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Re: Request for DSM committee to meet with MAA's

Posted by kea on 2010-March-03 10:09:47 EST, Wednesday
In reply to Request for DSM committee to meet with MAA's posted by michaelmelsheimer on 2010-March-02 00:03:20 EST, Tuesday
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here's some info from the web.

i want to draw everybody's attention to the comment link at the bottom of the draft DSM pages, "Want to comment on this proposal? Please Login or Register Now.": http://www.dsm5.org/Pages/Registration.aspx

i think it would be good if people registered there themselves and expressed their disatisfaction with their continued pathologization by the APA, in the absence of rational enquiry and/or sensitivity to empirical data, and in the presence of heavy coercive political pressure.

naturally enough, nobody is going to do that, as our condition is one of enforced silence, and more than silence really. there is no need to enforce our silence, since we have no voice to begin with.

so i think it would be really great if michael &co at b4uact could act as spokespeople, and people here and at BC and other forums could communicate their feelings about the DSM indirectly through those vectors. naturally enuf, trolls will attempt to invalidate our attempts at speech by submitting their own statements, and we'll just have to rely on b4uact to screen those out.

for me, the really significant thing is that while most of the DSM exists merely to enhance drug sales to people experiencing normal life events, the section on pedophilia is used to stigmatize and curtail the rights and freedoms of ordinary people. it does this by defining a sexual orientation as an 'illness', by interpreting that 'illness' as not only antisocial but determined exclusively on the basis of forensic data and for the purposes of a forensic agenda.

it isn't science, it's authoritarianism.


the draft DSM-V


Sexual and Gender Identity Disorders
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=186

Paraphillias
302.4 Exhibitionism
302.81 Fetishism
302.89 Frotteurism
302.2 Pedophilia
302.83 Sexual Masochism
302.84 Sexual Sadism
302.3 Transvestic Fetishism
302.82 Voyeurism
302.9 Paraphilia Not Otherwise Specified


Pedohebephilic Disorder
  1. Over a period of at least six months, one or both of the following, as manifested by fantasies, urges, or behaviors:
    1. recurrent and intense sexual arousal from prepubescent or pubescent children
    2. equal or greater arousal from such children than from physically mature individuals
  2. One or more of the following signs or symptoms:
    1. the person is distressed or impaired by sexual attraction to children
    2. the person has sought sexual stimulation, on separate occasions, from either of the following:
      1. two or more different children, if both are prepubescent
      2. three or more different children, if one or more are pubescent [7]
    3. use of child pornography in preference to adult pornography, for a period of six months or longer [8]
  3. The person is at least age 18 years and at least five years older than the children in Criterion A.
Specify type:
  • Pedophilic Type—Sexually Attracted to Prepubescent Children (Generally Younger than 11)
  • Hebephilic Type—Sexually Attracted to Pubescent Children (Generally Age 11 through 14)
  • Pedohebephilic Type—Sexually Attracted to Both
Specify type:
  • Sexually Attracted to Males
  • Sexually Attracted to Females
  • Sexually Attracted to Both


Rationale


[1] The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.
This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on.
In general, the distinction between paraphilias and paraphilic disorders is reflected in the format of the diagnostic criteria for specific paraphilias. Paraphilias are ascertained according to the “A” criteria, and paraphilic disorders are diagnosed according to the “A” and “B” criteria. The distinction between paraphilias and paraphilic disorders is discussed in the context of specific diagnoses by Blanchard (2009b, 2009c).
The second broad change applies to paraphilias that involve nonconsenting persons (e.g., Voyeuristic Disorder, Exhibitionistic Disorder, and Sexual Sadism Disorder). We propose that the B criteria suggest a minimum number of separate victims for diagnosing the paraphilia in uncooperative patients. This was done to reflect the fact that a substantial proportion—perhaps a majority—of patients referred for assessment of paraphilias is referred after committing a criminal sexual offense. Such patients are not reliable historians, and they are typically not candid about their sexual urges and fantasies. The criteria have therefore been modified to lessen the dependence of diagnosis on patients’ self-reports regarding urges and fantasies. This change also addresses the past criticism that the word “recurrent” in the DSM-IV-TR A criteria says nothing beyond “more than once” and is too vague to be clinically useful. The reason for diagnosing specific paraphilic disorders from multiple, similar offenses in uncooperative patients is to achieve a level of diagnostic certitude closer to the certitude in diagnosing these disorders from self-reports in cooperative patients. It is not derived from legal theory or practice.
The suggested minimum number of separate victims varies for different paraphilias. This represents an attempt to obtain similar rates of false positive and false negative diagnoses for all the paraphilias. The logic runs as follows: Paraphilias differ in the extent to which they resemble behaviors in the typical adult’s sexual repertoire. For example, sexual arousal from seeing unsuspecting people in the nude seems more probable, in a typical adult, than sexual arousal from hurting or maiming struggling, terrified strangers. It follows that the more closely a potentially paraphilic behavior resembles a potentially normophilic behavior, the more evidence should be required to conclude that the behavior is paraphilically motivated. We have therefore suggested, for example, three different victims for Voyeuristic Disorder but only two different victims for Sexual Sadism Disorder. We felt that fewer than three victims for Voyeuristic Disorder would result in too many false positives and more than two victims for Sexual Sadism Disorder would result in too many false negatives.

[5] We propose that the diagnosis of pedophilia (the erotic preference for children in Tanner stage 1) be revised to include hebephilia (the erotic preference for children in Tanner stages 2–3) and that the revised entity be named Pedohebephilic Disorder. One set of specifiers for Pedohebephilic Disorder would allow the clinician to record whether the patient is most attracted to prepubescent (Tanner 1) children, most attracted to pubescent (Tanner 2–3) children, or equally attracted to pubescent and prepubescent children.
There are four reasons for replacing Pedophilia with Pedohebephilic Disorder. These reasons are: (a) Hebephilia (the erotic preference for pubescents) is similar to pedophilia in that both involve sexual attractions to persons who are physically quite immature (Blanchard, 2009a; Blanchard et al., 2009b), (b) Many men do not differentiate much or at all between prepubescent and pubescent children and offend against both (Blanchard et al., 2009b), (c) Many hebephilic patients are getting DSM diagnoses anyway—they are diagnosed as pedophilic under a very liberal definition of “prepubertal child,” or they are diagnosed with “Paraphilia NOS (Hebephilia)” (Levenson, 2004), and (d) This would harmonize with an ICD definition of Paedophilia: “A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age” (ICD-10 F65.4; emphasis added).
It should be noted that the proposed specifier, “Sexually Attracted to Prepubescent Children,” would reflect the classical definition of pedophilia. Thus, this change would produce little disruption in on-going clinical or epidemiological research.
There is another important point to be noted. A change from Pedophilia to Pedohebephilic Disorder in DSM-V would primarily affect the precision of diagnosis, not the number of people being diagnosed. In DSM-IV-TR, the definition of “child,” as an erotic object, is someone “generally age 13 years or younger.” In the definition proposed for DSM-V, this guideline would be moved only one year, to age 14 years or younger. As stated above, patients are already being diagnosed with “Paraphilia NOS (Hebephilia)” (Levenson, 2004). It is therefore possible that the replacement of Pedophilia with Pedohebephilic Disorder in DSM-V would result in little or no increase in the number of people being diagnosed. In fact, this change could conceivably result in a decrease in the number of people being diagnosed, because there are currently no age guidelines for “Paraphilia NOS (Hebephilia).”

[6] A second major change in the proposed diagnostic criteria for Pedohebephilic Disorder is the amalgamation of the DSM-III approach to ascertainment and the DSM-III-R approach to ascertainment (which was the basis for the versions in DSM-IV and DSM-IV-TR). According to DSM-III, a patient is pedophilic if his sexual interest in children is greater than his interest in adults. According to DSM-III-R, a patient is pedophilic if his sexual interest in children is intense.
There is no obvious clinical reason to regard the DSM-III-R approach as an advance over the DSM-III approach (Blanchard, 2009b; Blanchard et al., 2009a). There might, for example, be men who could honestly say that, due to age, ill health, current medications, or natural constitution, they have no intense sexual urges or fantasies at all, but such feelings as they have are directed solely toward children. It would be absurd them to exclude them from ascertainment as pedophiles. We have therefore proposed to incorporate both approaches to ascertainment in the A criterion for Pedohebephilic Disorder.
Our reasons for recommending the use of both approaches also relate to the clinical realities of ascertaining pedophilia or hebephilia in patients charged for sexual offenses against children. Many or most such patients are unreliable when it comes to reporting their erotic interests. Even those who are well aware that they have a pedophilic or hebephilic orientation may deny this. The examining clinician is forced to make an inference about the patient’s sexual interests, whether the clinician is looking for evidence that the patient’s interest in children is intense or evidence that the patient’s interest in children is greater than his interest in adults. Which type of inference is possible depends on the type of evidence available. Depending on the data, it is sometimes possible only to infer that the patient’s interest in children is intense, and sometimes possible only to infer that the patient’s interest in children is greater than his interest in adults (Blanchard et al., 2009a).

[7] The clauses pertaining to number of different victims may be understood as follows: Suppose that the patient is assigned 1 point for each pubescent victim and 1.5 points for each prepubescent victim. Then Criterion B is satisfied if the patient has accrued a total of 3 points or higher.

[8] Some research indicates that child pornography use may be at least as good an indicator of erotic interest in children as “hands-on” offenses (Seto, Cantor, & Blanchard, 2006).

References

Blanchard, R. (2009a). Reply to letters regarding Pedophilia, hebephilia, and the DSM-V [Letter to the editor]. Archives of Sexual Behavior, 38, 331–334.
Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0
Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3
Blanchard, R., Kuban, M. E., Blak, T., Cantor, J. M., Klassen, P. E., & Dickey, R. (2009a). Absolute versus relative ascertainment of pedophilia in men. Sexual Abuse: A Journal of Research and Treatment, 21, 431–441.
Blanchard, R., Lykins, A. D., Wherrett, D., Kuban, M. E., Cantor, J. M., Blak, T., et al. (2009b). Pedophilia, hebephilia, and the DSM-V. Archives of Sexual Behavior, 38, 335–350.
Levenson, J. S. (2004). Reliability of sexually violent predator civil commitment criteria in Florida. Law and Human Behavior, 28, 357–368.
Seto, M. C., Cantor, J. M., & Blanchard, R. (2006). Child pornography offenses are a valid diagnostic indicator of pedophilia. Journal of Abnormal Psychology, 115, 610–615.


Severity


PEDOHEBEPHILIC DISORDER (PEDOPHILIC TYPE)

1. During the past two weeks, how often did you feel the urge for sex involving a (male or female) child under the age of 11?

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

2. During the past two weeks, how often did you feel aroused while imagining (or remembering) yourself being sexual with a child under the age of 11?

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

3. During the past two weeks, how exciting was the idea of sex involving a child under the age of 11?

1. Not at all exciting
2. Slightly exciting
3. Moderately exciting
4. Strongly exciting
5. Extremely exciting


4. During the past two weeks, how many different children under the age of 11 did you approach sexually?

1. 0
2. 1
3. 2
4. 3
5. 4 or more

5. Over the course of your life, excluding the past two weeks, how many different children under the age of 11 did you approach sexually?

1. 0
2. 1
3. 2
4. 3–50
5. More than 50



PEDOHEBEPHILIC DISORDER (HEBEPHILIC TYPE)

1. During the past two weeks, how often did you feel the urge for sex involving a (male or female) child age 11 through 14?

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

2. During the past two weeks, how often did you feel aroused while imagining (or remembering) yourself being sexual with a child age 11 through 14?

1. Never
2. Once
3. About once a week
4. Several times a week
5. About every day

3. During the past two weeks, how exciting was the idea of sex involving a child age 11 through 14?

1. Not at all exciting
2. Slightly exciting
3. Moderately exciting
4. Strongly exciting
5. Extremely exciting

4. During the past two weeks, how many different children age 11 through 14 did you approach sexually?

1. 0
2. 1
3. 2
4. 3
5. 4 or more

5. Over the course of your life, excluding the past two weeks, how many different children age 11 through 14 did you approach sexually?

1. 0
2. 1
3. 2
4. 3–50
5. More than 50

DSM-IV


Pedophilia

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).
B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
C. The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.

Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13- year-old.

Specify if:
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both

Specify if:
Limited to Incest
Specify type:
Exclusive Type (attracted only to children)
Nonexclusive Type



some other links



The new DSM-5 Web site, which includes proposed revisions and draft diagnostic criteria, is now available at www.dsm5.org.
http://www.psych.org/dsmv.aspx
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=186


DSM-5 Publication Date Moved to May 2013
“Extending the timeline will allow more time for public review, field trials and revisions,” said APA President Alan Schatzberg, M.D.” The APA is committed to developing a manual that is based on the best science available and useful to clinicians and researchers.”
http://meagenda.wordpress.com/2009/12/10/press-release-dsm-5-publication-date-moved-to-may-2013/


Task Force questions critical appointments to APA’s Committee on Sexual and Gender Identity Disorders
“We are very concerned about these appointments. Kenneth Zucker and Ray Blanchard are clearly out of step with the occurring shift in how doctors and other health professionals think about transgender people and gender variance. It is extremely disappointing and disturbing that the APA appears to be failing in keeping up with the times when it comes to serving the needs of transgender adults and gender-variant children.”
http://www.thetaskforce.org/press/releases/pr_052808



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