Faculty of Medicine, Imperial College, London, UK
[Sexual Offender Treatment, Volume 5 (2010), Issue 1]
The proposed inclusion of a hebephilic sexual orientation (early pubescent males and/or females) in DSM-5 compromises the scientific credibility of psychiatry. Moralism about the age of an acceptable sexual partner drives this proposal. It ignores common patterns of sexual arousal, cultural variability, and historic precedents. It blurs the domains of psychiatry and law. The age of sexual consent is 14 in much of Europe. An example of the new "mentally disordered" would be a 19 year old with a consenting 14 year old. Where sexual interaction is legally accepted, but pathologized as mental disorder, psychiatry attempts to act as an agent of social control.
Key words: hebephilia, pedophilia, sex offender, mental illness, DSM-5
Hebephilia is sex with pubescents. The proposed American Psychiatric Association DSM 5 catalogue of mental disorders defines it as at least an equal attraction to pubescents, age 11-14, as attraction to adults. Sexual contact with pubescents must have occurred on at least three occasions and there needs to be a 5 year age difference between the parties.
Diagnosing hebephilic behavior as mental disorder brushes aside common patterns of psychosexual development, sidesteps cultural influences on sexuality, ignores historic precedents, insults much of Europe and elsewhere that legalizes sex with 14 year olds, or younger, and attempts to insinuate psychiatry as an agent of social control.
My professional training is in medicine, psychiatry, and law. I should be able to distinguish issues within the domain of psychiatry vs. the domain of law. The rationales for including hebephilia in the proposed DSM 5 confuses these domains.
This confusion is demonstrated by the principal architect of the sexual paraphilia component of DSM 5 as he justifies including hebephilia (Blanchard 2010):
Another justification is that "In large scale surveys that sampled individuals from the general population and included questions regarding sexual experiences with older persons when the respondent was underage, a substantial proportion report ages at occurrence that fall within the normal time frame of puberty." This too hardly proves that sex with pubescents is a mental disorder, though it can be a crime.
A further rationale is the overlapping penile responsivity between persons attracted to prepubertals and to pubescents. But there is also overlap between those attracted to pubescents and to adults. This does not demonstrate psychopathology in attraction to pubescents. It demonstrates that sexual arousal is a continuum.
What is the essence of mental disorder? For a while DSM required subjective distress associated with social dysfunction or impairment. But then subjective distress was cast away as many "sexual disordered people" are not distressed about their sexuality. Thus there are pedophiles who celebrate this pattern of romantic and sexual love. Social disadvantage can flow from societal discrimination, including criminal prosecution. But should this diagnose mental disorder?
Arguably, homosexuality met criteria for disorder but was deleted from the list. This was the result of political pressure and a reappraisal of whether the characteristics of homosexual orientation constituted a disorder, rather than a benign variant of sexuality. Opposed as many persons were (and to a lesser extent still are) to homosexuality, this opprobrium pales in contrast to attitudes toward pedophilia. Pedophilic persons do not have an effective professional or political lobby as did homosexual persons in the early 1970s. However, unpopular behavior, without more, does not warrant further stigmatization as mental disorder.
The DSM committee is concerned that "the current definition of pedophilia is excluding from specific diagnosis a considerable proportion of men who have a persistent preference for humans at an incomplete stage of physical development". Whence the 11th Commandment: "Thou shalt not have sex with those not fully mature"? The Commandment could have been carved: "Thou shalt not have sex with those before reproductive capacity." This would permit sex with many 13 year olds.
In several European countries the age of legal consent to engage in sexual behavior falls within the range of pathology proposed for the DSM 5. (www.avert.org) The age of consent is 14 in Italy, Croatia, Austria, Serbia, Albania, Bulgaria, Lithuania, Estonia, Hungary, Portugal, and Germany. It is 13 in Spain. Thus, the carefree Italian or German adult romancing 14 year olds will not be threatened with criminal prosecution. The only punishment will be the psychiatric label of mental disorder.
In non-European countries the age of consent also falls within the DSM 5 "no-go" area. For example, it is 14 in Chile, Columbia, Ecuador and Peru. In Mexico it is 12.
Some sexual activities have been both crimes and mental disorder, such as homosexuality in the US. Some remain crimes elsewhere, such as homosexuality. A nation or jurisdiction can express its dissatisfaction with a sexual practice by making it a crime. But that is an issue for the legislature. If a society is accepting a pattern of sexual behavior, but psychiatry labels it mental disorder requiring treatment and change, psychiatry fulfils its often ascribed condemnatory designation of acting as an agent of social control.
Several studies demonstrate the relatively common attraction by adults to pubescent or younger persons. Among university males about 20% reported some sexual attraction to children (Briere and Runtz 1989). In a penile arousal study with normal controls about 25% showed arousal to children equal to that for adults (Hall et al. 1995). In another 80% of heterosexual normal subjects were aroused by photos of both adult and adolescent females (age 12-16) (Freund and Costell 1970). Yet another found a group of child molesters and controls to have similar arousal patterns to slides of pubescent girls (12-15) (Quinsey et al. 1975).
There are millions of adult males in European countries where sex with 14 year olds is legal. Extrapolating from studies of normals who have attraction to adolescents, if even a tenth of these acted on their attraction, the ranks of the mentally ill would be swelled by as many as were cured when homosexuality was dropped from the DSM.
I have published a paper challenging the designation of pedophilia as a mental disorder (Green 2002). My argument did not endorse the behavior, nor did it argue for decriminalization. Rather, calling on cross-cultural practices, historical precedents, and human sexuality research, utilizing questionnaires and phallometry, it argued that pedophilia did not meet the criteria of mental disorder.
With this publication history, some who disagree with that earlier writing may dismiss my arguments for not including hebephilia in DSM as merely "more of the same". So, for this discussion I am willing to concede a period of juvenile development when sexual conduct directed to that person by an adult can constitute a mental disorder.
If there must be a bright line for disorder, it could be puberty, Tanner stage 2. Designating age as the bright line ignores the substantial variability in physical development. For a specific age, a person could be prepubertal or mid-pubertal. Particularly problematic for DSM-5 is that many persons are at Tanner Stage 4 (of 5) at 13 years. And age at puberty is getting younger.
However, age may be a better correlate of cognitive development than physical maturation (Litt 1995). Nevertheless, 12 year olds are not passive blobs: the age of criminal responsibility in England is 10.
Sexual interaction with persons at an incomplete stage of sexual development has been accepted behavior in a range of cultures. In England the age of consent was 12 years for 600 years. This continued to the late 19th century. When the age of consent was raised it was a by-product of child labor laws that forbade children from helping support their family. They turned to child prostitution which was frowned upon, so the age for legal sex was raised (Working Party 1979). At about this time the average age of menarche was 15. These consenting girls were well below puberty.
A recent report from Afghanistan illustrates the continuing socially accommodated behavior seen elsewhere as pedo/hebephilia. "For centuries, Afghan men have taken boys, roughly 9-15 years old, as lovers. Some research suggests that half the Pashtun tribal members in Kandahar and other southern towns are 'bacha baz', the term for an older man with a boy lover. Literally it means 'boy player'. The men like to boast about it. 'Having a boy has become a custom for us. Whoever wants to show off should have a boy. Even after marriage, many men keep their boys. A favored Afghan expression goes: 'Women are for children, boys are for pleasure'." (Brinkley 2010)
What constitutes sexual disorder can be culture bound. Many readers are not old enough to recall the psychiatric morbidity of masturbation, as published in the Boy Scout Handbook, warning about "abuse of the body". However, most can recall that some 3% of the population was disordered before 1973 when homosexuality came in from the cold.
Critics of hebephilia as a diagnosis also point to its growing misuse in US civil commitment law in 20 states and the federal government. This permits lifetime detention after a prison sentence has run its duration. 20% of civilly committed persons in the states of Wisconsin and Washington currently are held by that chain. Over 3000 Americans are detained, perhaps until death.
One critic argues, "Hebephilia is being advanced as a mental disorder by a small cadre of government experts intent on legitimizing the indefinite detention of men who have committed culturally repugnant acts with minors and who do not meet the diagnostic criteria of other, more established disorders." These experts are characterized as a "lucrative cottage industry" (Franklin 2010).
The DSM diagnosis, Paraphilia NOS (not otherwise specified), is used to civilly commit, but is rejected by some courts. A federal judge held that "paraphilia NOS hebephilia" might qualify as a clinical diagnosis, but did not reach the threshold of "serious mental disorder" required for commitment (US v Abregana 2008). In another case, the court held that professional literature may establish hebephilia as a "group identifier or label", but not as a generally accepted clinical diagnosis". (United States v Shields 2007). If hebephilia becomes a specific DSM diagnosis this could enable courts to apply it more readily.
My criticism of sexual predator law is long-standing. In 1994, with Brody, I attacked the pioneering Washington State law.
"Because there is currently no proven treatment of sex offenders, and because we are not yet able to predict future behavior, sexual predators confined under this law will be unable to prove that they are no longer a danger in order to be released... Offenders committed under this law may spend their lives in a mental health facility under preventive detention... Available treatments are not adequate to ensure future safety and the law selects poor candidates for treatment." (Brody and Green 1994). The Washington State law was opposed by the Washington State Psychiatric Association.
In 1994 the APA constituted a Task Force to investigate sexual predator laws. It issued its report in 1999 (Zonana et al. 1999):
"In the opinion of the Task Force, sexual predator commitment laws represent a serious assault on the integrity of psychiatry...bending civil commitment to serve essentially non-medical purposes, sexual predator commitment statutes threaten to undermine the legitimacy of the medical model of commitment...(P)sychiatry must vigorously oppose these statutes, to preserve the moral authority of the profession and to ensure continuing societal confidence in the medical model of civil commitment." (Zonana et al. 1999, p. 173)
It is ironic that the American Psychiatric Association has been opposed to civil commitment laws, but its DSM Committee is proposing a formal diagnostic category that will enhance its utilization.
The nature of the person's offense must be considered. A habitual violent rapist represents a very different universe of public safety from a person who enjoys genital fondling with a compliant pubescent. Currently, the latter are being entombed along with the former by sexual predator law. The Kinsey researchers 50 years ago were hardly taken aback by men who are now labelled hebephiles. These persons' sexual activity was with persons "biologically ready for coitus". The men "scarcely merit(ed) the emotionally charged label of sex offender" (Gebhard et al. 1965).
Persons for whom there is compelling evidence that they pose a public risk can be sequestered without a psychiatric diagnosis. A thwarted suicide bomber can be locked away without a diagnosis of "explosive self harming disorder".
The proposed diagnosis may not attach short of sexual contact with a pubescent person, even when the attraction is intense. But, if diagnosis requires action, then psychiatry, the scientific discipline of the emotions and thought, is turned on its head. No matter how crazy the thought, according to the DSM, it is not a disorder unless acted upon.
The APA is a body representing a medical profession still striving for scientific respectability. The farce of science cross-dressing as democracy made psychiatry a laughing stock 35 years ago. It held a popular vote of its membership on whether homosexuality should remain in its list of disorders (Bayer 1981). Decreeing in a few years time that a 19 year old who prefers sex with a 14 year old has a mental disorder will not enhance psychiatry's credibility.
An argument for including hebephilia in DSM is that this facilitates research. Psychiatric research does not require categorizing a sexual orientation as disorder. We can study why persons are attracted to octogenarians, the morbidly obese, or even those attracted to persons of their own sex, without labelling the attraction disorder.
I propose an alternate diagnostic system. If a person has a pattern of sexuality that from that person's perspective interferes with a more desirable sexuality, and seeks help reducing the former and enhancing the latter, this can be diagnosed and treated as a sexual dysfunction. There could be subtypes of sexual dysfunction to designate the obstacle to the pattern of desirable functioning. Thus, erectile failure could be the culprit, or insufficient arousal to legal age partners, or to partners who don't enjoy being bound, gagged, and whipped. But the primary diagnosis need not be erectile failure, pedophilia/hebephilia, or sadism. As Moser (2009) points out, Obsessive-Compulsive Disorder may manifest as compulsive hand washing, but the diagnosis is not hand washing disorder. It is OCD.
This proposed system would avoid inevitably including persons who have some erectile failure, strong attraction to non-adults, or to trussed women in a compendium of the mentally disordered. It would be of diagnostic clinical concern only when it is of personal concern.
Categorizing a person five years older than another person who is in early or mid-pubescence and who has sexual contact with the younger as psychiatrically disordered ignores evidence based understanding of psychosexual development, what should constitute psychiatric disorder, contributes to lengthy needless incarcerations, and undermines psychiatry's long journey toward professional credibility. It will disserve human sexuality and psychiatry for decades. Many readers are too old to wait for its deletion from DSM 6.
Faculty of Medicine
St. Dunstan's Road,
London W6 8LN, UK