Changes to the proposed criteria for the paraphilias

From March 10 until April 20, it was possible for people to make comments on the DSM-5 website regarding their proposed diagnostic criteria. In the article APA: Comments Lead to Changes in DSM-5 Draft we learn that over 8000 comments were made.

Based on this feedback, no changes have been made for the sexual dysfunctions (in fact, things regarding the sexual dysfunctions and DSM-5 have been pretty quiet) but a few have been made regarding the paraphilias. These are listed on the page Recent Updates to Proposed Revisions for DSM-5 on the DSM5.org website.

(5/17/2010) Sexual and Gender Identity Disorders Work has made the following updates:

For all Paraphilia Disorders, two specifiers were added: in remission and in controlled environment; for Pedohebophilic Disorder, wording of Criterion B(3) was revised to read “use of pornography depicting prepubescent or pubescent children…” and criterion C now includes reference to Criterion B; Transvestic Disorder now includes the specifier With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male); In the criteria for Transvestic Disorder, the qualification that the patient must be male was removed from Criterion A. This change made the criteria consistent with other paraphilias, for example, the criteria for Pedohebephilic Disorder, Pedophilic Subtype, which do not formally exclude females from potential diagnosis even though this condition is extremely rare in females.; Hypersexual Disorder now includes wording changes to Criteria A(1) and C, and now includes Criterion D (at least 18 years old).

Regarding "Transvestic Disorder", I get a distinct sense of mockery. Critics of this diagnosis in the trans community have pointed out how its clearly (hetero)sexist nature can be seen in that (in previous DSMs) it explicitely restricted the diagnosis to heterosexual males.

In Ray Blanchard's literature review of this diagnosis, he suggested retaining this. However, in the version posted on dsm5.org in Feb., the requirement of being heterosexual was removed. Now they are suggesting the requirement of being male be removed. Of course, this just makes the diagnosis even broader--something that critics of the diagnosis are not likely to be pleased with. Yet it does mean that they may have to give up certain lines of criticism.

Also, I have a suspicion that "paraphilia in remission" means that someone need not actually meet criteria A and B to receive one of these diagnoses--that is, I suspect that this specifier will encourage people to ignore the actual diagnostic criteria.

Asexual Studies Email List

For people researching asexuality (or interested in researching asexuality) an Asexual Studies Email List has recently been created.*

Here is it's description:

Within the past decade, a growing number of individuals, self-identifying as asexual, have come together to form asexual communities. Although self-definitions vary widely, many of these individuals describe themselves as experiencing little or no sexual desire. In addition, they do not regard asexuality as a pathological condition but, rather, as a #variant of human sexual expression. For researchers in the field of psychology and related disciplines, the elaboration of asexual identities and the growth of online asexual #communities raise a range of questions about pathology, normativity and normality, the universality of sexual desire, the importance of sexuality to self-identity, and societal conceptions of what it means to be a fully-functioning person. This list provides a forum for researchers in this growing field to meet, network and exchange ideas.

*A while ago, something on Google Groups was set up with a similar purpose, but it has fallen into disuse and has problems with spam.

Commenting on the Paraphilias Subworkgroup

Most of us have learned to be wary of reading the comments on the internet, but for the Psychiatric Times, I have found some of the comments that people have left regarding the DSM-5 Sexual and Gender Identity Disorders Workgroup (and especially the Paraphilias Subworkgroup) are quite interesting. There are people with very serious concerns about how this process has been going who have been using that as a platform to get their voices heard.

A while ago, I reported on an article that Allen Frances (chair of the DSM-IV Taskforce) wrote, a response that Ken Zucker (chair of the DSM-5 Sexual and Gender Identity Disorders Workgroup) made, and Frances response to that. It seem that there are two versions of this.

In the recent version Rory Houghtalen (Google tells me he's a forensic psychaitrist) provides an interesting anecdote:

[There was] a session held at the at the American Academy of Psychiatry and the Law annual meeting this past October in Baltimore where the recommendations of the DSM 5 workgroup was presented then critiqued by an expert panel and the audience. I cannot recall more than a handful of comments from either the panel or the audience that supported the recommendations for changes to the paraphilic disorders criteria sets or the inclusion of new diagnoses related to hypersexuality or paraphilic coercive disorder. Rather there was a loud and consistent plea for the workgroup to return to the drawing board. The level of defensiveness Dr. Krueger displayed in the face of negative feedback was disappointing and surprising. Discussion spilled into the hallway after where a straw poll indicated that many left the session with the impression that the workgroup would hunker down and ride out the criticism rather than listen to the thoughtful critique of experts and practicing professionals who expressed grave concerns about its recommendations.

On the earlier version of the article, a fascinating comment was made by Richard Kramer (who explains who he is in his comment):

One of the issues that has yet to be addressed is the fact that in regards to "pedohebephilia,"the DSM is currently being revised in the absence of data from representative samples of those people under consideration. If experts are right, there are hundreds of thousands of people (most experts estimate over a million) in the general population who are preferentially attracted to children or adolescents (emotionally and sexually). Yet, DSM revisions are being based on limited data only from unrepresentative correctional populations who cannot be honest with researchers. It is well-known among social scientists that data from such populations are highly biased and misleading. Such limited data hardly lead to "diverse perspectives" or to "a thorough, balanced review of scientific data" as specified by APA Statements regarding DSM revisions.

In fact, Dr. Blanchard writes that his proposed diagnostic criteria are based on the assumption that patients will be dishonest. Do other subworkgroups base their criteria on such assumptions? If one is interested in accurate diagnostic criteria, it would seem to be more effective to find solutions to this problem than to be content with misleading information and a situation where the only subjects are those who are encouraged to be dishonest while clinicians must outsmart them. It seems hard to believe that such an adversarial approach would result in accurate diagnosis or effective treatment.

This approach, along with the lack of accurate information, breeds fear both in society and among people who are attracted to minors. In my work with a non-profit organization (B4U-ACT) in Maryland, I have met many minor-attracted people not under the supervision of the correctional system, some of whom seek mental health services but are extremely feaful of condemnation solely for their feelings of attraction. I have also been contacted by teenagers who have engaged in cutting or attempted suicide due to their attraction to children. They do not feel safe contacting professionals or suicide hotlines. Fear forces minor-attracted people into hiding, making the gathering of accurate information even more difficult. Perpetuating this vicious cycle does not lead to reliable diagnostic criteria (nor to effective child protection policies). It renders the APA powerless to gather and disseminate accurate information.

There is a solution to this otherwise intractable problem. Our organization has facilitated communication and cooperation between mental health professionals and minor-attracted adults, and has proposed to establish in-person dialog with the paraphilias subworkgroup for the purpose of obtaining more accurate information. The ultimate goal is to reduce barriers between professionals and people who are attracted to minors for their benefit as well as the benefit of children and society in general.

So far, Dr. Blanchard has replied as follows:

1. He stated that members of the subworkgroup are too geographically scattered to meet with us. We replied by offering to meet with only one or two members.

2. He responded by saying that for the reason already given, the subworkgroup would not meet with us. He did not acknowledge the need for accurate information.

3. He wrote that his subworkgroup would never discourage minor-attracted people from seeking clinical assistance. We replied by noting that failing to include representation from patient and family groups as stipulated by APA policy seriously discourages them from receiving mental health care. The need to promote a cooperative relationship with clients is well known in the mental health field.

4. He wrote that to "ensure fair and equal treatment of all advocacy groups," APA policy precludes his subworkgroup from meeting with us. We replied that this was puzzling since the APA held a symposium at its 2009 Annual Meeting to "bring together transgender advocates and DSM-V group members," thus it was unclear how meeting with transgender advocates but not with us was fair and equal treatment. We also did not see how such a policy could be reconciled with the following APA statement: "To ensure that those involved in the revision process represent diverse perspectives, disciplines, and areas of expertise, the Task Force and work groups represent a variety of clinical and scientific disciplines, patient and family groups..." We wonder how minor-attracted patients or their families had been represented in his workgroup.

We fully support the APA's stated positions as cited above, but see evidence that the paraphilias subworkgroup may be reluctant to adhere to them.

Recently, Allen Frances has written a letter to the APA board of Trustees, which is posted in the Psychiatric Times. In the comments there, Richard Green leaves serious critique of the Paraphilias Subworkgroup:

For the past 15 years I have been in Europe, having retired from a professorship at UCLA. My specialty has been gender and sexual behavior. The DSM5 is making a major error in the sections on paraphilias. Including paraphilias along with paraphilic disorders stigmatizes persons with no mental disorder. They only practice an atypical pattern of sexual behavior. The inclusion of hebephilia is especially inappropriate here in Europe. The age of sexual consent is 14 in many countries. The DSM 5 will pathologize those who prefer sex with 14 year olds. The old cry of psychiatry as an agent of social control returns. This must not happen, Richard Green MD, JD, FRCPsych

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It certainly will be interesting to see how things continue to develop.

Asexual Erasure

A reader recently drew my attention to an interesting article about bisexual erasure: The epistemic contract of bisexual erasure by Kenji Yoshino. Although it was published in Jan. 2000--before the birth of the asexual community--the author was clearly aware of asexuality and the issue of asexual erasure.

Though the article does not discuss the issue much, he has a fascinating note on the subject, which I will except from (it's a long end note.)

It is with some regret that I have decided not to attempt a systematic discussion of asexuals in this article, especially since asexuals are, if anything, more likely than bisexuals to be erased in sexuality discourse. To concede that there are two forms of desire--cross-sex and same-sex desire--is to recognize the analytic possibility of at least four kinds of persons.

Not only does he recognize the issue, but--even without there being an asexual community--he has considerable insight into the matter.

My regret is made keen by the convergences between bisexual and asexual erasure, most notably the refusal by both self-identified straights and self-identified gays to acknowledge either category. Thus asexuals, like bisexuals, are prone to being accused of duplicity or false consciousness, or, more specifically, of being closeted gays.

The decision to defer a discussion of asexuals for another day, however, is supported by the undertheorized divergences between bisexuality and asexuality, which suggest that the two topics deserve separate analysis. While both doubled and absent desire appear to threaten straights and gays, they do so in quite different ways. To take one crude cut at that difference, consider the disparate ways in which the time-honored conflation of sexuality and sin ramifies across bisexuality and asexuality. If this conflation leads some to view bisexuals as particularly culpable because of their "promiscuous" desire for both sexes...it leads some of the same people to view asexuals as particularly pure.

In the asexual community, there have been some attempting to take this view, yet the majority view has been to reject it. In fact, the tendency has been to emphasize the differences between asexuality and celibacy, a point often raised in most introductions to asexuality. For the historically interested, this matter was discussed early on on Haven for the Human Amoeba, and there was an intentional decision to de-emphasize the similarities between asexuality and celibacy. What I find fascinating about Yoshino's article is that he cites the very same issue reason for doing so as was cited in Haven for the Human Amoeba--yet it is one which I have rarely seen discussed in the asexual community since.

While such purity is often ascribed to celibacy...it is not obvious whether that ascription applies equally to the subset of celibates who are asexual. Celibacy may be pure because it constitutes a conquest of the baser desires of the body; if so, the celibate asexual's claim to purity is attenuated because his licentious desire is not overcome, but rather absent. And even if described as pure, the absence of desire may be viewed as a disquieting purity, insofar as our hedonic pleasure in others is viewed by some as a generative, fecundating, and humanizing force even (or perhaps especially) when sublimated....Thus, while bisexuality and asexuality may in some senses be viewed as simple opposites (oversexed v. undersexed), they share negative connotations. But these connotations, in turn, are differently negative.

The issue of asexual erasure is not something I have often seen discussed in the asexual community, there is one notable excption: there is a thread on asexual erasure. Other than this, the only mention of the term that I managed to find (via google) was its use as a tag once on an asexual blog.

For people interested in the incorporation of asexuality into larger academic debates, I would definitely recommend taking a look at Yoshino's article. (It's kind of long--about 50 pages with another 50 pages of notes--but it is interesting.)

Sex DSM-5--and the Apocalypse: A commentary

Earlier today, Daniel B. Block MD had an editorial published in the Psychiatric Times: Sex, DSM-5— and the Apocalypse: A Commentary, one of the few that I've seen recently dealing with HSDD.

I find his commentary interesting because there is a certain naivety and insight. From reading it, it seems that he has not read the proposed changes to this diagnosis and hasn't read up as much as he might on some of the debates surrounding these issues, yet his commentary also shows a very healthy dose of common sense and clinical insight. (And a healthy skepticism when a pharmaceutical representative tried to "inform" him about Female Hypoactive Sexual Desire Disorder.)

Commenting on the DSM-IV-TR criteria for HSDD, he writes:

From these criteria, “I’m not in the mood” (and not happy about not being in the mood) is a disorder. There really is no room for not being in the mood. How about if someone is not in the mood because her husband only pays attention to her when he wants sex and then when he does typically considers grabbing his wife’s breast and making a joke as foreplay? Or the man whose wife, girlfriend, or significant other only seems to want sex on her own terms and has had a chronic pattern of using sex in a manipulative fashion throughout their relationship? (I have had various patients complain of just these things.) Do I diagnose these patients with an illness—a disorder? Or are they simply unhappy and perhaps desiring of sex but with someone else or in a setting where their current relationships are on better ground? How about if someone is simply just too tired because he/she worked hard all week?

I remember fondly one of my favorite teachers in medical school and residency – Dr Jack Benson. He told the following story of a 90-year-old man who once presented to him for consultation because he was experiencing trouble maintaining an erection as well as getting one as often as he would have liked. (There was no sildenafil back then.) Dr Benson was making a teaching point that would echo the words of Sir William Osler: “Listen to the patient: He is telling you the diagnosis.” Or, he is telling you what the problem or issue is. It turned out that this healthy 90-year-old widower had 3 healthy girlfriends, all about 20 years younger than he and all demanding sex from him (no HSDD there!). He was simply too tired to keep up and had very little knowledge of human sexuality beyond the basics. Dr Benson helped to reframe his situation for him and the man went away relieved there was nothing wrong with him.

The currently proposed criteria for this diagnosis actually make relationship problems a specificier (meaning lack of interest in sex because one's partner is a jerk is a disorder if it causes distress or "impairment.") I understand that the goal is to help facilitate treatment in such cases, but, as Dr. Block points out, this really makes no sense.

(From my reading of the relevant reports of the Sexual Dysfunctions Workgroup, I detect a certain ambivalence regarding these issues.)

Unexpected directions

Since I found the asexual community about 2.5 years ago, it has taken my life in directions I would never ever have expected. My attempts to make sense of asexuality and subsequent interest in academic work on the matter has resulted in this blog, the Asexual Explorations website, and my work with AVEN doing outreach to the DSM-5 Sexual Dysfunction Subworkgroup.

The interests that I gained through that and through the background reading I did to get informed on the issues has caused me to take considerable interest in not only how HSDD turns out in DSM-5, but also what shape the Paraphilias take and issues of how our society approaches sexual violence and sex-offenders. In many ways, I now find myself more interested in the Paraphilias than in HSDD, and this has had a definite effect on what I've been blogging about.

It causes me to ask about the direction that my blog is taking. The aim of my blog is, as my subtitle says, "Thinking critically about asexuality," yet I now find myself sometimes talking more about other issues, and I'm wanting feedback from readers on the matter.

I've considered making a second blog about the Paraphilias issues, but I've already spent a lot of work developing this blog and getting a readership, and making a separate blog would result in these issues getting less visibility than they would otherwise. One of the main reason that I'm blogging about these things is because I think they are issues needing more visibility and awareness. I also want people (myself included) to think about these issues in light of asexuality and to think about what relationship asexuality has to things like the DSM diagnoses labeled "Paraphilias" and to issues of how our society approaches combating sexual violence.

On the other hand, my blog is primarily about asexuality and I this is--I assume--what readers are most interested in. I certainly still post about these things and try to keep people updated on the academic literature on the matter. And I expect that in the future, more of my posts will be more specifically focused on asexuality. So, I guess I'm just curious what readers think about the directions that my blog has been taking. Should I create a second blog? Should I try more to tie issues to asexuality? Or would that be pointless and annoying? Let me know what you think.

DSM5 Paraphilias subworkgroup advisor teams up with Focus on the Family

Each of the DSM Workgroups' members choose people to act as advisors. For the Paraphilia Subworkgroup, one of the people they have chosen to act as one of their advisors is William O'Donohue, who along with seven members of Focus on the Family and a few others sent a letter to David Kupfer, chair of the DSM-5 Task Force.

In a press release about it on Citizen Link, we find a signatory saying that

at issue is the watering down of some sexual disorders in an effort to normalize them.

“There are groups out there that are basically sexual-activist groups,” he said. ”They are trying to edit and change perceptions of certain sexual behaviors.”

That includes certain paraphilias, such as Sadism, Masochism and various fetishes.

If you look at the letter itself, they say

Changes to criteria for many of the paraphilias appear to further the states goals of sexual-activist groups that aim at social and legal acceptance for non-normative and disordered sexual behaviors. Namely, we refer to the working group's declaration that paraphilias are not "ipso facto" disorders and the suggested requirement that specified numbers of victims exist before diagnosis

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What they are referring to is the fact that that the Paraphilias Subworkgroup has proposed to require multiple victims before a diagnosis is made, as in the case of Exhibitionism

Exhibitionistic Disorder

A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the exposure of one’s genitals to an unsuspecting stranger.

B. The person is distressed or impaired by these attractions, or has sought sexual stimulation from exposing the genitals to three or more unsuspecting strangers on separate occasions. [2]

Background: The reason for this is, essentially, that being diagnosed with one of these can be harmful to the person thus diagnosed; consequently patients often have motivation not to be honest. As a result, some clinicians try guess which patients are acting out of a "paraphilia" or if this is just a one time kind of thing. (For instance, many people who sexually abuse children aren't sexually attracted to children, and many people who are sexually attracted to children never engage in sexual contact with children. The question, then, is how to identify if someone is sexually attracted to children if they deny such attractions. Specifying a number of victims is a way that is being proposed to do that. Another soultion to this problem that some clinicians use is simply to ignore the DSM diagnosis of pedophilia, and treat people convicted of child-molesting the same regardless of whether or not they're sexually attracted to children.

Now the claim that Paraphilias are not ipso facto disorders is a change without substance that the Paraphilias subworkgrouop is making that they're trying to pass off as being progressive. Basically, DSM-IV-TR says that if someone meets Criteria A and B, they have a Paraphilia, which is mental disorder. If they don't meet both, they don't. The Paraphilias subworkgroup is proposing that anyone who meets Criterion A has a paraphilia, and anyone who meets A and B has a Paraphilic Disorder, which is a mental disorder. Thus, anyone who has a Paraphilia, doesn't have a mental disorder! (Which is what the DSM already says...)

The authors of the above quoted letter are objecting to this because they don't want people to have to meet criterion B before saying they have a mental disorder--that is, they're objecting to the status quo, but are pretending to be objecting to this "new" proposal.

I find this--not to mention their comments about gender identity--rather disturbing, especially since this includes someone the Paraphilias Subworkgroup specifically chose as one of their advisors.

I'm also rather curious who these supposed "activist groups" are. A number of organizations representing people in the trans community have been lobbying to get "Transvestic Fetishism" removed, but other than that, I haven't seen any organizations lobbying the APA about the "paraphilias." And I have been looking enough that I'm pretty sure I'd know about them if they existed.