Hebephilia is a Mental Disorder?
of Medicine, Imperial College, London, UK
First published in Sexual
Offender Treatment, Volume 5 (2010), Issue 1
Reproduced here with the permission of the copyright owner.
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.
Why Diagnose Hebephilia?
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
This confusion is demonstrated by the principal architect of the sexual
paraphilia component of DSM 5 as he justifies including hebephilia (Blanchard
- "The modal age of victims of
sexual offenses in the United States is 14 years; therefore the modal age
of victims falls within the time frame of puberty." But, what is a
"victim"? Can it be a willing participant who did not experience
trauma but could not consent legally? Whether this is the case, or the
victims were all aggressively assaulted, this is a concern of the law in
criminalizing the conduct, not of psychiatry in pathologizing.
- "In samples of sexual
offenders recruited from clinics and correctional facilities, men whose
offense histories or assessment results suggest erotic interests in
pubescents sometimes outnumber those whose data suggest erotic interest in
prepubertal children." This does not demonstrate that attraction to
pubescents is a mental disorder, although acting on it may be a crime.
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 Merits Psychiatric Diagnosis?
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
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.
Psychiatry vs. Law
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.
How Rare is Hebephilic Attraction?
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.
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.
What About Pedophilia?
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
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.
Historical and Cross-cultural Influences on Acceptable
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.
Sexual Predator Law
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,
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
The Lunatics Have Taken Over the Asylum
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
Will Sex Researchers Be Left "Empty Handed"?
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.
DSM-5 TR (Text Revision)
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.
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.
- Bayer, R.
(1981). Homosexuality and American psychiatry: The politics of diagnosis. New
York: Basic Books.
- Blanchard, R.
(2010). The DSM diagnostic criteria for pedophilia. Archives of
Sexual Behavior, 39, 304-316.
- Brinkley, J.
(2010). The lost boys of Afghanistan. StarTribune.com. August 25.
- Brody, A.
& Green, R. (1994). Washington State's unscientific approach to the
problem of repeat sex offenders. Bulletin of the American Academy of
Psychiatry and the Law, 22, 343-356.
- Franklin, K.
(2010). Hebephilia: a quintessence of diagnostic pretextuality. Behavioral
Sciences and the Law 28 (online first). DOI: 10.1002/bsl.934
- Freund, K.
& Costell, R. (1970). The structure of erotic preference in the
non-deviant male. Behavior Research and Therapy, 8, 15-20.
- Gebhard, P.,
Gagnon, J., Pomeroy, W., & Christenson, C. (1965). Sex offenders: An
analysis of types. New York: Harper and Row.
- Green, R.
(2002). Pedophilia as a mental disorder. Archives of Sexual
Behavior, 31, 467-471.
- Hall, G.,
Hirschman, R., & Oliver, L. (1995). Sexual arousal and arousability to
pedophilic stimulation in a community sample of normal men. Behavior
Therapy, 26, 681-694.
- Litt, I.
(1995). Pubertal and psychosexual development. American Academy of
Pediatrics, 16, 243-247.
- Moser, C.
(2009). When is an unusual sexual interest a mental disorder? Archives
of Sexual Behavior, 38, 323-325.
- Quinsey, V.,
Steinman, C., Bergerson, S., & Holmes, T. (1975). Penile
circumference, skin conductance, and ranking response of child molesters
and normals. Behavior Therapy, 6, 213-219.
- United States
v Abregana (2008). 574 F. Supp 2d 1123 (D. Hawaii).
- United States
v Shields (2007). 522 F. Supp. 2d 317 Court (D. Mass.)
- Working party
on the age of consent in relation to sexual offenses working paper (1979).
HMSO, June, para.10.
- Zonana, H., Abel, G., Bradford,
J. et al. (1999). Dangerous sex offenders: a task force
report of the American Psychiatric Association. Washington DC:
American Psychiatric Press. p 173.