Monday, December 28, 2009

The Pathologization of Asexuality?

Since finding the asexual community, two terms that have entered my vocabulary are “pathologize” and “medicalize.”

The OED defines "pathologize" (in its modern sense) as a transitive verb meaning, "To regard as pathological or a suitable subject for pathology; esp. to regard as psychologically unhealthy or abnormal," with the first quote coming from 1980. In OED's quotes, it always carries a negative connotation (though some authors use the term with an air of skepticism towards this judgment.) Medicalize is defined as, " trans. To give a medical character to; to involve medicine or medical workers in; to view or interpret in (esp. unnecessarily) medical terms." Likewise, it has a negative connotation. The OED's second quote:
1979 Daily Mail 27 Jan. 7/7 The drug industry, the Government, the chemist, the taxpayer and the doctor all have vested interests in ‘medicalising’ problems that should not really belong in the sphere of medicine at all
.
The terms are often used to criticize what is seen as regarding “normal behavior” or “normal variation” as disease, disorder, or dysfunction. They are used to critique regarding as a medical problem what might be better seen as a legal problem, a social problem, or maybe just an everyday-life sort of problem--or maybe not even a “problem” at all, arguing that the only problem is the perception as such.

While asexuality is not, strictly speaking, presently regarded as a mental disorder, the diagnosis Hypoactive Sexual Desire Disorder is too close for comfort for many in the asexual community.

A question that I have long wrestled with is this: Why does it bother us that asexuality is (almost sort of) considered a mental disorder? Why do we feel that this is a problem?

When I get sick, I don’t protest against medicalization or insist that there is nothing wrong with me. I don’t feel that I am somehow less of a person for having an illness. There are many things that I readily regard as pathological, and few would argue that nothing is properly the domain of medicine. (The only ones I can think of do so from a mystical bent.)

The question concerning the pathologization of asexuality is this: If there is nothing wrong with admitting one has an illness/disorder/dysfunction when one does have one, and if we often find nothing wrong with saying that various things about ourselves or others may be pathological without negative judgment on our (or their) value as people, why are we so opposed to regarding asexuality as (psycho)pathological?

I don’t mean this as a rhetorical question, nor do I mean to suggest we accept without comment HSDD. Intuitively, I want to say, “That's different.” For some things, it feels appropriate to classify them as pathological; for many, this will be very uncontroversial (like liver cancer.) There seems to be something different about calling asexuality disordered than does make is problematic when, for many of these others, calling them pathological does not seem problematic. The question is, “What is the difference? How is it different?” And not just, "How is it different from liver cancer?" But "How is it different from other things of much less severity that we readily regard as pathological?"

I'm not going to try to answer the question now, but hope to start to do so over the next few months. I attempted this in a series over the summer, but, as my most recent blog summary notes, I got through all of two posts before hitting a serious case of writer's block. I've done more reading and thinking, and I think I'm ready to attempt it again.

Friday, December 11, 2009

DSM-V anticipated date of publication moved back a year

For some time, there have been serious criticism of the DSM-V process, including criticism that the process is not transparent enough and that there is no way they can finish by May 2012. Yesterday, an article about the matter, to appear in New Scientist on Saturday, was published website: Pscyhiatry's Civil War. Published along side it was a scathing editorial titled Time's up for psychiatry's bible.

Within hours of it appearing online, the American Psychiatric Association issues a press release: DSM-5 Publication Date Moved to May 2013

The press release also indicated that, according the the chair of the DSM-V task-force,
draft changes to the DSM will be posted on the DSM-5 Web site in January 2010. Comments will be accepted for two months and reviewed by the relevant DSM-5 Work Groups in each diagnostic category. Field trials for testing proposed changes will be conducted in three phases.


This seems to be a positive development. For some interesting commentary on the matter, see New Scientist expose of psychiatry’s "civil war" on the blog, In the news, which is where I first learned about the articles and the press release.

Wednesday, December 2, 2009

More News on Paraphilic Coercive Disorder

A few months ago, I wrote a couple of posts here and here on a diagnosis proposed for DSM-V: Paraphilic Coercive Disorder (PCD), and I wrote about a profoundly troubling report on the matter by an advisor to the Paraphilias Subworkgroup for DSM-V (who, for some unknown reason, called it Coercive Paraphilic Disorder. If you google each of the names in quotes, you'll see the difference.) That report argued against including the diagnosis (a conclusion I agree with), but gave just about the scariest argument publishable in defense of that conclusion.

Since then, there have been three additional reports published by advisors to the paraphilias subworkgroup, two of which are on PCD (other groups only publish reports by workgroup members.) In my previous post I gave two possible explanations for the really scary report: either it is a diversionary tactic or they’re wanting to give the worst possible argument against the diagnosis in order to gain support for it.

The second of the reports on PCD seemed quite promising—the author gave some very sensible arguments against including it (basically, that it has dubious scientific support and would have rather undesirable consequences in terms of research on understanding the causes of rape [by causing researchers to focus on the wrong questions] and in terms of misapplication with respect to laws permitting the “civil commitment” of sex-offenders [i]after[/i] they finish their sentences. These laws, which a number of US states have, are, in my view, are of very questionable constitutionality: they essentially take away procedural due process rights and violate the US Constitution’s ex post facto and double jeopardy clauses, though the Supreme Court has [wrongly, I think] rejected these arguments to date.)

A third report has recently been published arguing in favor of adding the diagnosis. Having read it, it feels as though it would be very persuasive if I didn’t know anything about the matter (or know to be very skeptical of certain lines of research that he cites.) Based on this third report, I am fairly strongly inclined to think that the Paraphilias Subworkgroup members really do want to add this diagnosis in DSM-V. There is a very telling piece of evidence if you read the acknowledgements at the end of these reports:

First report, argues against PCD:
Thanks are due to Rick Beninger, Joe Camilleri, Grant Harris, Martin Lalumie`re, and Marnie Rice for their comments on an earlier version of this manuscript. The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.


Second report, argues against PCD:
I would like to thank Jane Harries, Matthew King, Elizabeth Saunders, and Judith Sims-Knight for their insightful comments and suggestions on an earlier version of this article. The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.


Third report, arguing in favor of including PCD:

The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). I wish to thank members of the subworkgroup for their discussion of an earlier version of this paper and their role in refining and developing the diagnostic options that are discussed. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association. (emphasis mine)


And, just for additional contrast, another report by an advisor to the paraphilias subworkgroup (on a different matter):
The author is an advisor to the Paraphilias subworkgroup of the DSM-V Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). This article is a revised version of a commentary submitted on July 17, 2009 to the Workgroup. I would like to thank Jobina Li for help with the references. The views expressed are those of the author and not necessarily those of Public Safety Canada.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.


Which of these things is not like the others?

In case you hadn’t guessed from the section I bolded, only one of these authors mentions having ever discussed their report with members of the Paraphilias Subworkgroup. Now, my understanding was that the whole point of having official advisors is for them to, you know, advise? By, like, talking with the workgroup members? In just about every other report I’ve read so far, authors acknowledge the helpful input from other workgroup members. (The exceptions are those by Ray Blanchard who finished his reports of pedophilia and “transvestic fetishism” not long after the workgroups were formed; in the former, he thanked two people for comments about a single point, and in the latter, he thanked several people for “their stimulating conversations, over many years.”)

Now, I may be reading a little too much into the fact that only one of their advisors acknowledges ever speaking with the people they’re advising about the matter on which they are advising them. (Though I assume that they’ve probably all met before, as it isn’t that big of a field.) Still, it does seem suggestive.

And I really don’t like what it suggests. In the second report on PCD published online, Raymond Knight sums up the reasons:

First, identifying and reifying a taxon implies a research strategy that emphasizes extreme group designs that attempt to distinguish the putative taxon from other discrete groups of rapists that have been formed for comparison purposes [reference]… Searching for the identifying characteristics of a non-existent taxon will delay the task of discerning the underlying dimensions of rape and explicating their etiology and life course.

Second, the criteria for civil commitment depend on some form of mental disorder to legitimize the process and keep it from becoming unconstitutional preventive detention [references]. Moreover, it is required that it be demonstrated that the mental disorder is a likely source of the offender’s sexual offending. In commitment proceedings for rapists Paraphilia NOS, nonconsent has frequently served the role of a sexual aggression inducing mental disorder, despite the lack of specific criteria for its implementation and the absence of evidence of its reliability and validity [reference]. The inclusion of PCD would inappropriately legitimize this ‘‘disorder’’ and grant it the imprimatur of the DSM, which is almost universally cited by expert witnesses in civil commitment proceedings. The present review indicates that the diagnosis has little empirical support, and it would be a travesty to grant it a status that would perpetuate its misuse.

Tuesday, December 1, 2009

More news on the DSM: Women who want to want

Women who want to want, an article published his past weekend in the New York Times Maganize, discusses the future of the diagnosis female Hypoactive Sexual Desire Disorder (HSDD) in the DSM-V, focusing on Lori Brotto, the member of the sexual of DSM-V subworkgroup for Sexual Dysfunctions who wrote the report on female HSDD (which I have discussed here). (She has also been involved in research on asexuality.)

It was an interesting article that I would definitely encouraged readers to take a look at. Here's my favorite part:
Brotto knows too that there are sexologists who maintain that desire by any definition — whether the sheer lust Basson minimizes or the responsive variety she trumpets — is almost entirely a cultural invention rather than a biological reality; that it has been made to seem essential by the sex scenes in movies and the advice columns in magazines; and that it is best deleted from the D.S.M. Leonore Tiefer, a professor in the psychiatry department at New York University and the author of a collection of essays titled “Sex Is Not a Natural Act,” argues that the contrivance is compounded by the pharmaceutical industry, which offers research money to sexologists who find ways, no matter if unconsciously, to inflate hugely the numbers of women suffering from an already-fictive condition — a disorder that the drug companies intend to cure. High numbers help to increase awareness, which stokes demand. To what extent this theory represents truth, as opposed to being merely plausible, is hard to sort out.


I wouldn't exactly endorse the claim that lust is a cultural invention without qualification--like many claims about this or that being "social constructs" (whatever that means), the statement seems to conflate "the sheer biological/psychological fact of the experience of lust" one the one hand, and "the conceptualization of lust and corresponding beliefs" on the other. (The former, presumably is rather biologically rooted; the later much less so, except to the extent to which all human conceptualizations of anything are rooted in general abilities of reasoning, conceptualization, thinking etc. based on how human brains work.)

Other than that, I'm generally inclined to agree. (Although, the facts are somewhat more complicated in the sense that the medicalization of low sexual desire considerably preceded the release of Viagra, which is when, according to Tiefer's analysis, the pharmacuticals realized just how much money they could make were they ever to invent "the pink pill.")