Thursday, July 22, 2010

LGBT rhetoric and responses: Part III

This past semester, a U of I adjunct religion professor sent an email to one of his classes arguing that utilitarian logic that would lead to the approval of gay sex would also lead to the approval of human/animal sex and adult/child sex, and then argued that any disconnection between sex and procreation was wrong. The email resulted in the head of the Religion Department telling him he would no longer be teaching at the university, which has created considerable conservative backlash. I have been using this as a springboard for discussion of anti-LGBT rhetoric and common responses.

In my first post, I examined his argument that utilitarian reasoning behind the acceptance the acceptance of same-sex sexuality would lead to the acceptance of sex between children and adults and between humans and animals. I argued that a) there is an important element of truth the his argument, and that b) standard LGBT responses (to get offended and be highly dismissive or such arguments) are unproductive for two reasons. First, to advance their own politics, they are far too accepting of irrational hatred of people attracted to children. Second, such responses communicate to persuadable but as yet unpersuaded people that there is no good response to such arguments. (In fact, such LGBT rhetoric made it a much slower process than it might have been for me to change my own beliefs on the matter.)

In my second post, I examined his positive arguments for his own position, and (I feel) generally demolished them. In this post, I wanted to give serious consideration to the argument that acceptance of gay sex leads to the acceptance of adult/child sex. I wanted to do this to help promote critical thinking in such discussions, and to help in the persuasion of the unpersuaded but persuadable. Much of this will be based on my own thinking as I as I tried to understand the matter when my religion was leading me one way and my conscience another.

Argument 1: In regarding the Divine as the basis of ethics, there is a serious question raised at least as early as Plato (in the Euthyphro): Is that which is good good because it is what God commands? Or does God command it because it is good? (For Plato, there was the additional issue of the possibility of the god disagreeing with each other, a problem that monotheism does not have.) If what is good is good because God commands it, if God says to love your neighbor, that would be good, but if God says to go commit genocide, that would be good. In such a view, it is as though God should be obeyed not because God is good, but because God will give you the ultimate smack down if you don't. In the other case (God commands it because it is good), then there must be some sort of absolute goodness that exists above God, in which case God is not God.

One attempt of monotheist theologians to address this problem has been something of a natural law approach--that which is good is good because it is in accord with how God made things (and God's character), and God commands it because it is consistent with that--God, having created us, knows what it best for us and commands us accordingly. In such a case, there should (generally) be some rational basis for knowing the Divine commands apart from scripture. (Something like this is the Natural Moral Law position discussed in my last post.) In such a case, to maintain a belief that sex is only okay within heterosexual marriage, some reason must be given why same-sex sexuality is wrong. In my previous post, I addressed one (rather unconvincing) attempt to answer this. For me, I felt it was necessary to have some reason other than "because." I felt that somehow it had to be shown that this rule protects people or prevents harm.

I have seen some attempt to make this argument. Sometimes they will argue that anal sex is unhealthy or whatever. (The "logic" here seems to be that unprotected anal sex with people whose STD status is unknown is risky, therefore anal sex is dangerous.) I've seen other attempts at arguing that there is an increased risk of harm with gay sex, therefore it is wrong. I've seen this bolstered by evidence that in many cases adult/child sex causes no harm, but surely that does not mean it is okay. Therefore, they argue, only a likelihood of harm is necessary. Then to argue that gay sex causes an increased likelihood of harm, they'll argue that gay men tend to have more sexual partners than straight men and that this is because of (inherent) sex differences between men and women. More sex-partners means greater likelihood of getting an STD, such people tend to be (nominally) big supporters of monogamy, etc. (Those making this argument seemed to ignore the fact that, even if valid, the argument would not lead to a prohibition of lesbian sex.)

I do think there is something important recognized by this logic. In order for some act to be morally wrong, it is not necessary that it cause harm in all instances. A good example is drunk driving. This does not always cause harm, but it has a high risk of (very severe) harm. This can be usefully contrasted with another dangerous behavior: driving. Numerous people are killed every year in automobile accidents, many of whom were not engaging in particularly risky behavior.

In contrasting driving with drunk driving, an important point can be seen. In the case of the former, there are plenty of risks associated with it, but there are numerous means that can be taken to reduce those risks--requirements for drivers licenses, requiring a certain level of vision, traffic signals, police monitoring, prohibiting particularly risky behaviors such as driving under the influence, etc. In the case of drunk driving, however, there do not seem to be any good ways to allow non-harmful instances (ones where no one ends up getting hurt) and prohibiting the others. As such, the behavior should be completely prohibited.

Applying this logic to sexuality, I think the point is clear as to why the attempted argument against gay sex simply does not work. Both gay sex and straight sex can be practiced in highly risky ways (often called high risk sexual behavior.) The gender of the partner is of little relevance to the basic means of avoiding high-risk behavior and practicing safer sex.

Now apply the same reasoning to adult/child sex. There is plenty of evidence (a link for those wanting references) that adult/child sex is not always harmful; sometimes the child feels both at the time and in retrospect that it was a positive experience; sometimes it is the child who initiates it. However, children are a vulnerable population and therefore particularly vulnerable to sexual exploitation. Childhood sexual abuse is a very real problem and there is a very real need to protect children. A key consideration for the moral question is whether adult/child sex is more like driving or drunk driving. I will let readers attempt to answer that question for themselves.

Argument 2: In addressing the likelihood of harm question, there is another direction that it needs to be asked from. All prohibitions cause harm, and there is the question of whether the good brought about by the prohibition outweighs this harm. (A prohibition against murder, for instance, brings about harm to those convicted of murder. This is generally considered acceptable because it is much better than just allowing anybody to go around killing anybody they wanted and getting away with it.) With same sex sexuality, it is clear that quite a lot of harm to people is done by such prohibitions (as even the slightest understanding of the experience of gay men and lesbians makes clear. It harms bisexuals as well, and it harms trans people given that many acts of violence against trans people are committed on the basis of believing them to be gay, rather than trans, blurring the boundary between homophobia and transphobia.)

While much harm comes from such prohibitions, I really can't think of any good that comes from them. Note that this line of logic is a kind of utilitarian ethic, but it is one that looks at a level above individual acts, considering larger social consequences. Applying this line of reasoning to consensual adult/child sex, I think it is clear that the situation is quite a bit more complicated than it is for sex between consenting adults.

Argument 3: My third argument is one I will not develop, but it long troubled me when I still believed that sex is only okay in heterosexual marriage. I think that if I had seen/heard someone else make it, it would have troubled me (in a good way) even more. Can "hate the sin; love the sinner" possibly be the basis for a sufficiently strong opposition to homophobic violence? A similar question applies to transphobic violence. By getting conservatives worked up about how this is such an important moral issue, how our morals are being degraded by acceptance of "the gay lifestyle", and all that jazz, is this going to help convince people how serious and how wrong homophobic violence is? Is it going to get them motivated to seriously combat it? I am skeptical.

Sunday, July 18, 2010

More thoughts on LGBT rhetoric

I recently addressed some topics in LGBT rhetoric (and anti-LGBT rhetoric), using an email by former adjunct professor of religion at University of Illinois Dr. Ken Howell as a springboard. (He was dismissed because of it.) I did this for a few reasons. First, I wanted to challenge some LGBT responses to conservative arguments on the grounds that it a) is too accepting of the stigmatization of groups even more hated than LGBT people, and b) it is too dismissive of conservative arguments, with the result that convincable moderates may be left unconvinced. As such, I want people to take conservative arguments seriously--seriously enough to be able to give reasoned responses that display genuine engagement with those arguments.

There I addressed his argument against (popular versions of)utilitarian sexual ethics in which he attempt to use a reductio ad absurdam to show that acceptance of homosexuality requires the acceptance of sex between humans and animals and sex between children and adults. At that point in his argument, he feels that he has successfully refuted utilitariamism. He then makes a positive argument for his own position: sexual ethics should be based on Natural Moral Theory, which basically says that sexual acts have inherent meaning, and that rightness and wrongness should be based on this inherent meaning:
Natural Moral Theory says that if we are to have healthy sexual lives, we must return to a connection between procreation and sex. Why? Because that is what is REAL. It is based on human sexual anatomy and physiology. Human sexuality is inherently unitive and procreative. If we encourage sexual relations that violate this basic meaning, we will end up denying something essential about our humanity, about our feminine and masculine nature.

In further discussion, he applies this same reasoning to trans-issues and also tries to make a connection between it and contraception:
A survey of the last few centuries reveals that we have gradually been separating our sexual natures (reality) from our moral decisions. Thus, people tend to think that we can use our bodies sexually in whatever ways we choose without regard to their actual structure and meaning. This is also what lies behind the idea of sex change operations. We can manipulate our bodies to be whatever we want them to be.

If what I just said is true, then this disassociation of morality and sexual reality did not begin with homosexuality. It began long ago. But it took a huge leap forward in the wide spread use of artificial contraceptives. What this use allowed was for people to disassociate procreation and children from sexual activity. So, for people who have grown up only in a time when there is no inherent connection between procreation and sex –- notice not natural but manipulated by humans –- it follows "logically" that sex can mean anything we want it to mean.

Now, the conservative background I came from was Evangelical, and the Evangelicals differ from the Catholics regarding contraception. The standard Evangelical opinion seems to be that using sex (in heterosexual marriage) for the purposes of pleasure and increasing emotional intimacy are also legitimate. This in itself is interesting: it suggest that accepting non-procreative sex does not necessarily lead to acceptance of homosexuality, contrary to Dr. Howell's argument. The difference between Evangelical and Catholic arguments is essential to understand to have meaningful discussions of the matter. Far too often, queer rhetoric makes claims about how "society" values above all else heterosexual, procreative sex in the missionary position. This is simply not true of "society" nor is it true of most Evangelicals. No, it is merely a straw man that makes for nice rhetoric to embolden your supporter in opposing your opponents, but at the same time it alienated your opponents as well as moderates sympathetic to them.

I find the argument based on REALITY quite interesting. While Sexual Reality and How We Dismiss it makes some very interesting points (worth looking at but that I won't be discussing here), I will bring up a few points worth considering. First, the "naturalness" arguments based on "compatibility" of male and female anatomy (which seems to underlie his argument) actually seems to ignore female anatomy and physiology. What exactly are female orgasms for? How about clitorises? Because of the connection of male orgasms to ejaculation, the importance of male orgasms for procreation is clear enough, but what about female orgasms? What's their point? If you want to say that sex is "for" pleasure, you can find a purpose for them, but if sex is "for" procreation, it's much more difficult. Likewise, what are clitorises for? Many females do not orgasm from vaginal stimulation only, but also require clitoral stimulation. How does this part of REALITY fit with "complementary=natural" arguments? Probably not very well. It would be interesting to see how he would deal with intersex people as well. Are they required to be celibate?

Furthermore, the argument that this view of sexuality is based on REALITY makes a fundamental is/ought error. It is though to say that one function of sex is procreation (quite true), therefore that is THE purpose. Yet, if you look at actual sex in the real world, it is clear that sex is used for quite a lot of things: procreation, intimacy, feeling feminine, proving one's virility, asserting dominance, humiliating others, enhancing one's social status, revenge, pleasure, release of sexual tension, exploring one's sexuality, making money... The list goes on. How we you get from "this is what sex is used for" to "this is what sex is for"? It seem to me that the way is via an entirely an after-the-fact justification.

His argument has still more problems: even if we accept that sex if for procreation, why does it follow that this is its only legitimate use? If you believe that "books are for reading" does it then follow that it immoral to use a book as a paperweight? Or that it is immoral to use a box of old journals as a doorstop? (If it is, then I'm guilty of that one!)

Towards the end of his article, he then makes an argument that is rather popular in Catholic Natural Law philosophy:
As a final note, a perceptive reader will have noticed that none of what I have said here or in class depends upon religion. Catholics don't arrive at their moral conclusions based on their religion. They do so based on a thorough understanding of natural reality.

The idea is that their position is one that people should be able to arrive at completely independently of Catholic doctrine, though I am inclined to wonder, if this is the case, why have so few arrived at such a conclusion. Still, it highlights an important (and disturbing) observation I made about argumentation several years ago. Most of the arguments for positions that we think of (and that we think are convincing) are arguments developed after the fact to justify a position that we already hold (for entirely different reasons)--arguments that never persuaded us of anything. And yet we tend to think that they should be persuasive to others.

I still have more to say on this subject, especially regarding the arguments/reasons/positions that eventually led me to change my own views on these matters.

Friday, July 16, 2010

Thoughts on LBGT politics

At the University of Illinois-Champaign Urbana (where I am a student), there has recently been something of a stir regarding the firing of a member of the religion faculty for opinions about homosexuality expressed in an email he sent to his Modern Catholic Thought class.

I wanted to use this opportunity to address something in LGBT rhetoric that has long bothered me. I grew up Evangelical and, while my views have changed considerably, it was a long process, and there was a long time in which I felt my religious views taking me in one direction regarding homosexuality and my conscience taking me in another, and I was trying hard to figure out what to think. One of the major things that made it take so long was standard LGBT arguments--I wanted to be convinced by them, but there were serious objections and questions I had that simply weren't addressed. In retrospect, there were arguments that I think could have convinced me (as my views eventually did change), and I wanted to blog about this both to increase LGBT people and their allies's understanding of more conservative views and to help them to be more persuasive in their arguments.

A Facebook group challenging his dismissal posts the email that prompted this situation. His argument isn't especially novel, but I want to summarize it for the purpose of analysis. I encourage readers to take his argument seriously, rather than quickly dismissing it or being offended by it.

The email was, purportedly, about ethical theory and utilitarianism, and he decided to use homosexuality to "illustrate" his position:
Before looking at the issue of criteria, however, we have to remind ourselves of the ever-present tendency in all of us to judge morality by emotion....Empathy is a noble human quality but right or wrong does not depend on who is doing the action or on how I feel about those people, just as judging an action wrong should not depend on disliking someone.

So, then, by what criterion should we judge whether sexual acts are right or wrong? This is where utilitarianism comes in. Utilitarianism in the popular sense is fundamentally a moral theory that judges right or wrong by its practical outcomes. It is somewhat akin to a cost/benefit analysis....I think it's fair to say that many, maybe most Americans employ some type of utilitarianism in their moral decision making...

One of the most common applications of utilitarianism to sexual morality is the criterion of mutual consent. It is said that any sexual act is okay if the two or more people involved agree. Now no one can (or should) deny that for a sexual act to be moral there must be consent. Certainly, this is one reason why rape is morally wrong. But the question is whether this is enough.

In standard anti-gay fashion, he then brings up two rather popular analogies:
If two men consent to engage in sexual acts, according to utilitarianism, such an act would be morally okay. But notice too that if a ten year old agrees to a sexual act with a 40 year old, such an act would also be moral if even it is illegal under the current law. Notice too that our concern is with morality, not law. So by the consent criterion, we would have to admit certain cases as moral which we presently would not approve of. The case of the 10 and 40 year olds might be excluded by adding a modification like "informed consent." Then as long as both parties agree with sufficient knowledge, the act would be morally okay. A little reflection would show, I think, that "informed consent" might be more difficult to apply in practice than in theory. But another problem would be where to draw the line between moral and immoral acts using only informed consent. For example, if a dog consents to engage in a sexual act with its human master, such an act would also be moral according to the consent criterion. If this impresses you as far-fetched, the point is not whether it might occur but by what criterion we could say that it is wrong. I don't think that it would be wrong according to the consent criterion.

The part where he argues for his own position will be reserved for a later post.

I am going to suspect that few readers of my blog are especially convinced by his argument. In my critique, I do not want to simply tell people who already agree with me how incredibly wrong he is. Rather, I want to give a critique that takes seriously his arguments, finding what genuine insights they have, and on that basis make arguments that may help to allow for more meaningful dialogue rather than simply angry shouting--and, I hope, making more LGBT allies.

A very common response in LGBT politics is to quickly condemn anyone who makes a parallel between homosexuality on the one hand, and adult-child sex or human-nonhuman sex on the other. I don't think this is helpful because, quite frankly, there is an important truth that this argument recognizes. Accepting gay sex as morally okay requires giving up "Because it's a rule, dammit!" and "Ewww!!!!!" as the basis for sexual ethics. I also suspect that there is a universal cross-culturally tendency for some conservatively minded people to have a deep fear that abandoning certain current norms and rules will inevitably lead to an anything-goes antinomianism. This fear seems to be connected to the many anti-gay slipper slopes that are used.

By bringing up adult-child sex and bestiality, there is a profound irony given the professor's initial statement that we shouldn't "judge morality by emotion." The only reason that these reductio ad absurdam arguments might work is if people strongly feel that of course those things are wrong. I think it's safe to say that these views were not the result of long and careful thinking, but a strong emotional attachment to the societal norms they grew up with (many societies have rather different views on both of these). Pedophilia is an incredibly emotion-laden issue in our society around which rational discourse is genuinely difficult. There was a paper published in a highly respected journal in the late 1990's (Rind et al. controvercy) that did a meta-analysis of previous studies and found that in many cases, adult-child sex is not harmful, that it is more likely to be perceived as positive or neutral if the child consented (in the sense of feeling they were a willing participant), and if the child was male. At first, there wasn't much of a response to it, but then someone on the radio talked about it, and then Dr. Laura got a hold of it, and eventually congress passed a resolution condemning the study. If empirical results that don't fit the received wisdom in this area can get condemned by congress, it doesn't exactly encourage people to do research in this area. Yet in the absence of good research and good data, it is impossible to create informed public-policy.

People do not choose to be attracted to children, and this group of people is one of the most hated groups in American society (and likely other societies too.) "Pedophiles" (a very loosely used term to lump together anyone who is attracted to children and anyone who has engaged in sex with a child [except as a peer of the child]) are an utterly abhorred group of people. They grow up being told that they are monsters, that there is no hope for them, and that they to destroy the lives of numerous children. The organization B4U-ACT, a Maryland non-profit organization aiming to promote mutual understanding between "minor-attracted people" and mental health professionals, has a powerful sideshow that I would strongly encourage all readers to take a look at it. The current situation in the US towards sex-offenders is based on intense hatred and irrational prejudice, often ignoring basic questions necessary for good public policy like "Would this work? What side-effects might it have? Is it an effective use of public resources? Are there other more cost-effective ways to achieve the same goals?" Furthermore, because of SVP commitment and sex-offender registration laws, our current position is that the Constitution simply does not apply to sex-offenders. These have only been upheld by the courts on the fiction that they are not punishment. I think the irony, then, of bringing up sex between children and adults--while encouraging basing opinions on "reason" rather than "emotion"--is rather hypocritical. In modern American society, questioning the received wisdom on the matter is utter heresy, as is even suggesting that the reality of the situation may be more complicated than people want to admit. (And neither of these requires approval of sex between children and adults.)

The typical LGBT response, to get offended by the comparison of homosexuality and pedophilia, is harmful in two ways. First, it accepts and contributes to the stigmatization of a much more hated group. Second, it's not convincing to "moderates"--people conflicted on the subject of homosexuality who could be convinced but aren't. By responding to an argument by getting offended (and in this case getting a professor fired), it communicates that there is no good answer to the argument, that the only way to address it is by attacking a straw man, or attacking the most scary anti-gay people out there, as though everyone with traditional views of sexual ethics was just like Fred Phelps.

A major part of much anti-gay rhetoric is to make a big distinction between desire and behavior. Having gay feelings isn't wrong, they say, only acting on gay feelings is. Much of the pro-gay rhetoric tends to collapse these, making it necessary to accept the latter to accept the former. (Interestingly, while pro-gay rhetoric tends to minimize the difference between attraction and behavior, pro-asexual rhetoric emphasizes this difference in our attempt to distance ourselves from celibacy.)

Going back to the issue of pedophilia, many who argue for treating people attracted to children as human beings certainly do not think that doing so will necessitate approving adult-child sex. (Interestingly, some of the most virulent anti-pedophile websites actually do seem to accept this. For instance, the blog absolute zero opposes B4U-ACT claiming that their "real goal" is to make adult-child sex legal. Absolute Zero's logic--if you can call it that--only works on the assumption that not demonizing people attracted to children will necessarily lead to the acceptance of adult-child sex. If this premise is rejected, there is no reason whatsoever to oppose the work of B4U-ACT.)

If the logic "accepting the person requires accept the desired behavior" is not accepted for pedophilia, it does not apply straightforwardly to homosexuality either. Some reason must be given why the logic works in one case but not the other. (Which is not to say that such logic is impossible to give.)

I have a lot more to say on this subject, but hopefully this post will give some food for thought. I imagine that it should prove to be controversial.

Special theme issue of Psychology and Sexuality about asexulaity: Call for Papers

There is going to be an upcoming issue of the new Journal Psychology and Sexuality about asexuality. The call for papers has just been released. For anyone interested in writing something, contact information is given below.

I Do Not Miss What I Do Not Want: Asexual Identities, Asexual Lives
Special theme issue of Psychology and Sexuality

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 empirical and theoretical questions which have heretofore gone largely unaddressed. This special issue of Psychology & Sexuality invites papers which contribute to the academic and social understanding of asexuality.

We welcome papers from the discipline of psychology and allied disciplines. We also welcome papers from outside the discipline that speak to the field of psychology. Interdisciplinary and multidisciplinary work is most welcome.

Possible topics include though are not limited to:

- Asexual identities
- Asexuality and assumed pathology
- Asexuality and sexual normativity
- Asexuality and love
- Asexual relationships
- Asexuality and the LGBT community
- The universality and/or particularity of sexual desire
- Marginalization of asexuality
- Asexuality and the internet
- Social and political goals of the asexual community

This issue will represent a significant contribution to our understanding of asexuality by bringing together a range of papers on the topic for the first time. It will also provide an opportunity both to map the current state of research on asexuality and to provide a direction for future scholarship and inquiry.

For information about the journal Psychology & Sexuality visit:

If you have questions, please conduct one of the guest editors for the issue:
Mark Carrigan -
Kristina Gupta -
Todd G. Morrison -

Submission Due Date: Feb 2011
Full length papers (6000 words) and shorter articles (1000-2000 words)

Thursday, July 15, 2010

More on sexual dsyfunctions and DSM-5

As I've reported before, the DSM-5 Sexual Dysfunctions Subworkgroup's literature reviews have been published online. They divided them up into male and female disorders with the ones for females published in Archives of Sexual Behavior and the ones for males published in the Journal of Sexual Medicine. All are available for free here except for the one on HSDD in males.

For the male sexual dysfunctions, commentary was published with the original article, except for the one of HSDD, and for the female ones, a number of commentaries were recently published in the Journal of Sexual medicine: Responses to the Proposed DSM-V Changes. Recently, the DSM-5 Sexual Dysfunctions Subworkgroup has published overall responses to the commentary: Response of the DSM-V Sexual Dysfunctions Subworkgroup to Commentaries Published in JSM.

Of the changes, the ones most relevant to the asexual community are those regarding HSDD. The current proposal is to change this diagnosis to Sexual Interest/Arousal Disorder and make separate diagnoses for men and for women. (No indication is given regarding individuals who do not fit neatly into a gender binary.) As of now, there is no published commentary on the proposed male SIAD, but there is some commentary on the proposal for female SIAD.

Here are a number of points/arguments that were made:
The current proposal is to merge HSDD and Sexual Arousal Disorder (in women) into SIAD. Some authors opposed this. Others supported it. One commentary argued that the proposal be taken even further and that desire, arousal, and orgasmic disorders be lumped into a single diagnosis.

One commentary argued that one of the currently proposed criteria should be made necessary for diagnosis: "(5) Desire is not triggered by any sexual/erotic stimulus (e.g., written, verbal, visual, etc.)" One reason they wanted to add this was because of the possibility that lack of arousal could be because of relationship problems, poor partner technique or the like.

Some commentaries raised the question of whether it makes sense to base a diagnosis on distress, and at least one

In response to these, the Sexual Dysfunction Subworkgroup has argued

-They still think that merging HSDD and Sexual Arousal Disorder is a good idea, but also merging Female Orgasmic Disorder is not such a good idea.

-Whether (5) (quoted above) should be required for a diagnosis will be a matter that will be considered and data from the field trials will be relevant in answering it.

-They are planning on adding the phrase "consideration should be given to context" in the diagnostic criteria for both SIAD and Female Orgasmic Disorder.

For those who are interested, I would definitely recommend reading the full articles, which you may be able to downloaded from the above links, or they can be obtained from the authors.

No mention of asexuality was made in any of the commentaries or the response to them.

Tuesday, July 6, 2010

Flibanserin rejected and HSDD questioned

As many readers likely already know, the FDA did not approve Flibanserin.
The efficacy was not sufficiently robust to justify the risks," said Dr. Julia Johnson, the panel's chairwoman and head of obstetrics and gynecology at the University of Massachusetts Medical School. (link)

In a recent editorial in the Psychiatric Times, Ronald Pies, the editor of that publication uses this opportunity to raise a fundamental question: FDA Lacks Desire for Flibanserin—But Does Hypoactive Sexual Desire Disorder Even Exist?
He gives a much-deserved rebuttal to an argument for regarding this as a disorder and why we should be so concerned about it
Dr Sue Goldstein, who oversees clinical trials at the San Diego Sexual Medicine Center, writes that:

“We are the forgotten gender,” she said. “We’ve been told to accept this dysfunction. Do we accept cancer or heart disease?” she said. “Do we or do we not have the right to choose whether we want treatment?”

Comparing reduced sexual desire to heart disease or cancer seems quite a stretch to me.

Then citing a different expert saying that a sexual problem is only a disorder if it causes the person distress, he comments:
what if the woman’s “distress” is related solely or primarily to the expectations of her sexual partner, as in the case of Mrs M? If Mrs M were suddenly marooned on a desert island, without her demanding husband (now there’s a fantasy!), would she experience any sexually-related “distress”? I have argued in several contexts that true disease generally ought to meet 2 criteria: the presence of intrinsic suffering and substantial incapacity. I have used the “desert island test” to distinguish between conditions, such as major depression and schizophrenia; and, for example, antisocial personality disorder (APD).

The first 2 usually meet the desert island test, whereas the third (APD) usually does not (although there are undoubtedly exceptions). For example, the person with severe, melancholic major depressive disorder is likely to experience both intrinsic suffering and incapacity, even on a desert island—despite the absence of interpersonal contact and responsibilities. He or she is still likely to feel guilty, worthless, suicidal, and have difficulty concentrating (for example, on building a raft), difficulty eating, sleeping, etc. All other things being equal, the stranded person with APD is likely to feel just fine, thanks--except perhaps for missing those exhilarating Ponzi schemes. (I acknowledge that these hypotheses require confirmation through actual research, which I suspect would not pass muster with most institutional review boards). By these lights, APD is not usually an instantiation of disease (dis-ease), though I am aware that some “sociopaths” are subjectively distressed and certainly provoke distress in others.

He fully supports providing help for people distressed about sexual problems--clinicians often provide help for people without any disorder, and the DSM has a section in the back called V-Codes which is for conditions that are not disorders but may be the object of clinical attention. (A number of relationship problems are involved.)

His argument raises a fundamental question about what is a disorder. Generally, people feel that it must involve something having gone wrong in the individual (this is necessary to exclude "normal pain") and that the condition causes distress or disability. With distress, there is the fact that all sorts of things can cause distress. (People can be distressed about being too tall or too short, having a nose that is too big or too large, about wanting to be an artist while their parents want them to be a lawyer, etc.) Many feel that something must be inherently distressing for the distress requirement to count. (Migraines and panic attacks, for instance, are generally considered to be inherently distressing.)

What is interesting is that he never even considers the possibility that HSDD could be a disorder because it is inherently impairing. Why this is interesting is that such (rather far fetched) logic was the justification for first including it in the DSM in the first place--it was an impairment in ability to experience the "normative" full human sexual response cycle that was then in vogue. If we reject that lack of interest in sex is a disability and that only inherent distress counts, there is no logical basis for including HSDD in the DSM.

Saturday, July 3, 2010

Further explorations of the landscape of the paraphilias and DSM-5

A few weeks ago, I wrote about some of the background relevant to understand the current controvercies regarding this part of the DSM. In this post, I want to continue on that focusing specifically on events beginning in May 2008 when the American Psychiatric Association (APA) announced the membership of the various workgroups (although some additinoal people were added later. (See here for short biographies of the members of the Sexual and Gender Identity Disorders Workgroup.) The Sexual and Gender Identity Disorders Workgroup is divided into three subworkgroups: The Gender Identity Disorder Subworkgroup, the Paraphilias Subworkgroup, and the Sexual Dysfunctions Subworkgroup.

There was substantial negative reaction on the part of the trans community to the committee's membership, especially regarding the appointment of Kenneth Zucker as the chair of that committee and Ray Blanchard as the chair of the Paraphilias subworkgroup, as they are not necessarily the most popular psychologists among some in the trans community. (See this article as an example of an article unhappy about this appointment.) There was even a petition urging the APA to remove them. The petition was later modified to urge the removal of Martin Kafka (who is currently on the Paraphilias Subworkgroup) on the grounds that he has supported pharmacological treatment for cross dressing. The petition got over 9500 signatures.

The next major controversy regarding the Paraphilias Subworkgroup occured in response to the article Pedophilia, Hebephilia, and the DSM-V by Ray Blanchard, Amy Lykins, Diane Wherrett, Michael Kuban, James Cantor, Thomas Blak, Robert Dickey, and Philip Klassen. The abstract states:
The term pedophilia denotes the erotic preference for prepubescent children. The term hebephilia has been proposed to denote the erotic preference for pubescent children (roughly, ages 11 or 12–14), but it has not become widely used. The present study sought to validate the concept of hebephilia by examining the agreement between self-reported sexual interests and objectively recorded penile responses in the laboratory....[The] results indicated that hebephilia exists as a discriminable erotic age-preference. The authors recommend various ways in which the DSM might be altered to accommodate the present findings. One possibility would be to replace the diagnosis of Pedophilia with Pedohebephilia and allow the clinician to specify one of three subtypes: Sexually Attracted to Children Younger than 11 (Pedophilic Type), Sexually Attracted to Children Age 11–14 (Hebephilic Type), or Sexually Attracted to Both (Pedohebephilic Type). We further recommend that the DSM-V encourage users to record the typical age of children who most attract the patient sexually as well as the gender of children who most attract the patient sexually.

There were seven letters to the editor published in Archives of Sexual Behavior in response to this article, which, along with the original article and a response by Blanchard to the seven letters to the editor, were published in the June 2009 issue of that journal. In general, the responses pointed out that the argument "It exists; therefore it is a mental disorder" is missing some crucial steps in the middle. They also pointed out methodological problems with the study (because when you don't like someone's politics, you attack their methodology; that's just how stuff works in scientific areas with potentially significant political consequences.) For those interested in this, the forensic psychologist Karen Franklin has a page on her website about Hebephilia and the DSM-5 Controversy that has a bibliography including some more recent articles on the subject.

There's plenty more to write about regarding controversies surrounding DSM-5, and I'll definitely have more to say about the matter.