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Title: Hebephilia: A Postmortem Dissection
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Arch Sex Behav
SPECIAL SECTION: DSM-5: CLASSIFYING SEX
Hebephilia: A Postmortem Dissection
Springer Science+Business Media New York 2015
Abstract In 2008, the concept of hebephilia, which denotes
an erotic preference for‘‘pubescent children,’’was suggested by
Blanchard and his team for inclusion in the DSM-5 (Blanchard
et al., 2009). Four years later, the APA’s Board of Trustees opted
for the status quo and rejected that proposal. This essay sheds
light on the reason for this rejection. I consider three important
questions related to hebephilia: Does hebephilia exist? Is it a
disease? And what would have been the social consequences of
including it in the DSM? I argue that if Blanchard failed to
convince others that hebephilia should be included in the DSM5, it is not because he focused too much on the first question and
was unable to offer a convincing answer to the second one, but
because he made the mistake of dismissing the third one as
extraneous. The DSM is not intended to be a pure research
manual, and a category like hebephilia cannot be evaluated
without taking into account its potential forensic impact. In
part or in whole, the decision to include a new diagnostic
category in the DSM is, and always should be, a political
Keywords Hebephilia Pedophilia Paraphilia DSM-5
The category of hebephilia denotes an erotic preference for individuals who are in the Tanner stages 2–3. The Tanner stages
describe the development of puberty, from 1 (prepubertal) to 5
& Patrick Singy
Union College, Schenectady, NY 12308, USA
(fully mature). They are determined by visible characteristics,
such as the size of the breasts and genitalia or the presence of
pubic hair. Due to natural variation, the correspondence between
physical characteristics and age can only be approximate, but
Tanner stages 2 and 3 roughly correspond to ages 11–15. Hebephilia thus falls between pedophilia, which is the erotic preference for prepubescent children, and ephebophilia, which was
first described by Hirschfeld (1906, p. 198) as the non-pathological erotic preference for young people between the ages of
16 and 20. Most people agree that pedophilia is a disease (for an
important exception, see Green, 2002) and no one, to my knowledge, has offered a serious argument for making ephebophilia
into a disease. By contrast, the pathological status of hebephilia
has been the topic of a heated debate, which is the focus of this
Hebephilia was proposed in the summer of 2008 for inclusion in the DSM-5 by a team of researchers led by Blanchard
(Blanchard et al., 2009). Four years later, the Board of Trustees
(BOT) of the American Psychiatric Association, which publishes the DSM, rejected Blanchard’s proposal. This horse is
dead and I have no intention to beat it any further. But a dissection is in order. That is, I am not interested in striking one
more blow against the concept of hebephilia; after all, I have
argued elsewhere that the acrimonious debate about the
diagnostic validity of hebephilia was pointless and misguided
(Singy, 2015). Instead, I would like to understand better why
Blanchard was not able to win over the BOT. This rather narrow
question will lead me to explore the relation between science and
politics pertaining both to the DSM and to Blanchard’s work.
As I gaze upon the corpse of hebephilia, I distinguish and
pull apart three strands of questions that have regularly surfaced since Blanchard’s suggestion to include hebephilia in
the DSM-5: (1) Does hebephilia exist as a condition (but not
necessarily as a disease), i.e., are there people in the world who
are predominantly attracted to what Blanchard calls‘‘pubescent
Arch Sex Behav
children’’? (2) Is hebephilia a disease? (3) What would have
been the social consequences of including hebephilia in the
Does Hebephilia Exist?
The first question is an empirical one. In the 1950s, Kurt Freund
(1914–1996) invented the penile plethysmograph, a technology to measure erections. Working at the Kurt Freund
Laboratory of the Centre for Addiction and Mental Health in
Toronto, Blanchard, whose mentor was Freund himself, used a
penile plethysmograph to conduct his research on 3166 male
patients between 1995 and 2009 (Blanchard, 2010). The research design was the following: The subjects were sitting with
their penises covered with a glass cylinder, which was sealed
and plugged to a machine that measured the changes in air pressure in the cylinder caused by the tumescence or detumescence of the penis. Blanchard then presented the subjects with
different erotically charged images and observed if there was a
correlation between certain types of images and the tumescence of the penis. The results were that some people have the
strongest erections when they are presented with images of
children (the‘‘pedophiles’’), that others have the strongest erections when they are presented with images of adults (Blanchard
calls them the‘‘teleiophiles’’), and finally that some people fall
in between: their erections correlate most strongly with images
of‘‘pubescent children.’’This last group is the hebephiles.
While a few scholars have criticized Blanchard’s statistical
analysis (see, for instance, Duschinsky & Chachamu, 2013;
Plaud, 2009), in the main, his opponents have conceded that
some people have a distinct erotic preference for ‘‘pubescent
children’’—and in Blanchard’s terms, then, hebephilia exists.
For instance, in a paper criticizing Blanchard et al.’s (2009)
article, Moser (2009) made clear that he is ‘‘not challenging
their conclusion that sexual interests in pubescent and prepubescent minors are distinct entities (albeit with some overlap)’’(p. 323). Blanchard (2013) accused one of his main opponents, Frances, of incoherently insinuating that ‘‘there is no
such thing as hebephilia, and it’s normal anyway’’(p. 676). But
the first half of this statement is a clear misreading of Frances’
argument. For Frances and most of the critics of hebephilia,
there is not much doubt that hebephilia exists. In fact, for them
it is precisely because this type of attraction is so common that
hebephilia cannot possibly be a disease (Frances & First, 2011,
p. 84; Wakefield, 2011, p. 206). Blanchard (2013) was correct
to note that ‘‘few critics…chose to acknowledge the overwhelming evidence that hebephilia exists’’(p. 676), but failed
to understand that this is, in part, because they had no bone to
pick with him here.
Is Hebephilia a Disease?
If Blanchard’s opponents did not argue with him about the existence of hebephilia, it is also and mostly because this issue is
simply beside the point. The belief in the existence of X is
obviously anecessary condition for X tobeincludedin the DSM,
but it is fortunately not a sufficient one. It is commonly believed
that heterosexuality, homosexuality, and other socially accepted
types of sexuality exist, yet they are not (or no longer) in the
DSM. So while Blanchard devoted his intellectual energy to
answering the first question, it is the second question that would
seem to be crucial for deciding whether hebephilia has its place
in the DSM-5. This is essentially a philosophical question that
hinges on one’s definition of disease, and this is what most of
the critics of hebephilia have focused on.
Oddly enough, Blanchard himself demonstrated very little
interest in this question. In the 2009 article that suggested hebephilia for inclusion in the DSM-5, he did not bother to define
the concept of mental disorder or to explain why hebephilia
qualifies as one. The most he did was to imply, by way of a peculiar word choice, that hebephilia is similar to pedophilia, and
therefore is similarly pathological. As we have seen above, he
regularly referred to the preferred sexual objects of hebephiles
as‘‘pubescent children’’(Blanchard et al., 2009), and sometimes
even as‘‘early pubescent children’’(Blanchard, 2012).Given that
these expressions are meant to describe girls and boys who are
going through pubertal changes and who are roughly between
the ages of 11 and 15, the term‘‘adolescents’’would certainly
have been more appropriate. But by calling them‘‘children,’’
Blanchard brought hebephilia closer to pedophilia, which has
been considered pathological since the late nineteenth century.
This lexical trick did not suffice. Critics complained that
Blanchard et al.‘‘completely overlook the question of how we
decide which sexual interest patterns should be considered a
mental disorder’’(DeClue, 2009, p. 317; see also Tromovitch,
2009). In response, Blanchard’s first reaction was not to address
the problem head-on by making an argument for the pathological status of hebephilia, but to try to render this issue
irrelevant by making a distinction between the‘‘clinical implications’’and the‘‘sex-research implications’’of his work. Whether hebephilia is considered a disease or not has clinical implications, he explained, but it does not have consequences for
research, which is what concerns him (Blanchard, 2009, p. 331).
Already in the article introducing hebephilia, Blanchard and his
team claimed that‘‘several studies have demonstrated the utility
of specifying a hebephilic group,’’but carefully added:‘‘at least
for research purposes’’ (Blanchard et al., 2009, p. 336). Such
statements imply that Blanchard himself was open to the possibility that the specification of a hebephilic group is not necessarily useful when we step out of the laboratory. This concession
certainly could not help convince his critics that hebephilia has
Arch Sex Behav
its place in the DSM-5, since, after all, the DSM-5‘‘was designed
first and foremost to be a useful guide to clinical practice’’
(American Psychiatric Association, 2013, p. xli).
When forced by his critics to demonstrate the pathological
nature of hebephilia, Blanchard adopted two strategies, both
unsatisfactory. The first and most developed one was essentially
negative. Instead of explaining why hebephilia should be considered a disease, he claimed that the two main arguments
commonly used to demonstrate that hebephilia is not a disease—
hebephilia would be evolutionary adaptive and statistically common (see, for instance, Frances, 2013, pp. 200–203)—do not, in
fact, hold water (Blanchard, 2013). He argued that the evolutionary argument is unacceptable because, assuming that the
evolutionary function of sex is reproduction, it would logically
imply that homosexuality should be reinstated in the DSM,
something that neither he nor his opponents desire.1 As for the
statistical argument, Blanchard explained that it is based on a
misunderstanding on the part of his opponents, since hebephilia
is not defined as a sexual attraction to‘‘pubescent children’’
(something that is indeed quite common), but as a sexual
preference for this group (something that is much rarer). I will
not discuss here the validity of Blanchard’s response. Suffice it
to say that, even if he were correct, this strategy amounts to
showing that his critics are wrong, which is not at all the same
thing as showing that he himself is right. A positive argument
for the pathological status of hebephilia was still lacking.
This is what his second strategy was supposed to offer. This
time, Blanchard proposed a general definition of paraphilia in
order to show that hebephilia falls into it. This definition, which
was first suggested in 2009 (Cantor, Blanchard, & Barbaree,
2009, p. 527), was eventually adopted with some minor modifications in the DSM-5:‘‘The term paraphilia denotes any intense
and persistent sexual interest other than sexual interest in genital
stimulation or preparatory fondling with phenotypically normal,
physically mature, consenting human partners’’(American Psychiatric Association, 2013, p. 685). As far as hebephilia goes,
two criteria in the definition are crucial, but not in the same way.
First, the criterion of physical maturity is apparently the most
important one since it has clearly been introduced specifically in
order to establish the pathological status of hebephilia (and pedophilia). The syllogism is straightforward: hebephilia is an
erotic preference for people who are not physically mature, the
definition of paraphilia states that to have a strong and persistent
sexual interest in people who are not physically mature is a disorder: therefore, hebephilia is a disorder. But the second premise
begs the question: why is a strong and persistent sexual interest
in people who are not physically mature a disorder? It cannot be
because it is not evolutionary adaptive, since Blanchard rejects
Wakefield’s (1992, 2011) influential‘‘harmful dysfunction’’analysis of
mental disorder offers an obvious response to Blanchard’s point here, but
as far as I know Blanchard never discusses Wakefield’s work.
the use of evolutionary theory for nosological purpose, as we
have seen. Given that Blanchard never explains why a sexual
preference for physically immature people should be considered
pathological, his reasoning is left to be perfectly circular: hebephilia is a disorder because it is a disorder.
The second relevant criterion, consent, is stronger from a
logical point of view, but raises other very important and wellknown political and epistemological problems. Blanchard does
not spell out what he means by‘‘consent,’’but everything seems
to indicate that he takes the word in the usual legal sense. According to this meaning of consent, someone who is below the
age of consent cannot, by definition, give consent, no matter his
or her actual level of psychological maturity, and no matter
whether he or she expressed the desire to engage in a sexual act.
In the U.S., the legal age of consent is fixed by each State and
ranges from 16 to 18. Interestingly, there is one instance where
Blanchard used a psychological (as opposed to legal) meaning
of consent. In a 2010 article he mentioned in passing the possibility that some victims of pedophiles and hebephiles might
have been‘‘consenting.’’However, this mention was made
precisely to argue that this type of consent is not relevant for his
research: ‘‘For the present study, the total number of different
children under the age of 15 with whom the patient had interacted sexually was called the victim count. It did not matter, for
the purpose of computing this variable, if the child was…consenting or coerced’’(Blanchard, 2010, p. 1247). For Blanchard,
hebephilia would then be a paraphilia, and therefore a disorder,
because people who have this condition have a sexual preference for‘‘victims’’who are (legally) unable to give consent, even
if these‘‘victims’’voluntarily engaged in the sexual activity.
With this ‘‘consent’’ criterion, Blanchard extricated himself
from the circularity of the‘‘physically mature’’criterion, but he
also made the concept of paraphilia into a pure value concept,
i.e., a concept that is fully determined by the values of a given
society. For Blanchard, what makes hebephilia a disease is not
that it is biologically abnormal or evolutionarily dysfunctional,
for instance; it is only that it is an object of social condemnation.
As Wakefield (1992) argued many years ago, the pure value
view leaves the concept of disorder‘‘open to unconstrained use
for purposes of social control’’(p. 376). Let us simply mention
the always very instructive example of drapetomania, this socalled disease proposed by a nineteenth-century racist psychiatrist to explain why some slaves try to flee from their masters
(Cartwright, 1851). Of course, we empathize with slaves while
we loathe adults who have sex with people who are under the age
of consent, but this should not mask the fact that, from a conceptual point of view, hebephilia (as defined by Blanchard) is
analogous to drapetomania. If we think that drapetomania is not
only morally revolting, but also conceptually flawed, then we
must reject Blanchard’s definition of hebephilia. In other words,
if we think that the definition of mental disorder cannot be fully
reduced to our values, then the pathological status of hebephilia
needs to be established on other grounds than a legal category
Arch Sex Behav
like consent. Blanchard’s definition of paraphilia certainly could
not convince anyone who was not already convinced.2
At that point, we might be tempted to conclude that the BOT
rejected hebephilia because this condition does not meet the
requirements for the concept of‘‘disorder.’’There is, however,
an obvious objection to this explanation: in the history of the
DSM, both the inclusion and the rejection of nosological categories have probably never been decided by determining whether a condition fits or not a general definition of mental disorder.
Frances (2010), who is in a good position to know this since he
was chair of the DSM-IV Task Force, admits that‘‘historically,
conditions have become mental disorders by accretion and
practical necessity, not because they met some independent set
of operationalized definitional criteria’’ (p. 5). Even in the famous case of homosexuality, the historical record clearly indicates that it is not because homosexuality did not fit the definition
of mental disorder that it was removed from the DSM in the
1970s, but, inversely, because it was no longer culturally permissible to have homosexuality in the DSM that a definition of
mental disorder was crafted in order to justify the political decision to remove homosexuality (Bayer, 1987).
There is no reason to think that, in contrast to its predecessors,
the DSM-5 suddenly became a paragon of conceptual coherence
and that decisions were made on scientific rather than pragmatic
grounds (for a multifaceted appraisal and critique of the DSM-5,
see Demazeux & Singy, 2015). In line with a vast literature
criticizing the many conceptual problems that have always
plagued the DSM, an editorial was published in 2008 in the
American Journal of Psychiatry that denounced the manner in
which DSM revisions had been made in the past: ‘‘conceptual
questions were considered on an ad hoc basis by individual work
groups and task force. This inefficient and potentially confusing
approach results in inconsistencies….Progress is not made by
driving quickly down a road if it is the wrong road’’ (Kendler
et al., 2008, pp. 174–175). The authors, who included some of
the most senior psychiatrists, suggested the creation of a Conceptual Issues Work Group in order to improve the situation for
the DSM-5. This Work Group would have been in charge of
addressing conceptual questions such as:‘‘What is the definition
of a mental disorder? If disorder X is proposed for DSM-V, how
will we decide whether it represents a legitimate psychiatric
condition?’’(Kendler et al., 2008, pp. 174–175). Unfortunately
but unsurprisingly, the proposal to appoint this Conceptual Issues Work Group was declined by the DSM-5 Task Force.
As regards hebephilia itself, conceptual haziness was painfully on display on both sides of the debate. For while Blanchard
did not convincingly prove that hebephilia is a disorder, his most
vocal opponent, Frances, hardly did any better at demonstrating
Let us note in passing that while Blanchard’s proposal to introduce
hebephilia was soundly rejected by the BOT, the consent criterion in the
DSM-5’s general definition of paraphilia logically validates the category
of hebephilia. On this incoherence, see First (2014).
the opposite. In blogs, articles, and books, he hammered home
the same message: the concept of hebephilia‘‘is absolutely absurd just on the face of it’’(Frances, 2012). But he also claimed
that it is impossible to definemental disorder:‘‘Ihave read dozens
of definitions of mental disorder (and helped to write one) and I
can’t say that any have the slightest value whatever….Indeed,
the concept of mental disorder is so amorphous, protean, and
heterogeneous that it inherently defies definition’’(Frances, 2010,
p. 5; see also Greenberg, 2010). Frances does not know what a
mental disorder is, but he somehow knows that hebephilia is not
one. As such, his belief in the non-pathological status of hebephilia is based on an intuition that appears to have no more
justification than Blanchard’s opposite but equally strong intuition that hebephilia is a disease (on the incoherence of Frances’
criticism of the DSM-5, see Singy & Demazeux, 2013).
What Would Have Been the Social Consequences of
Including Hebephilia in the DSM?
Blanchard’s initial reluctance and ultimate failure to explain
why hebephilia is a disease probably did not help his cause, but
it certainly cannot fully explain the BOT’s decision to reject
hebephilia. His mistake appears rather to have been that he has
entirely ignored the third and most burning question raised by
hebephilia: even if it were true that hebephilia exists and that it
is a disease, what would have been the social consequences of
including hebephilia in the DSM? This is a thoroughly political
Blanchard’s research does not exist in a historical vacuum.
Since the late twentieth century, many Western countries have
become particularly worried about preventing at all cost sexual
crimes against children, to the point that some of these countries
are applying preventive measures against people for the crimes
they might commit in the future. An increasing number of U.S.
states have adopted sexually violent predator (SVP) laws, which
permit the civil confinement of people who are deemed sexually
dangerous (see Janus, 2009, for an excellent analysis of SVP
laws). One requirement for these laws to be constitutional is that
the defendant suffers from a mental illness. For instance, an adult
who had sex with a teenager and who is seen as suffering from a
disease called ‘‘hebephilia’’ might be subject to SVP laws. The
APA’s clear dismissal of ‘‘hebephilia’’ therefore makes the application of SVP laws to rapists of ‘‘pubescent children’’ constitutionally more problematic (though certainly not impossible,
since lawyers do not need to restrict themselves to DSM diagnoses; hebephilia has indeed been used regularly for several
years: see Franklin, 2010, pp. 751–752; Huttenbach & Grudzinskas, 2014; Tucker & Brakel, 2012). Recently, in North Carolina,
Judge Terrence W. Boyle refused to predicate civil commitment
on hebephilia, arguing that this diagnosis is too controversial
among health care professionals (Franklin, 2012). If hebephilia
had been in the DSM, his decision might have been different.
Arch Sex Behav
The relationship between the law and mental disorders goes
both ways: the constitutionality of SVP laws hinges on the
presence of a mental disorder in the defendant, and disorders are
created to fulfill such legal requirements. Historically, most paraphilias owe their existence to their forensic rather than clinical
relevance. Sadism, fetishism, homosexuality, exhibitionism, and
so many other‘‘perversions’’were first described in the second
half of the nineteenth century by Krafft-Ebing (1965 [first edition, 1886]) and other forensic psychiatrists before and after him,
who all discussed the legal responsibility, the legal rights, and the
social danger of people suffering from ‘‘perverted’’ sexual instincts. As Foucault (2003) argued in his historical analysis of the
abnormal individual, the nineteenth-century notion of ‘‘perversion’’ enabled ‘‘the series of medical concepts and the series of
juridical concepts to be stitched together’’ (p. 34; see also
Mazaleigue-Labaste, 2014). Hebephilia itself was invented to
classify sexual offenders (Glueck, 1956). An observable corollary of the forensic origin of the paraphilias is that the less a sexual
preference is forensically relevant, the less it is studied by scientists.Thisiswhytherehasneverbeenanyseriousandsustained
scientific study of the sexual preference for people with red hair.
Similarly, we can safely predict that the scientific study of homosexuality will continue to lose its momentum as gay rights
continue to gain strength: whether homosexual behavior is the
result ofa free choice ordeterminedby a‘‘gaygene,’’for instance,
is a relevant question only as long as society looks suspiciously
on homosexual behavior and ponders issues of moral and legal
The way paraphilias have been conceptualized in the DSM
guarantees their enduring forensic relevance. From the DSMIII to the DSM-5, a necessary condition for something to be
considered a paraphilic disorder (formerly called‘‘paraphilia’’)
has been that it entails harm.3 While most diseases, including
sexual dysfunctions like erectile disorder or female sexual
interest/arousal disorder, qualify as disorders because they are
harmful to the individual who has the condition, most paraphilic disorders are disorders because they entail ‘‘personal
harm, or risk of harm, to others’’(American Psychiatric Association, 2013, pp. 685–686, my italics). This explains why‘‘in
contrast to the disorders from almost every other DSM-5 diagnostic class, individuals with paraphilic disorders, especially in
the United States, are mainly seen in forensic settings’’(First,
2014, p. 191). In Blanchard’s own study,‘‘the majority of patients had one or more sexual offenses’’(Blanchard et al., 2009,
p. 337). It is the issue of harm to others and, by implication, of
social risk and legal responsibility, that is and has always been at
From the DSM-III to the DSM-IV-TR, harm was a necessary requirement
for all disorders, not just for the paraphilias. This is no longer the case in the
DSM-5, which states in its official definition of mental disorder that‘‘mental
disorders are usually associated with’’ harm (American Psychiatric Association, 2013, p. 20, my italics; see Cooper, 2015).
the core of the concept of hebephilia. Like many paraphilias,
hebephilia is a forensic concept before anything else.
The peculiarity of Blanchard’s work is that it ignores entirely
the forensic context that gives hebephilia its relevance. His
laboratory ‘‘does not address forensic questions (e.g., criminal
responsibility, fitness to stand trial)’’(Blanchard et al., 2007, p.
289), his published work avoids any discussion of forensic issues, and when asked directly he resists in the strongest terms
any association with forensic practice:‘‘I have never testified in
any criminal case in any country….My motives for researching
hebephilia had absolutely nothing to do with American SVP
laws. I know that there are fine researchers whose work focuses
on social policy, but I am not one of them….I have the same
discomfort with American SVP civil commitment laws that
many others have expressed’’(personal communication, August
9, 2013).4 It would therefore be unfair to accuse Blanchard of
having lobbied for the inclusion of hebephilia in the DSM-5 with
the intention of justifying the use of this diagnosis in the courtroom and of strengthening SVP laws.
It is difficult to square Blanchard’s conviction that hebephilia
should be included in a future DSM with his criticism of the
forensic context in which this category is deployed. On the surface, the weight of tradition might be the simplest answer to this
conundrum:‘‘The true reason I proposed that hebephilic disorder be included in DSM-5 as a near-relative of pedophilic disorder is simply that the clinical sexology community in which I
had been trained, and in which I worked for over 30 years, took
the existence of hebephilia for granted and routinely diagnosed
patients with an erotic preference for early pubescent children as
hebephiles’’(personal communication, August 9, 2013).
More interestingly and getting at the heart of the problem,
Blanchard’s lack of concern for the forensic implications of
hebephilia follows from a positivist epistemology. He believes
that‘‘research on hebephilia itself not only can but should be divorced from non-scientific issues….I think it is the business of
the law to adjust itself to clinical science and not the other way
around’’(personal communication, August 9, 2013).5 A similar epistemological position has been expressed by others who
have lamented the rejection of hebephilia. For instance, Balon
(2014) recently complained about the role of politics in the
BOT’s decisions on the paraphilias:
An article by Cantor (2012), a collaborator of Blanchard, confirms that
the main people working on hebephilia have not been personally involved
with SVP laws:‘‘Neither I, nor Blanchard, nor Freund, nor Zucker has ever
been retained for SVP testimony, either by prosecution or by defense’’(p.
There is no reason to doubt the candor of this statement, but one also
cannot help but note that it clearly contradicts Blanchard’s own definition
of paraphilia, where the legal criterion of consent is what makes hebephilia
into a disorder. In this definitionit is clinical sciencethat adjusts itself to the
law, since its domain of research is carved out by means of a legal criterion.
If this criterion changes (for instance, if the legal age of consent is raised or
lowered), then the clinical determination of what counts as hebephilia
must logically change accordingly.
Arch Sex Behav
Paraphilias, now Paraphilic Disorders, have been frequently the center of controversy and thus exposed to
politics and political decisions. Nevertheless, some of us
(surprisingly, including me, as I should know the organizational politics better) expected rational changes of
diagnostic criteria not necessarily based on full proof facts,
but based at least on the expert opinions. Through a complicated process, the American Psychiatric Association
selected Work Groups of experts in each area, including
the area of paraphilias. Thus, those of us with some remnants of rationality expected that the experts in those areas
would be heard and respected. Alas, it seems that we have
been naı¨ve! (p. 1235)
But naı¨vete´ does not quite capture what is at stake here. The
problem is not that a separation between the scientific study of a
concept and its political impact is difficult or impossible, and
that it would be naı¨ve to think otherwise. What Blanchard and
others have failed to understand is that when it comes to the
DSM, politics is not an outside and unwelcome influence, but is
deliberately woven into the fabric of the manual. The DSM was
never meant to be a pure research instrument or even a simple
clinical manual. In line with its previous editions, the DSM-5
announces that ‘‘it must be applicable in a wide diversity of
contexts’’(American Psychiatric Association, 2013, p. xli),
among which there is, of course, the forensic context.
Since the DSM-III, the dangerous possible consequences of
the use and abuse of the DSM in the courtroom have been increasingly stressed by the writers of the DSM themselves
(Shuman, 2002). The DSM-III benefitted from the expert advice
of a Liaison Committee formed by the American Academy of
Psychiatry and the Law (Decker, 2013, pp. 270–272), the DSMIV had an official group of ‘‘Advisers on Forensic Issues’’
(American Psychiatric Association, 1994, p. 862), while the
DSM-5 appointed a Forensic Review Committee (American
Psychiatric Association,2013, p.897). The functionof the latter
was to offer its expert opinion on questions like the following
ones:‘‘Were the new diagnostic criteria particularly likely to be
misused in the courts or in other adjudicative contexts? Might
they be confusing to the courts or to others relying on them for
nonclinical purposes? Could they have other unanticipated consequences? Might a given set of changes leave psychiatrists open
to increased risk of liability?’’(Appelbaum, 2014, p. 137).
Even if it were in theory possible to separate the scientific
study of hebephilia from its forensic fallout, to take this fallout
into account is therefore in the job description of the writers of
the DSM. Blanchard (2013) dismissed the forensic psychologists
and psychiatrists who rejected hebephilia on the basis of the
‘‘anticipated (or fantasized) consequences in the courtroom’’
(p. 676), but the DSM-5 Forensic Review Committee existed
precisely to think through these consequences before changes
were made to the DSM. Appelbaum (2014) gave recently an
insider’s perspective on this issue. As a key member of the
DSM-5 Forensic Review Committee, he explained that when
changes are made to diagnostic criteria,‘‘the potential impact on
forensic psychiatry and the legal system is substantial and must
be taken into account in the revision process’’(p. 136, my italics).
Unsurprisingly, the writers of the DSM prefer to emphasize
the importance of clinical research and scientific observation
over that of politics. This is why they need to do a delicate dance
around the role they give to extra-scientific factors. For instance,
while Appelbaum (2014) explained that one reason why hebephilia was rejected was‘‘the possibility of a substantial impact
in the courts,’’he also made sure to add that this was‘‘not a reason
in itself to reject the proposal’’(p. 138). Indeed, according to him,
all decisions made by the Forensic Review Committee ‘‘were
based primarily on the strength of the data supporting the validity of the proposed approach’’(p. 137, my italics). In the case
of hebephilia, Blanchard’s proposal was supposedly rejected
primarily because it is ‘‘problematic from an evolutionary perspective to characterize attraction to early pubescent children as
a disorder’’ (p. 138). But we need to take this statement cum
grano salis. Evolutionary psychiatrists and psychologists have
long bemoaned that evolutionary theory‘‘has left the bulk of psychiatry untouched’’(Miller, 2011, p. vi). Importantly, the DSM’s
lack of interest in evolutionary theory is not so much due to a
healthy skepticism toward such theory, but more to a methodological decision that has governed the DSM since its third
edition:‘‘Theapproach taken inDSM-IIIisatheoretical with regard
to etiology or pathophysiological process’’(American Psychiatric
Association, 1980, p. 7).
The vow of theoretical abstinence taken by the DSM was
supposed to be a protection against the theoretical biases of
clinicians (Demazeux, 2013, pp. 151–156). Unfortunately, it has
also undermined the possibility of a distinction between phenomenologically similar negative conditions, such as grief and
depression (Horwitz & Wakefield, 2007; Wakefield, 2015)
or natural anxieties and many mental disorders (Horwitz &
Wakefield, 2012). The invention of artificial nosological categories (Murphy, 2006, pp. 308–316) partly explains why in the
last decades more and more people have been diagnosed with
mental disorders:‘‘When symptoms were qualified without regard to their causes or to whether they indicated a mental illness,
there was no limit on the sorts of conditions that could enter the
new diagnostic manual’’(Horwitz, 2002, p. 73).
This is not the place to make an argument for the use of
evolutionary theory in psychiatry or even for the use of any
theory (for such an argument, see, for instance, Tsou, 2015). I
only want to point out that based on our knowledge of the history of the DSM in general, and of the hebephilia debate in particular, we need to be very suspicious of any post hoc justification for the rejection of hebephilia that conveniently paints a
picture of the DSM as a conceptually robust manual that uses
theoretical arguments against empirically weak and scientifically unsound ideas. The DSM is partly, but by design, a political
manual, and political considerations must logically carry all the
Arch Sex Behav
more weight that the categories at stake have a potentially high
forensic impact. Given that hebephilia is fundamentally and
essentially a forensic concept, any scientific reason for its rejection was most probably nothing more than window dressing,
meant to distract us from the decisive political reasons.
The BOT’s refusal to include hebephilia in the DSM-5 is
therefore best understood as a worry about the use and abuse of
psychiatry for forensic purpose. This worry is well documented. In 1999 an APA Task Force Report on dangerous sex offenders expressed in unmistakable terms its opposition to SVP
laws: these laws‘‘represent a serious assault on the integrity of
psychiatry’’ and ‘‘threaten to undermine the legitimacy of the
medical model of commitment’’(Zonana et al., 1999, p. 173).
The latter model‘‘is fundamentally paternalistic’’and exists‘‘to
protect individuals whose ability to recognize their need for
treatment is impaired by serious mental illness’’(p. 171). This
is very different from sexual predator commitment statutes,
which‘‘are not fundamentally paternalistic….Drafters of sexual
predator commitment statutes have attempted to cloak their
quasi-punitive intent in the language of medical commitment’’
(pp. 172–173). The APA Task Force concluded that‘‘psychiatry
must vigorously oppose these statutes in order to preserve the
moral authority of the profession and to ensure continuing
societal confidence in the medical model of civil commitment’’
(p. 173).6 In 2001, 739 members of the APA were surveyed about
their knowledge and support of civil commitment. Only 26.1 %
wanted the classification as a sexual predator to be grounds for
civil commitment (Brooks, 2007, p. 223). Had the APA been on
the contrary strongly in favor of SVP laws, it is a very safe bet to
say that hebephilia would have found a place in the DSM-5,
regardless of what evolutionary theory might have to say on
Hebephilia is stuck between a rock and a hard place. Either it is
detached from its forensic context, as Blanchard would have it,
but then it becomes difficult to understand why it would be any
more relevant to study hebephilia than it would be to study the
sexual preference for people with red hair. Or we take hebephilia
for what it is, i.e., a forensic concept, and then we cannot and
should not avoid a discussion about the role it is destined to play
in the courtroom, especially if one’s goal is to include hebephilia
in a manual that explicitly (if somewhat uncomfortably) requires
that social considerations be taken into account. Blanchard tried
to have his cake and eat it too. This was too ambitious a strategy
for a category that many find intuitively hard to swallow.
The chair of this Task Force, Howard Zonana, also participated in the
DSM-5 Forensic Review Committee, as did another member of the Task
Force, Steven K. Hoge.
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