The following is an extract of a report presented at a May 19,
2003, symposium sponsored by the American Psychiatric Association entitled
"DSM-IV-TR and the Paraphilias: An Argument for Removal."
The report can be downloaded as a PDF file from
< http://home.netcom.com/~docx2/mk.html
>
Charles Moser
Institute for Advanced Study of Human Sexuality
San Francisco, California
Peggy J. Kleinplatz
University of Ottawa
Ottawa, Ontario, Canada
The DSM-IV-TR (2000) sets its own standards for inclusion of diagnoses and for changes in its text. The Paraphilia section is analyzed from the perspective of how well the DSM meets those standards. The concept of Paraphilias as psychopathology was analyzed and assessed critically to determine if it meets the definition of a mental disorder presented in the DSM; it does not.
The Paraphilia diagnostic category was critiqued for logic, consistency, clarity and whether it constitutes a distinct mental disorder. The DSM presents "facts" to substantiate various points made in the text. The veracity of these "facts" was scrutinized.
Little evidence was found in their support. Problems with the tradition of equating particular sexual interests with psychopathology were highlighted. It was concluded that the Paraphilia section is so severely flawed that its removal from the DSM is advocated.
All societies attempt to control the sexual behavior of their members. One mechanism of exercising this control is to define a specific sexual interest as pathognomonic for a mental disorder. Historically and cross-culturally, even an accusation of interest in specific sexual practices could result in death, imprisonment, loss of civil rights and other social sanctions. Similarly, being classified as mentally ill could result in death, imprisonment, loss of civil rights and other social sanctions. Thus, the confounding of mental illness with unusual sexual desires is understandable.
Which sexual interests are proscribed often changes; masturbation, oral sex, anal sex and homosexuality were once considered mental disorders or symptoms of other mental disorders but are now typically accepted as part of the spectrum of healthy sexual expression. Similarly, there are conditions that were accepted as "normal" in the past but are now classified as mental disorders (e.g., hypoactive sexual desire, sexual aversion disorder and female orgasmic disorder). It is exceedingly difficult to eliminate historical and cultural factors from the assessment of unusual sexual interests. As such, empirically based, scientific definitions of healthy and pathological sexual behavior continue to elude us.
Cross-culturally, sexual activity considered "acceptable" in the United States is viewed as "stigmatized" in other cultures; similarly, sexual activity considered "acceptable" in the United States is "stigmatized" in other cultures. For example, non-marital coitus is accepted in the U.S. but is stigmatized harshly in many Moslem countries; topless sunbathing among women at public beaches is accepted in Western Europe but illegal and condemned in most of the United States. Violation of these cultural norms often results in strong negative reactions. Given the socio-cultural context in which such beliefs are embedded, it is not surprising that the lay public and even many sex experts cannot understand how unusual sexual interests can signify anything but mental disorders. Nevertheless, it is the assumption that unusual sexual interests constitute symptoms of or are mental disorders per se, that we are questioning.
The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual (DSM); it describes the diagnostic criteria and defining features of all formally recognized mental disorders. It serves as a definitive resource for mental health professionals. Although its primary influence is in the United States, its impact is global. A psychiatric diagnosis is more than shorthand to facilitate communication among professionals or to standardize research parameters. Psychiatric diagnoses affect child custody decisions, self-esteem, whether individuals are hired or fired, receive security clearances or have other rights and privileges curtailed. Criminals may find that their sentences are either mitigated or enhanced as a direct result of their diagnoses. The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas. A review of this area is not only a scientific issue, but also a human rights issue. The power and impact of the DSM should not be underestimated.
The DSM is revised at regular intervals. Diagnoses can be added or eliminated and diagnostic criteria reformulated with each new edition. There have been six editions to date (APA, 1952, 1968, 1980, 1987, 1994, 2000). The current edition is designated DSM-IV-TR (APA, 2000) and will be the focus of this paper.
With the publication of DSM-III in 1980, the focus of the DSM changed from a theoretically based, psychoanalytic model of illness to an evidence-based and descriptive model. The DSM is currently intended "[...] to be neutral with respect to theories of etiology" (APA, 2000, p. xxvi), based on objective observation and able to support its statements with empirical research. With this transition, the nomenclature of these disorders changed from "Sexual deviation" to "Paraphilia," a supposedly atheoretical, non-pejorative descriptor.
In the text of the latest edition of the DSM, it is asserted that a "comprehensive and systematic" (APA, 2000, p. xxvi) review of the literature was conducted in preparation of the DSM.
"The utility and credibility of the DSM-IV require that it [...] be supported by an extensive empirical foundation" (APA, 2000, p. xxiii).
The text indicates,
"...the majority of paragraphs in the DSM-IV have not been revised, indicating that, even after the literature review, most of the information in the original text remains up-to-date" (APA, 2000, p. 829).
Our own, extensive review found no literature to support most of the assertions made in the Paraphilia section of the DSM, and several studies were found that contradict the text (discussed below). Objective data to support the classification of the Paraphilias as mental disorders is lacking.
When the APA removed homosexuality from the DSM approximately 30 years ago, some observers thought that the other Paraphilias would also be removed from subsequent editions. The argument for removal of homosexuality was bolstered by the lack of objective research supporting its inclusion and research that failed to support the theory that homosexuals fit specific psychiatric stereotypes.
Nevertheless, some observers believe the removal of homosexuality was primarily a political act (Bayer, 1981). The situation of the Paraphilias at present parallels that of homosexuality in the early 1970s. Without the support or political astuteness of those who fought for the removal of homosexuality, the Paraphilias continue to be listed in the DSM.
The term "paraphilia" will be employed here in keeping with its use in the literature, even though we have serious reservations about the validity of the diagnosis and the applicability of this term. The rationale for the inclusion of the Paraphilia diagnostic category as it is constituted in the DSM-IV-TR (APA, 2000) will be addressed and challenged. It will be suggested that the construct of the Paraphilias is ambiguous and does not describe a diagnosable, distinct mental disorder. A review of the scientific literature does not support the inclusion of this diagnostic category in the DSM.
The concept that unconventional sexual interests are mental illnesses or crimes (religious or societal) predates both the DSM and modern psychiatry. Sanctions against individuals who engage in proscribed sexual behavior have changed over time. At first, it was considered a sin to be governed by penitentials and religious courts. Over time, civil laws were used to "control" the unacceptable behavior. In the [past], the medical model was applied to transform these "sins" or "crimes" into "pathology"
(Bullough & Bullough, 1977).
The assumption that Paraphilias are a form of psychopathology has been questioned, and each subsequent edition has attempted to address some of the perceived weaknesses in this diagnostic category. Nevertheless, the bulk of serious criticism
(Davis, 1996; McConaghy, 1999; Rubin, 1992; Silverstein, 1984; Suppe, 1984)
has not been addressed fully.
In the DSM, it is indicated that it is difficult to define a mental disorder as well as mental health. Nonetheless, the text defines a mental disorder as being
"...associated with present distress [...] or disability [...] or significantly increased risk of suffering death, pain, disability or an important loss of freedom" (APA, 2000, p. xxxi).
Individuals who engage in many common activities (scuba divers, gun owners, mountain climbers, inhabitants of many large cities and criminals) also incur increased risks of death, pain, disability, or loss of freedom but are not diagnosed with mental disorders. This apparent contradiction demonstrates that social context can affect the application of this definition.
To clarify the definition, the DSM further states,
"Neither deviant behavior (e.g., political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above" (p. xxxi).
There is concern that psychiatric diagnoses can be used inappropriately to discredit dissenters; at least in some venues, criminals have more rights and credibility than psychiatric patients do. The above statement was added to protect the labeling of unpopular or illegal activities as mental illnesses, but the last clause allows the clinician to disregard this distinction.
The DSM does not define healthy sexuality, much less healthy mood, thoughts or personalities. Unfortunately, the range of "healthy" human sexual behavior is not known, thus creating potential pitfalls in the diagnostic process. The DSM is meant to be interpreted by an experienced and objective clinician. Without consensus from the scientific literature, however, clinicians are often forced to rely on their own subjective evaluations.
The problem here is that engaging in "Paraphilic" behavior qualifies the participant a priori as a candidate for diagnosis. In addition, when individuals have unusual sexual interests, there is often speculation that any presenting problems are related to their sexuality. When a behavior per se signifies a diagnosis, then by definition the behavior is symptomatic of the disorder. This confound obscures the possibility that for at least some individuals, their specific sexual behaviors are healthy expressions of sexuality and beneficial to them. The fact that specific sexual behaviors are socially unacceptable or illegal is, and should be, irrelevant to the diagnostic process.
Historically, this was the situation that confronted homosexuals. When homosexual patients presented to a psychotherapist with any problem, it was often assumed that the problem was caused or exacerbated by their homosexual interests.
Gieles, F.E.J., Is
pedophilia a mental disorder?
Discussion in Archives of Sexual Behavior; Report
The December 2002 issue is a special about pedophilia.
