Monday, February 22, 2010

And in related news...

In a post I made yesterday, I made brief reference to an editorial by Allen Frances titled Opening Pandora’s Box: The 19 Worst Suggestions For DSM5. Today, a response has been made by Kenneth Zucker, chair of the DSM-V Sexual and Gender Identity Disorders Workgroup: Pandora Replies to Dr Frances, which also contains a response by Dr. Frances. They have some rather intersting things to say about the paraphilias, which I give excerpts from:

Zucker writes
In his commentary, Dr Frances (who was the editor of the DSM-IV) fails to mention the epistemological problems he created by clumsily implementing the requirement of distress and/or impairment to diagnosis a paraphilia. In the versions of the DSM prepared under Dr Frances’ supervision, a person cannot have a paraphilia unless he is distressed by that paraphilia or he is harming other people because of it. A distinct but harmless paraphilia cannot exist, by definition. A man cannot be a fetishist, for example, even if he masturbates into rubber boots on a regular basis, unless he is bothered by this behavior or is impaired in his psychosocial functioning. In DSM-IV-TR, there is no such thing as a well-adjusted paraphile; they are defined out of existence.

It is ironic that Dr Frances criticizes the wording of the proposed diagnostic criteria for the paraphilias, when the criteria prepared under his supervision contained such logical absurdities. He has often and ominously warned of future, possible “unintended consequences” of the wording details of the diagnostic criteria, but he has been strangely silent about clear errors in diagnostic criteria that should have been obvious in the DSM-IV. In order to correct this problem, the Paraphilias Subworkgroup has introduced the proposed distinction between ascertaining a Paraphilia versus diagnosing a Paraphilic Disorder. In my view, this is an extremely creative distinction that might do well in distinguishing people who have paraphilic behavior from those who have a paraphilic disorder. He had his kick at the paraphilic can and missed it.

Frances writes in his rebuttal:
I thank Dr Zucker for accurately stating my position and then illustrating it with a particularly vivid and well-chosen example. I continue to find no reason to label as mental disorder sexual urges, fantasies, or behaviors that are harmless to others and cause no distress or impairment to the individual. As psychiatrists, we have our hands full taking care of the suffering and distress caused by real mental disorders. There is no need for us to expand our purview to cover sexual thoughts and behaviors that are private and harmless.

The behaviors captured by “paraphilic coercion” and “hypersexuality” are anything but private or harmless—but that does not make them mental disorders. There is no infallible definition guiding what should, and what should not, be included in the official manual of mental disorders.

Many decisions can be tough calls. But it seems abundantly clear that these proposals from the Sexual Disorders Work Group have no place in DSM5. They offer little gain and would create significant problems. The construct “paraphilic coercion” has already contributed significantly to a grave misuse of psychiatry by the legal system in the handling of sexually violent predators—a misuse much opposed by the APA in a task force report and amicus brief to the Supreme Court.

Understanding Dr. Frances criticisms of the diagnosis "Paraphilic Coercive Disorder" requires a certain amount of background, which I intend to write about soon.


SlightlyMetaphysical said...

First of all, thanks for all the research you do to keep the asexual community in the know. We're all indebted to you.

"In DSM-IV-TR, there is no such thing as a well-adjusted paraphile; they are defined out of existence."

I have to admit, while reading this bit, I thought "No, they're not written out of existence. They're written out of the book about mental disorder. They're very different things."

Having said that, the distress criteria is problematic. I'm a gleefully happy asexual, but if I told you that my sexuality has never caused me uncomfortable identity dilemmas, never been the subject of mild bullying, never negatively affected the way I interact with people, I'd be lying.

When do you think we'll hear this theory about the line between paraphelias and parapheliac disorders? As in; months or years?

ACH said...

The distinction between "paraphilias" and "paraphilic disorder" is discussed on the webpage, has been written about in some of the reports by the paraphilias subworkgroup, and is discussed in 3 presentations that Ray Blanchard gave last year, which can be found on his website.

As for the distress problem, it stems from an intractable problem created by the very concept of "mental disorder." First, in science categorization is really hard--anyone can whip together a category and slap a name on in, but making one with explanatory power is really hard (and getting evidence to justify it is as well.) In psychiatry, the present state of knowledge makes this problem almost impossible to deal with. Moreover, labeling certain thoughts/feelings/behaviors as pathological is inherently a value judgment, communicating that THESE ARE PROBLEMS and should be fixed, whether the person is distressed about it or not, whether they are causing any problems or not. When you go and slap a distress criterion on a diagnosis to deal with this, whatever scientific legitimacy some category may have (if it even had any) is completely shot to crap.

There is no solution to this. Trying to create a distinction between "paraphilias" and "paraphilic disorder" attempts to do this, but it still fails because, by classifying certain sexual interests as paraphilias, it singles them out in ways that supposedly "normal" ones are not, putting them in an intermediate category between "normal" and "disorder." Thus, the negative value judgment on harmless thoughts/feelings/behaviors remains.