Tuesday, June 8, 2010

Exploring the landscape of DSM-5 and the Paraphilias: Background

There has long been a certain amount of discontent with this group of diagnoses--most therapists simply ignore them, they're mostly used by groups who focus on the treatment of sex offenders, and many involved in the treatment of sex offenders ignore these diagnoses finding them useless.

In 2003, there was an issue of Archives of Sexual Behavior on the issue of pedophilia. There was an article by Richard Green arguing that it makes no sense to regard pedophilia as a mental disorder and paper on ethical issues; these were followed by a number of peer commentaries. Green's article can also be found here.

Also in 2003, the American Psychiatric Association had a symposium about the Sexual and Gender Diagnoses of the DSM, the papers from which resulted in this book which is a reprint of these articles appearing in Journal of Psychology and Human Sexuality.

In the introduction to that issue, the authors make a telling statement:
Toward that end, this volume was originally conceptualized as dialogic, with contributors from psychiatry and other mental health disciplines both criticizing and defending the existing DSM diagnoses. However, things did not work out as originally planned. Critics of the DSM abounded, but its defenders were more difficult to enlist. Furthermore, all of the criticism came from non-psychiatric contributors. Non-psychiatric criticism of the DSM is not in itself problematic; the DSM was always intended to represent the up-to-date collective wisdom of all mental health professionals. Consequently, mental health experts who are not psychiatrists have routinely participated in developing earlier editions of the DSM.

However, none of the non-psychiatric contributors who participated in developing the DSM-IV (and who might ostensibly be willing to defend the diagnostic criteria of sexual and gender identity disorders) were willing or able to contribute to this volume. We were, however,fortunate to have two eminent psychiatrists, Paul Fink, MD, and Robert L. Spitzer, MD, provide some brief commentaries on the papers dealing
with Gender Identity Disorder (GID),

One paper, DSM-IV-TR and the Paraphilias: An Argument for Removal, by Charles Moser and Peggy Kleinplatz, as the title suggests, argued that the paraphilias should be removed from the DSM. (A another version is also available.)

The paraphilias are something of an odd collection of sexual interest in activities that are illegal and ones that are legal and essentially harmless. However, arguing for the removal of the paraphilias entail arguing for the removal of pedophilia--an extremely hot button issue. Because of this, they made a rather explicit statement about the matter:
We wish to clarify that our suggestion to remove the paraphilias, which includes pedophilia, from the DSM does not mean that sexual acts with children are not crimes. We would argue that the removal of pedophilia from the DSM would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes. Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred. Any interpretation of our work as supporting adult-child sexual interactions is misguided and wrong.

Nevertheless, highly selectively chosen parts of their presentation were leaked to the media and to organiations like NARTH. Fear-mongering and outright deception resulted in alarm that the APA might "normalize" pedophilia. In response to this, APA issues a press-release regarding pedophilia. It opens:
Pedophilia, included in the American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders (DSM) since 1968, continues to be classified as a mental disorder. The DSM is the standard classification of mental disorders used by mental health professionals and provides clear, objective descriptions of mental illnesses, based upon scientific research. Pedophilia is categorized in the DSM-IV-TR as one of several paraphilic mental disorders. The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that generally involve nonhuman subjects, children, or other nonconsenting adults, or the suffering or humiliation of oneself or one’s partner.

Notably absent from this is the fact that a) it's widely recognized that disorder is a value-laden concept and is not entirely scientific, and b) the scientific foundation for this group of diagnoses is much weaker than for many in the DSM. The press release included a statement from Darrel Regier saying:
“there are no plans or processes set up that would lead to the removal of the Paraphilias from their consideration as legitimate mental disorders.

In fact, in the 2003 symposium, Robert Spitzer, who has a tendency to speak candidly at times, suggested what may be the biggest reason for keeping the paraphilias in the DSM:
What are the consequences if we go the route that Drs. Moser and Kleinplatz suggest and remove the paraphilias from the DSM? First of all, it is not going to happen because it would be a public relations disaster for psychiatry. There was already a little disaster when the initial DSM-IV put in the “clinical significance” criterion that had the effect of requiring distress or impairment before pedophilia could be diagnosed. The APA wisely corrected that in DSM-IV-TR.
(He is referring to the fact that DSM-IV said that pedophilia was only a mental disorder if the person was distressed or impaired because of it. DSM-IV-TR changed that to add that it is also a disorder if the person "has acted on it.")

Moser and Kleinplatz's response was rather bluntly titled: Politics versus Science: An Addendum and Response to Drs. Spitzer and Fink

1 comment:

SlightlyMetaphysical said...

"The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that generally involve ...... the suffering or humiliation of oneself or one’s partner."

Well, that's not even TRYING to look like you're not calling people into BDSM sick and wrong.