheactualclinician.Thesubworkgroupshould Marques,Miederanders,Day,Nelson,&vanOmmeren,2005)?
imagineconcretestepstheclinicianwouldneedtotaketoassess What should be stated regarding this important issue as it is
eachcriterionandpossiblesourcesoferrorinthesestepsaswell essentiallyrelevanttothepredictivevalidityortreatmentutility
as the magnitude of this error. If the subworkgroup asks for ofthediagnosis?Istheassumptionthatsomeorientationscanbe
somethinglike‘‘arousingfantasies,’’thesubworkgroupshould changedandsomecannotbe(e.g.,heterosexualorientations)?
thenask:Whatdoweknowaboutvalidlymeasuring‘‘arousing Thesubworkgroupshouldexplicitlyaddressthisquestion,i.e.,
fantasies’’?Doesthisrelytoomuchonself-report?Ifthesub- whataretheassumptionsaboutwhatkindofthingpedophiliais:
workgroup recommends criteria such as‘‘is aroused by chil- Ispedophiliaasexualorientationandisthisakindofthingthat
dren’’:Howdoesthesubworkgroupsuggestthattheclinician canbechanged?Perhapstheonlyreasonabletreatmentgoalis
actually validly measure this construct—Self-report? Victim forindividualstoactless(ornotatall)ontheirorientation,much
statements?Plethysmograph?Abelscreen?Ifasafieldwedon’t as inthe waythatapersonmaynotactontheirinterestina
knowhowtomeasuresomeproposedcriterion(especiallyina coworker(althoughthesituationisabitdifferent,thegoalwould
caseofareluctantclient),thenthesubworkgroupshouldbevery benevertoactinanywaytowardone’sorientation)—Isthis
cautious in asking clinicians to make decisions about issues evenpossibleorevenfeasible?
wherethecurrentstateofthescienceofassessmentdoesnot
allowclinicianstovalidlytothis.
Forexample,amajorconcernwiththerevisedcriteriaisthat AnAlternativeProposal
theclinicianisforcedtomeasurethemagnitudeoftheclient’s
sexualarousal—CriterionAcallsforthedeviantarousaltobe InsteadoftheproposedCriteriaAandB,Iwouldsuggestone
‘‘greater or equal’’than the arousal from mature individuals. diagnosticcriterion:Thepersonissexuallyattractedtochildren
Howisthecliniciantovalidlyundertakethismeasurementtask? oradolescentsundertheageof16asevidencedbyoneormore
Thecurrentstateofmeasurementtechnologysimplydoesnot ofthefollowing:(1)self-report,(2)laboratoryfindings,(3)past
allowforthisquantificationtobepracticallyorvalidlyassessed. behavior.
Moreover,therearestillimportantconceptualissues:Whyis ThesamesubtypingoptionsusedbyBlanchardwouldstillbe
therethissortofaccountingsystem(moreattractiontoadults, used(e.g.,attractedonlytomales,females,pedophilic,hebe-
thereforenoproblemvs.netattractionistowardchildrenthere- philic,etc.).Thiscarvesnatureatitsjoints—thecoreproblemis
foreproblem).Isn’tanysexualattractiontochildrenabnormal, anysexualattractiontochildren—thisisapathological,abnor-
treatmentworthy,notexpected,aharmfuldysfunction,etc.,in malcondition.Itisirrelevantifitisdistressingtotheindividual
andofitselfandthusindependentofwhetherthereisalsoadult (with the exception that this possibly denotes a further prob-
attraction?Thepresenceofsomenormalsexualattractionisa lem)—thissexualattractionhasthepotentialtocausesignificant
potentiallyimportantorthogonalissue,notanoffsettingormiti- harmtoothersandisalsonotinthebestinterestsoftheindi-
gatingone. vidual.Itcertainlyisfarlessproblematicifthepersonhasnever
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590 ArchSexBehav(2010)39:587–590
actedonthissexualattraction(assumingthisispossibleinthe AmericanPsychiatricAssociation.(2000).Diagnosticandstatisticalman-
broadestsense)butthesexualattractionitselfisstillproblem- ualofmentaldisorders(4thed.,textrev.).Washington,DC:Author.
Blanchard,R.(2009).TheDSMdiagnosticcriteriaforpedophilia.Archives
atic.
ofSexualBehavior.doi:10.1007/s10508-009-9536-0.
Levenson, J. S. (2004). Reliability of sexually violent predator civil
Acknowledgment TheauthorisanadvisortotheDSM-VWorkgroup commitmentcriteria.LawandHumanBehavior,28,357–369.
onSexualandGenderIdentityDisorders(Chair,KennethJ.Zucker, Marques, J. K., Miederanders, M., Day, D. M., Nelson, C., & van
Ph.D.). Ommeren,A.(2005).Effectsofarelapsepreventionprogramon
sexual recidivism: Final results from California’s Sex Offender
TreatmentEvaluationProject(SOTEP).SexualAbuse:AJournal
References ofResearchandTreatment,17,79–107.
O’Donohue, W., Regev, L., & Hagstrom, A. (2000). Problems with
theDSM-IVdiagnosisofpedophilia.SexualAbuse:AJournalof
Abel,G.G.,Becker,J.,Mittelman,M.,Cunningham-Rathner,J.,Rouleou,
ResearchandTreatment,12,95–105.
J.L.,&Murphy,W.(1987).Self-reportedsexcrimesofnonincar-
ceratedparaphiliacs.JournalofInterpersonalViolence,2,3–25.
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ArchSexBehav(2010)39:591–593
DOI10.1007/s10508-010-9603-6
LETTER TO THE EDITOR
Child Pornography Use and Internet Solicitation
in the Diagnosis of Pedophilia
MichaelC.Seto
Publishedonline:25February2010
(cid:1)SpringerScience+BusinessMedia,LLC2010
The DSM-V Paraphilias subworkgroup has proposed a history of child pornography use or sexual contact with a
numberofchanges tothediagnosticcriteriaforpedophilia minor(e.g.,Neutze,Seto,Schaefer,Mundt,&Beier,2009).
(Blanchard, 2009a). In this commentary, I briefly discuss Thesubsetofwell-adjusted,sexuallyinactive(withregardto
someofthesechangesinlightofrecentresearchoninternet- children)pedophilesmayindeedbelesscommonthanindi-
facilitated sexual offenders and focus on the relevance of vidualswhoaredistressedabouttheirpedophiliaorwhoact
childpornographyandinternetsolicitationwhenconsidering upon their interests, but this group is invisible in many
thediagnosisofpedophilia. respects because most of the research on pedophilia and
hebephilia has involved clinical or forensic samples (see
Seto,2008).
AscertainingParaphiliasversusDiagnosingParaphilic
Disorders
IsChildPornographyUseaRelevantBehavior?
Theproposeddistinctionbetweenascertainingaparaphilia
when the sexual interest exists and making a paraphilia In the absence of candid disclosure about sexual thoughts,
diagnosisonlywhenthereisevidenceofdistressorimpair- fantasies,orurges,diagnosisismorelikelytobereliableifit
mentaddressestheseemingparadoxthatapersonwouldnot isbasedonobservablebehavior.Isseeking,viewing,saving
bediagnosedwithpedophiliaunderDSM-IV(and,toalesser orsharingchildpornographyanexpressionofpedophilicinter-
extent,DSM-IV-TR)ifthepersonwassexuallyattractedto estsandthusarelevantbehavior(seeO’Donohue,Regev,&
prepubescent children but was not distressed or impaired Hagstrom, 2000)? Blanchard (2009a) suggested that child
(includingconflictwiththelaw)asaresult. pornographyuseshouldbeadiagnosticindicator,onthebasis
Blanchard(2009a)suggeststhat‘‘ego-syntonic,euthymic, ofastudyweconductedtogetheraswellasasubsequentstudy
chastepedophiles’’arerare.Consistentwiththissuggestion, fromthesameclinic(Blanchardetal.,2007;Seto,Cantor,&
Riegel(2004)found that95%of290self-identifiedhomo- Blanchard,2006).
sexualpedophilesrespondingtoananonymousonlinesurvey There is an intuitive and empirical link between male
acknowledged using child pornography at some point; the sexual interests and pornography choices. One does not
majority (59%) used child pornography‘‘frequently.’’The expectheterosexualmentoseekoutpornographydepicting
Dunkelfeld Project in Berlin, which used mass media men only or homosexual men to seek out pornography
advertising to recruit self-identified pedophiles wishing to depictingwomenonly.Wefoundevidenceforanassociation
refrainfromactingupontheirinterestsbycommittingsexual betweenchildpornographypossessionandpedophiliawhen
offenses, found that very few individuals assessed had no wecomparedthephallometrictestresultsof100childpor-
nography offenders with those of 178 sex offenders with
childvictims(Setoetal.,2006).Asagroup,thechildpor-
M.C.Seto(&)
nography offenders showed significantly greater sexual
IntegratedForensicProgram,RoyalOttawaHealthCareGroup,
arousal to children than did the offenders against children,
1804Highway2,Brockville,ONK6V5W7,Canada
e-mail:[email protected] andtherewasnosignificantdifferencebetweenthe53who
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592 ArchSexBehav(2010)39:591–593
hadnoknownhistoryofsexualcontactswithchildrenandthe prepubescent children from other minors (Rosenbloom &
remaining47whodid.Overall,61%ofthechildpornography Tanner,1998).
offendersshowedapreferencefordepictionsofchildrenover Analyses of child pornography images by law enforce-
depictionsofadults.Ourexplanationforthisfindingwasthat mentagenciesindicatethatthetypicalchilddepictedinchild
some non-pedophilic men commit sexual offenses against pornographyisaprepubescentgirl(e.g.,Wolak,Finkelhor,&
children, such as antisocial men who are willing to pursue Mitchell,2005,2009).Manyindividualschargedwithchild
sexualgratificationwithgirlswhoshowsomesignsofsexual pornographyoffensespossesssubstantialnumbersofimages
developmentbutarebelowthelegalageofconsent(seeSeto, ofprepubertalchildrenandthuswouldbecandidatesforthe
2008). In contrast, people opt for pornography that corre- diagnosisofpedophilia.Nonetheless,somechildpornogra-
spondstotheirsexualinterests,sorelativelyfewnon-pedo- phy users may have collections that are predominantly or
philicmenwouldchooseillegalchildpornography,giventhe exclusivelyofolderadolescentsundertheageof18.
abundanceoflegalpornographythatdepictsadults. Other parameters of child pornography collections may
InananalysisthatwasnotreportedintheSetoetal.(2006) help rule out alternative explanations, such as accidental
article,wefoundthatself-reportedinterestsinchildren,child access,curiosity,orsexualcompulsivity(Setoetal.,2009),
pornography use, and number of sexual child victims all includingnumberofimages,ratiosofcontentthemes,orga-
uniquely contributed to the prediction of phallometrically nization, and frequency of access: Curiosity or accidental
assessedsexualinterestinchildren.Other,smallerstudiesare accessishardtoargueifsomeonehasanorganizedcollection
alsoconsistentwiththeideathatchildpornographyuseisan ofthousandsofchildpornographyimages.Sexualcompul-
indicatorofpedophilicsexualinterests.QuayleandTaylor sivityis harder toargueifthe personhas muchmorechild
(2002)interviewed13menconvictedofchildpornography pornographythanothertypesofpornography,andifmany
offenses and found that the majority acknowledged the childpornographyfiles,butnototherpornographyfiles,are
material was sexually arousing and corresponded to their recentlyaccessed.
sexualfantasies.Seto,Reeves,andJung(inpress)foundthat
approximately half of their combined sample of 84 child
pornography offenders acknowledged that child pornogra- RealversusFictitiousChildren
phywassexuallyarousing,whileSetoandEke(2008)found
that a third of their sample admitted to a sexual interest in Blanchard(2009a)wrote:‘‘Irecommendthat,fordiagnostic
childpornographyorchildrenwheninterviewedbypolice. purposes,photographedchildrenandimpersonatedchildren
betreatedthesameasrealchildren.’’Iagree;logically,the
contentmattersmorethanwhetherthechildisreal.Inphallo-
ChildPornographyConsiderations metrictestingofsexualinterests,audiotapedstoriesdescrib-
ingsexualinteractionsbetweenanadultandafictitiouschild
Howmuchchildpornographyusewouldconstituteevidence canelicitsubstantialresponseswithdiscriminativeandpre-
of pedophilia? Setting a time period of 6 months or longer dictivevalidity(seeSeto,2008).Thus,animeormanga(car-
usageisarbitrary,butitisconsistentwithotherDSMdiag- toons)depictingadult-prepubescentchildsexisrelevantto
nostic criteria and serves the important role of excluding thediagnosiseventhoughnorealchildrenaredepicted,and
individualswhoaccesschildpornographyoutofcuriosityor stories describing adult-prepubescent child sex (illegal in
by accident. Forensic computer analysis could allow for a Canada if it does not have artistic or other merit, but not
moreobjectiveassessmentofthetimelineofchildpornog- criminalizedintheUnitedStatesgivenconstitutionalconsid-
raphy related behavior, including when child pornography erations)arealsorelevantindicatorsofpedophilicinterests.
wasfirstaccessed,thedurationofchildpornographyactivi-
ties,howoftenimagesweredownloaded,andhowrecently
imageswereviewed. InternetSolicitation
Thereareotherconsiderations,however,besidestimeline.
The age of the minors depicted in child pornography is a Blanchard (2009a) suggested that ‘‘another behavior that
relevantparameter.ChildpornographyinCanada,theUnited should be considered in the next revision of the DSM is a
States,andotherjurisdictionsislegallydefinedasdepictions patient’s sexual chat and/or attempts to arrange a meeting
ofminorsundertheageof18.Someoneinterestedinimages withapoliceofficerposingasachildontheInternet.’’This
ofunderagebutsexuallymatureolderadolescentswouldnot mayindeedberelevantbehavioraswell,butitdependsonthe
beexhibitingpedophilicinterests.Tobeconsistentwiththe age of the actual or fictitious minor. Given that pedophilia
rest of the diagnostic criteria, depictions of prepubescent applies to those with an interest in prepubescent children
childrenaremostrelevant.Preciselyestimatingageisdiffi- (mostofwhomareundertheageof12),internetsolicitation
cultbutonecanusetheTannersystemtoreliablydistinguish maybeofdiagnosticsignificanceinonlyasmallnumberof
123
ArchSexBehav(2010)39:591–593 593
cases.ResearchfromtheCrimesAgainstChildrenResearch Blanchard, R. (2009b).Reply toletters regarding Pedophilia,Hebe-
Center suggests that the modal age of minors involved in philia,andtheDSM-V[LettertotheEditor].ArchivesofSexual
Behavior,38,331–334.doi:10.1007/s10508-008-9427-9.
internetsolicitationsis15,withnominorsundertheageof12
Blanchard,R.,Kolla,N.J.,Cantor,J.M.,Klassen,P.E.,Dickey,R.,
(Wolak,Finkelhor,Mitchell,&Ybarra,2008). Kuban,M.E.,&Blak,T.(2007).IQ,handedness,andpedophiliain
What about those individuals who interact with under- adultmalepatientsstratifiedbyreferralsource.SexualAbuse:A
cover officers and not a real child? Consistent with my Journal of Research and Treatment, 19, 285–309. doi:10.1177/
107906320701900307.
commentsaboutfictitiouschildrendepictedinpornographic
Blanchard,R.,Lykins,A.D.,Wherrett,D.,Kuban,M.E.,Cantor,J.M.,
content,whatmattersinsolicitationcasesisthattheperson Blak,T.,…Klassen,P.E.(2009).Pedophilia,hebephilia,andthe
believedtheywereinteractingwithachild.Onlinerole-play, DSM-V.ArchivesofSexualBehavior,38,335–350.doi:10.1007/
wherethepersonknowinglyinteractswithaconsentingadult s10508-008-9399-9.
Harris,A.,Phenix,A.,Hanson,R.K.,&Thornton,D.(2003).Static-99
whopretendstobeachild,shouldnotcount.Thiswouldbe
coding rules revised—2003. Retrieved on September 12, 2005,
consistentwithcodingguidelinesforriskmeasurescurrently fromhttp://www.psepc-sppcc.gc.ca/publications/corrections/pdf/
usedwithsexualoffenders(Harris,Phenix,Hanson,&Thornton, Static-99-coding-Rules_e.pdf.
2003). Neutze,J.,Seto,M.C.,Schaefer,G.A.,Mundt,I.A.,&Beier,K.M.
(2009).Predictorsofchildpornographyoffensesandchildsexual
abuse in a community sample of pedophiles and hebephiles.
Manuscriptsubmittedforpublication.
O’Donohue,W.,Regev,L.G.,&Hagstrom,A.(2000).Problemswith
Conclusion
theDSM-IVdiagnosisofpedophilia.SexualAbuse:AJournalof
ResearchandTreatment,12,95–105.doi:10.1177/10790632000
IappreciatetheeffortsoftheDSM-Vsubworkgrouptobring 1200202.
Quayle,E.,&Taylor,M.(2002).Childpornographyandtheinternet:
greaterclaritytothediagnosisofsexualpreferencesforchil-
Perpetuatingacycleofabuse.DeviantBehavior,23,331–361.doi:
dren,andtherebytoincreaseitsreliabilityandthuspotential
10.1080/01639620290086413.
validity.Itisachallengingtask,asdemonstratedbythereac- Riegel, D. L. (2004). Effects on boy-attracted pedosexual males of
tiontoBlanchardetal.’s(2009)suggestiontoaddhebephiliato viewing boy erotica [Letter to the Editor]. Archives of Sexual
Behavior,33,321–323.doi:10.1023/B:ASEB.0000029071.89455.
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53.
potential impact ofthisnew diagnosis onsex offender civil
Rosenbloom,M.L.,&Tanner,J.(1998).Misuse ofTannerpuberty
commitment cases in the UnitedStates(Blanchard, 2009b). stagestoestimatechronologicalage.Pediatrics,102,1494.
Becauseofthehighstakesinvolvedinsuchcases(indefinite Seto,M.C.(2008).Pedophiliaandsexualoffendingagainstchildren:
Theory,assessment,andintervention.Washington,DC:American
commitmenttoasecuretreatmentfacility,withlowoddsof
PsychologicalAssociation.
being releasedtothecommunity),modificationofthediag-
Seto,M.C.,Cantor,J.M.,&Blanchard,R.(2006).Childpornography
nosticcriteriaforparaphiliasneedstobedonecautiously.Blan- offensesareavaliddiagnosticindicatorofpedophilia.Journalof
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thathebephiliacanbeascertainedasadistinctsexualinterestin
Seto,M.C.,&Eke,A.W.(2008,October).Predictingnewoffenses
pubescent children. Whether hebephilia would meet Wake-
committedbychildpornographyoffenders.Paperpresentedatthe
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is much less clear, however, given cogent arguments that SexualAbusers,Atlanta,GA.
Seto,M.C.,Reeves,L.,&Jung,S.(inpress).Motivesforchildpornog-
ancestralmenwereselectedtobesexuallyattractedtoyoung
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References
Wolak, J., Finkelhor, D., Mitchell, K., & Ybarra, M. (2008). Online
‘‘predators’’andtheirvictims:Myths,realities,andimplications
Blanchard, R. (2009a). The DSM diagnostic criteria for pedophilia. for prevention and treatment. American Psychologist, 63, 111–
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123
ArchSexBehav(2010)39:594–596
DOI10.1007/s10508-010-9607-2
LETTER TO THE EDITOR
Hypersexual Disorder: A More Cautious Approach
JasonWinters
Publishedonline:19February2010
(cid:1)SpringerScience+BusinessMedia,LLC2010
Kafka(2009)hasdoneanexemplaryjobofsynthesizingdispa- (5–10%).Thisdiagnosticmarkerhasnotbeenwidelyadoptedby
rate perspectives on dysregulated sexuality, and distilling the theacademicandclinicalcommunities,perhapsbecausethereisa
commonelementsintoHypersexualDisorder,aproposednew dearthofindependentempiricalsupport.Also,recentdatasuggest
diagnosisforthefiftheditionoftheDiagnosticandStatistical thatalargerproportionofthepopulationmaymeetthiscriterion,
ManualofMentalDisorders.Thereappearstobesubstantialclin- callingintoquestionitsspecificity.Forexample,inourstudyuti-
icalsupportforthisdisorder;however,strongempiricalevidence lizinganinternetbasedconveniencesample,43.9%(2559/5824)
demonstratingitsvalidityiscurrentlylacking.Further,previous ofmenand21.5%(1538/7166)ofwomenwouldhavemetthis
criticismsofthetheoreticalassumptionsunderlyingadysregu- criterionforhypersexuality(Wintersetal.,2010).Thesesubjects
latedsexualitydisorder,regardlessofhowitisconceptualized reported a totalweekly average sexual outletof seven or more
andlabeled,havenotyetbeenadequatelyaddressed(e.g.,Giles, orgasmsonKafka’s(1997)SexualOutletInventory.
2006;Levine&Troiden,1988;Moser,1993;Rinehart&McCabe, The other way in which increased or excessive sexual
1997;Winters,Christoff,&Gorzalka,2010).Fortheserea- behaviorhasbeenoperationalizedisbyitsqualitativenature.
sons,theadditionofHypersexualDisordertotheDSMmay Examples of sexual behaviors that are thought to be symp-
bepremature. tomaticofHypersexualDisorderinclude:compulsivemastur-
TomeettheDSMdefinitionforamentaldisorder,itmustbe bation, protracted promiscuity, and pornography, sex chat-
shown that Hypersexual Disorderrepresents a psychologicalor room,andphonesexaddiction(e.g.,Cooper,Scherer,Boies,&
behavioral syndrome that is the manifestation of a dysfunction Gordon,1999;Kafka&Hennen,1999;Raymond,Coleman,&
(AmericanPsychiatricAssociation,2000).InthecaseofHyper- Miner,2003).Yet,withintheliterature,thereisnoexplanation
sexualDisorder,thereisnoclearexplanationofthedysfunction. providedastohowtheseareoperationalizedandmeasured.Itis
Kafka’sdescriptionindicatesthatthedysfunctionismanifestas notclearwhenmasturbationbecomescompulsive,whenpro-
recurrentandexcessivesexualthoughts,feelings,andbehaviors. miscuity becomesprotracted,and whenthepursuitofsexual
Basedonthisassertion,wearetoassumethatthereisnormalsexual stimulibecomes a so-calledaddiction. Anonymous sex, one-
expressionandtoomuchsexualexpression(i.e.,thedysfunction), nightstands,andmultiplepartnersarealsoconsideredhyper-
andthatthereisadistinctandagreeduponboundarybetweenthe sexualbehaviors(e.g.,Coleman,Raymond,&McBean,2003;
two.Thisisnotthecase. Kalichman&Rompa,1995),butitseemsthatthesebehaviors
Kafka(1997)previouslyproposedthatexcessivesexuality(i.e., areconsideredpathologicalonlybecauseofanongoing,ifnot
hypersexuality)wasbestoperationalizedasaweeklyaverageof overtlystated,biasthatsexualexpressionoutsideatraditional
sevenofmoreorgasms,theintentionbeingthatonlyasmallpro- monogamousmaritaldyadisunhealthy.
portion of the population would be identified as hypersexual The criteria indicate that the sexual fantasies, urges or
behaviorscharacteristicofHypersexualDisordermayinterfere
with day-to-day responsibilities and activities. As has been
J.Winters(&) notedpreviously,thesetypesofexperiencescanbetypicalof
ForensicPsychiatricServicesCommission,BritishColumbia
healthy sexually active individuals, especially those in new
ProvincialHealthServicesAuthority,#300–307WestBroadway,
sexual relationships (Gold & Heffner, 1998; Moser, 1993).
Vancouver,BCV5Y1P9,Canada
e-mail:[email protected] Additionally,peopleoftenwillrepeatedlyeschewactivitiesand
123
