Saturday, March 13, 2010

Paraphilic Coercive Disorder: Historical Background

The Paraphilias subworkgroup for DSM-V has suggested adding a disorder called "Paraphilic Coercive Disorder" in DSM-V. Here are the proposed diagnostic criteria:
A. Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion.

B. The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occasions.

C. The diagnosis of Paraphilic Coercive Disorder is not made if the patient meets criteria for a diagnosis of Sexual Sadism Disorder.

A very similar diagnosis (under the name of "paraphilic rapism" and then "paraphilic coercive disorder) was suggested in the mid 80's to be included in DSM-III-R. There was strong political opposition to it, largely from feminists, which ultimately resulted in this diagnosis being rejected. Many of their concerns are just as valid today as they were then, so it is worth reviewing the matter.

A very good discussion of this history is found in the paper Commentary: Inventing Diagnosis for Civil Commitment of Rapists by Thomas K. Zander, which I will be relying on in this discussion. In the mid 80's the following diagnostic criteria were suggested:
A. Over a period of at least six months, preoccupation with recurrent and intense sexual urges and sexually arousing fantasies involving the act of forcing sexual contact (for example, oral, vaginal, or anal penetration; grabbing a woman’s breast) on a nonconsenting person.
B. It is the coercive nature of the sexual act that is sexually exciting, and not signs of psychological or physical suffering of the victim (as in sexual sadism).
C. The individual repeatedly acts on these urges or is markedly distressed by them.
(Note the use of AND in this version and the OR in the diagnostic criteria proposed for DSM-V.)

There was strong opposition to this diagnosis from a number of groups. Zander writes:
The American Psychological Association, the American Orthopsychiatric Association, the National Association of Social Workers, and the National Organization for Women mounted strong opposition to the proposed diagnoses. Even the U.S. Department of Justice, which rarely takes public policy positions on matters related to mental health, argued that the proposed diagnosis of PCD would be used by criminal defendants to avoid legal responsibility in criminal prosecutions for rape.

In addition to fears about the use of this diagnosis being used to lessen responsibility in rape cases, it promoted an idea of the cause of rape that strongly went against research at the time on the actual reasons for rape.
[B]y the mid 1980s, it was widely accepted that rape is a violent assault motivated by the rapist’s desire for power and dominance rather than by sexual arousal...and he gives an example of "a 1977 study that ranked the rapist’s motivation in accounts from 132 rapists and 92 victims found, '[T]he offenses could be categorized as power rape . . . or anger rape. . . . There were no rapes in which sex was the dominant issue; sexuality was always in the service of other, nonsexual needs.

A third line of objections to it involved scientific problems with it, including issues with validity (is this a real disorder?) and reliability (is it possible to distinguish paraphilic rapists from other rapists? If you get a bunch of clinicians to assess someone, can you get a moderate level of agreement among them on what disorder someone has?) (For discussion, see this and this.)

These issues remain as valid today as they did a quarter of a century ago. And now, in addition to these, there is a fourth major reason that this diagnosis needs to be kept out of DSM-V: the extremely disturbing civil liberties consequences it will have (and already does--many people are already being diagnosed with this under the name "Paraphilia NOS: nonconsent.)


SlightlyMetaphysical said...

The paraphilia debate is getting interesting. Is there anything being published on anything closer to HSDD, or are they being quiet on that front?

My thoughts (for the little they're worth), reading through what you'd written, were that, of course, it's dangerous and ill-advised to create a mental disorder for rape, especially one which is as actions-based as this seems to be (the wording is often, 'If you do ---, you are ---', rather than 'If you think ---, you are ---'). This is so dangerous, because there's a lot of people who will clutch at any straws to stop rapists being responsible for their actions.

Then I started thinking about what this does right. The medical model of 'rape', though they avoid the word (probably too political), is better than the legal model because it focuses on any sort of sexual activity, not 'sex', thus avoiding the seperation between rape and sexual harrassment. I began to think how this could be included in the legal model without getting to the situation where someone getting too touchy-feely in a night-club couldn't be charged the same offense as a rapist, and, yeah, got completely off topic even in my own head. Still, credit where it's due, this breaks down the boundaries between sex and related activities, which make so little sense in a modern context.

And, reading through the post again, I'm coming more and more to wholeheartedly embrace the sentiment (which I probably found on something you linked me too) that fetishes are not mental disorders. If someone acts on a fetish in a disturbed way, until we get considerably more research, it's safer to assume that it should be the same as someone acting on vanilla sex in a disturbed way.

ACH said...

From what I've seen, using a medical model for rape has been tried, and it has failed to deliver. What I think is needed is something more like a "public health model" that focuses more on education, on providing counseling services for victims. I've seen some interesting proposals of services that that provide mediation between victims and perpetrators with a "restorative justice" approach that avoids the legal system altogether. (Many people who have been raped want to avoid the legal system altogether--it often retraumatizes people; often they want the person to be held responsible for what they did, but don't want them to spend years in prison and then decades on public sex-offender registries, since often the rapist is a friend or relative.)

SlightlyMetaphysical said...

Yes, better education is desperately needed. I think if more people reflected on the reality that nearly everyone knows their rapist, this would be obvious, because the legal model is really designed for 'man in the bushes', a similar man, co-incidentally, to the lust-driven fetishist that the DSM seems to be trying to invent, whether he exists or not.

You misunderstand me when I say that the medical model has successes. I mean that I like the way ideas of non-consensuality can exist independant of strict definitions of 'sexual intercourse'. I don't mean that it would be best to automatically treat any or all parties as if they were mentally unhealthy.

ACH said...

"I mean that I like the way ideas of non-consensuality can exist independant of strict definitions of 'sexual intercourse'."
I'm still not entirely sure what you mean.

Regarding the rapist in the bushes, I'm pretty sure they exist, but this constitutes a very small part of sexual violence. A big part of the problem of how our society deals with sexual violence is that the most horrifying (but extremely rare) cases end up getting hugely publicized without making the important caveat that this is the EXCEPTION and NOT THE RULE for sexual violence. A big criticism has been that it's these highly exceptional cases that end up driving a lot of public policy.

SlightlyMetaphysical said...

Ok, I'll explain better. In the UK, the legal definition of rape is 'unlawful sexual intercourse with another person without their consent'. The word sexual intercourse is generally taken to mean penis-in-vagina. I don't know what the laws of precident are involving other forms of sex, but I doubt that anything non-penetrative is legally seen as rape. There are other laws, such as sexual assault, that deal with these 'lesser' crimes. It's a very phallo-centric view of sex. What I admired about the wording of the paraphiliac coercive disorder was that it made little distinction between various forms of sexual activity. The really important thing wasn't what actually happened, but the mental state of both individuals, the focus only on the lack of consent. Generally speaking, I think a focus on consent is a better way of adressing rape than a focus on actions.