Monday, February 22, 2010

Reports of the Sexual and Gender Identity Disorders Workgroup

I have just recently discovered that the (published) reports of the Sexual and Gender Identity Disorders Workgroup for DSM-V are posted online on dsm5.org here. For readers who have do not have online access to the journals these are in (i.e. through a university library), this should now make these article accessible if you are interested.

I've provided links to the ones that I think readers may be most interested in, which includes the introduction to the series, the reports of female HSDD, Sexual Aversion Disorder, and Female Sexual Arousal Disorder (which they have proposed to merge with HSDD.)

Also, Jack Drecher's paper on "Gender Identity Disorder" was, I thought, especially interesting from a historical perspective.

Zucker KJ. Reports from the DSM-5 Work Group on Sexual and Gender Identity Disorders. Archives of Sexual Behavior, 2009; in press

Brotto LA. The DSM Diagnostic Criteria for Sexual Aversion Disorder. Archives of Sexual Behavior, 2009; in press.

Brotto LA. The DSM Diagnostic Criteria for Hypoactive Sexual Desire Disorder in Women. Archives of Sexual Behavior, 2009; epub ahead of print.

Drescher J. Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior, 2009; epub ahead of print.

Graham CA. The DSM Diagnostic Criteria for Female Sexual Arousal Disorder. Archives of Sexual Behavior, 2009; in press.

On the dsm5 website, there are only two reports from this workgroup that are not presently available. For report for Sexual Masochism is not there as it has not yet been published online, but I am told it should be available any day now.

The report on male HSDD is also unavailable. The DSM5 website does not cite it, and rumor has it that this is because the article has not yet been completed.

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.

Sunday, February 21, 2010

Asexuality and the "paraphilias"

Of the proposed changes to the DSM that are now up on dsm5.org, perhaps one of worst is the inclusion of Paraphilic Coercive Disorder. (See this editorial by Allen Frances--biggest bigshot of DSM-IV for info on other problematic suggestions.)

I've written about Paraphilic Coercive Disorder (PCD) before, and readers may wonder what this has to do with asexuality. By delving into some of the history, I think it has quite a bit more to do with asexuality than you might first guess. In this post, I argue that there is a strong historical and ideological connection between the pathologization of asexuality and of the "paraphilias." In my next post in this series, I'll give some of the historical background for making sense of what including PCD in DSM-V would mean and why it is problematic for civil liberties and for effectively working to reduce sexual violence.

First, what are paraphilias? DSM-IV-TR (published in 2000) gives the following definition:
The essential features of a Parapihlia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months. (p. 566)

Included in this category are Fetishism, Sexual Masochism, Sexual Sadism, Pedophilia, Exhibitionism (exposing one's genitals to strangers), Frotteurism (rubbing ones genitals on strangers), and Transvestic Fetishism (no one actually knows, but it has something to do with men cross-dressing).

In DSM-I, the category was called "Sexual Deviation." In DSM-II, the name was changed to "Sexual Deviations." When homosexuality was (sort of) declared not to be a mental disorder in 1973, it had been listed in the "Sexual Deviations." Now, the logic of that decision made very problematic keeping any of the other "Sexual Deviations" in the DSM. (e.g. The Implications of Removing Homosexuality from the DSM as a Mental Disorder by Charles Silverstein.) It also made problematic having the "Sexual Dysufnctions" in there as well. (New York Times, Dec. 23, 1973, p.101). Yet, the development of sex therapy in the 70's caused the DSM-II's classification of sexual dysfunction--it just had two (frigidity and impotence)--to be considerably expanded in DSM-III (published in 1980). According to Spitzer, Williams and Skodol the sexual dysfunctions and the "sexual deviations" (renamed "paraphilias) had the same justification for being included in DSM-III in light of the DSM-III’s definition of mental disorder:
The concepts contained in this definition were helpful in deciding that it was not necessary to require distress before a psychosexual dysfunction, such as Inhibited Sexual Excitement (frigidity, impotence), would be diagnosed. Similarly, it was helpful in deciding that the diagnosis of such Paraphilias (Sexual Deviations in DSM-II) as Fetishism and Exhibitionism also need not require distress. The task force concluded that inability to experience the normative sexual response cycle (as in frigidity or impotence) represented a disability in the important area of sexual functioning, whether or not the individual was distressed by the symptom. The same logic applied to the requirement or preference for inanimate objects (as in Fetishism) or bizarre acts (as in Exhibitionism) for sexual arousal. (p. 153-154, italics original).

Now, this justification only works if the "paraphilic" interest was necessary or prefered for sexual arousal. (The DSM-III's definition of paraphilia said necessary. The definitions for most diagnoses said necessary or preferred, but exhibition and transvestism didn't even require this.)

Now, in DSM-III-R, the "requirement" that the sexual interest be necessary/preferred was changed so that the person only had to have "recurrent intense sexual urges and sexually arousing fantasies," along with a requirement that the person has acted on them or is distressed by them. In DSM-IV (1994), the acted-on-or-distressed requirement was changed to a distressed-or-impaired requirment, which was changed to an acted-on-or-impaired-or-distressed requirement for some of the diagnoses in DSM-IV-TR (2000).

A large part of the reason that the "paraphilias" are in the DSM is because people investigating sex-offenders find that they frequently have these sorts of "deviant" sexual fantasies. So such researchers say "Aha! This man has these sexual fantasies, and he acted on them causing harm to someone. Therefore he must have committed this crime because of his deviant sexuality!"

There are several massive problems with this. First, studies on non-clinical, non-criminal populations reveal that "paraphilic" fantasies are extremely common. (Research on "paraphilias" is pretty much exclusively done on men based on the belief that other than S&M, women don't have "paraphilias.") Studies on men pretty consistently have found that MOST men in whatever sample is used have "paraphilic" sexual fantasies. This means that regarding these fantasies as "deviant" is based on sheer delusion and denial of reality, and it means that having such fantasies is not an especially good explanation for why some people engage in illegal sexual acts and others don't.

Examining the ideology underlying regarding "paraphilias" as deviant demonstrates it to be the same as regarding asexuality as "deviant." In a textbook chapter on the Paraphilias by Gene Abel (a member of the DSM-III-R Paraphilias subcommittee), he chapter says in the first paragraph:
Although sexual behavior plays a role in the preservation of the species, its major function for human beings is to assist in bonding, to express emotion between individuals, and for recreation.(p. 1069)
(See B. Apfelbaum's article onSexual Reality and how we dismiss it for a devastating critique.)

Sometimes in queer and feminist discourses on sexuality, people will caricature our culture's sexual norms as based on a model where only heterosexual married coitus in the missionary position is acceptable. (I've never heard anyone support this despite the multitude of those attacking it.) While a focus on sex being for reproduction seems dominant is those relying on sociobiology/evolutionary psychology for pseudoscientific support for their sexual ideologies, the dominant view of sex in modern times seems to be the one that Abel gives. This seems to be what the DSM relies on. Charles Moser criticizes it as being "straight out of a bad romance novel" and "also pathologizes most of history." (p. 98). Still, this ideology pathologizes sexual interests that fail to conform to this bad-romance-novel based norm, including both asexuality (because we don't fall in love and get super interested in hot, steamy sex) and the "paraphilias" because people are interested (at least in their imaginations) in the "wrong" kind of sex (even if they are interested in the "right" kind as well.)

The inclusion of the "paraphilias" in the DSM has at least two very negative impacts. The first is that is stigmatizes people with kinky sexual interests who only carry out those interests with consenting adults. Second, it reinforces the myth that feminist researches have been fighting against for decades that sexual violence is principally erotically motivated.

Thus, it is clear that there is a historical and ideological connection between the pathologization of asexuality and the "paraphilias." They had the exact same justification for their inclusion in DSM-III, and they both are regarded as "deviant" by a sexual ideology that sees sex as being for love and romance and possibly recreation. (I'm not saying that sex is never about this, only that an inseparable connection between them is problematic.) In my next post in this series, I'll explain some of the historical background necessary for understanding the proposal for including PCD in DSM-V.

Wednesday, February 10, 2010

Proposed criteria for DSM-V now online

The American Psychiatric Association published today the provisional criteria for the DSM-V. The goal is to enable stakeholders to provide feedback before the criteria are finalized for use in field trials.

The site is dsm5.org. The here is a link for proposals for the Sexual and Gender Identity Disorders.

It seems that my guess way back when that they were trying to include "Paraphilic Coercive Disorder" turns out to be correct.

Tuesday, February 9, 2010

Rectuiting participants for a study on asexuality

Researches at UBC are currently engaged in the second part of a study trying to develop a better way of identifying asexuals in surveys not taken from the asexual community. If you're at least 19 and fluent in English, I strongly encourage you to participate. You don't have to have to be asexual, though.

Click here to participate

Sunday, February 7, 2010

New paper on asexuality

Scherrer, K. S. (2009) Asexual Relationships: What Does Asexuality Have to Do with Polyamory?. in M. Barker & D. Langdridge (eds) Understanding Non-Monogamies

I've ordered the book through the library, but I haven't gotten a chance to read it yet, but I thought that readers wanting to keep up on publications on asexuality would be interested.