[Blog/Commentary] [USA] DSM5 and Sexual Disorders - Just Say No
Stephanie Stevens
DSM5 IN DISTRESS
The DSM's impact on mental health practice and research.
by Allen Frances, MD
--
DSM5 and SEXUAL DISORDERS- JUST SAY NO
DSM 5 sexual disorders make no sense
Published on March 14, 2010
A major general problem in the preparation of DSM5 is that the various
Work Groups have been given far too little guidance and support. This
explains why: 1)most of the criteria sets are written so obscurely and
inconsistently; 2) the rationales for change vary so widely in depth
and quality across Work Groups,and; 3) so many suggestions that should
have no chance at all have made it this far without being tossed.
The Sexual Disorders Work Group has strayed furthest off the
reservation. It has made a series of radical and dangerous suggestions
that need to be dropped.
Sexuality <http://www.psychologytoday.com/basics/sex> is an
inherently difficult arena for psychiatric
<http://www.psychologytoday.com/basics/psychiatry> diagnosis because:
1) the field has generated remarkably little research and few
researchers; 2) there are no consensus norms in sexual behavior to
provide a useful boundary in deciding what constitutes a sexual mental
disorder; 3) individual and cultural biases
<http://www.psychologytoday.com/basics/bias> play a large and
difficult to sort out role,and; 4) decisions regarding the diagnosis
of sexual disorders can have profound and unanticipated forensic and
societal implications.
For all these reasons, changes in the definition of the Sexual
Disorders should be especially cautious and evidenced based. Instead,
the Work Group has taken full and reckless advantage of the DSM5
spirit of innovation
<http://www.psychologytoday.com/basics/creativity> . To get a flavor
for this, review their postings yourself (at www.DSM5.org
<http://www.dsm5.org/> )
Each of the Work Group's suggestions is based on the thinnest of
research support-usually a handful of studies often done by members of
the committee making the suggestion. None has been subjected to, or
could possibly survive, anything resembling a serious risk/benefit or
forensic analysis. I will discuss separately the problems with each
proposal, but will not keep repeating that none of them has anything
but a veneer of research support.
"HYPERSEXUALITY DISORDER"-this is the strangest of constructs. The
Work Group explicitly states that it is not meant to be equated with
"Sexual Addiction <http://www.psychologytoday.com/basics/addiction> "
(which apparently, and fortunately, was rejected by the DSM5 group
working on the "addictions")-but then goes on to base its proposed
definition exclusively on items that are borrowed directly from those
used to define substance dependence.
The fundamental problem with "hypersexuality" is that it represents a
half baked, poorly conceptualized medicalization of the expected
variability in sexual behavior. The authors have not thought through
how difficult it is to distinguish between ordinary recreational
sexual misbehavior (which is very common) and sexual compulsion (which
is very rare). Humans(especially males)frequently misbehave sexually
because our brain <http://www.psychologytoday.com/basics/neuroscience>
wiring tends to favor short term pleasure regardless of long term
consequences. Sexual misbehavior should be considered "sexual
addiction" only when it is compulsive, no longer pleasure driven, and
continues despite great costs that obviously outweigh any gain.
The authors are trying to provide a diagnosis for the small group
whose sexual behaviors are compulsive -but their label would quickly
expand to provide a psychiatric excuse for the very large group whose
misbehaviors are pleasure driven, recreational, and impulsive
<http://www.psychologytoday.com/basics/self-control> . The offloading
of personal responsibility in this way has already captured the public
and media fancy and would spread like wildfire. Making an official
mental disorder category of "hypersexuality" would also have serious
unintended forensic consequences in wildfire. Making an official
mental disorder category of "hypersexuality" would also have serious
unintended forensic consequences inthe evaluations of sexually violent
predators(SVP)-for more on this, see next section.
"PARAPHILIC COERCIVE DISORDER"-this is based on the idea that some
(probably a small proportion of) rapists qualify for a diagnosis of
mental disorder. They rape not opportunistically, or as an exercise in
power, or under the influence of substances or peer pressure-but
specifically because it is their preferred form of sexual excitement.
This proposal was explicitly rejected for DSM IIIR and was given no
serious consideration for DSM IV. The problem is the impossibility of
reliably distinguishing between the small group of hypothesized
"paraphilic" rapists (who would be given a mental disorder
diagnosis)and the much larger group of rapists who are simple
criminals.
The distinction has taken on huge significance because of an
aberration in the way the criminal justice system handles rapists.
Twenty states have passed SVP statutes mandating indefinite (usually
in practice lifelong) inpatient civil psychiatric commitment for
individuals who have:1)completed their prison sentence for a sexually
violent crime;2)have a diagnosed mental disorder, and; 3) are deemed
likely to repeat. The statutes are a well meaning effort to reduce the
threat to public safety posed by those recidivist sexual offenders who
have received prison sentences that are judged to be too short.
Although the SVP statutes have twice passed Supreme Court tests, they
rest on questionable constitutional grounds and may sometimes result
in a misuse of psychiatry.
Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis-
Paraphilia Not Otherwise Specified-has become a frequent justification
for the psychiatric commitment of rapists who are really no more than
simple criminals. Raising this diagnosis to official status would
greatly compound this misuse of civil psychiatric commitment.
"PEDOHEBEPHILIA"- this new category would extend the traditional
definition of Pedophilia
<http://www.psychologytoday.com/conditions/pedophilia> (Ie,requiring
that the desired sexual target be a prepubescent child) to include
pubescent teenagers. Clearly, sex with underage teenagers is
reprehensible and deserves appropriate punishment
<http://www.psychologytoday.com/basics/punishment> under the penal
code. It is, however, anything but clear when (and if) sexual
behaviors with teenagers should qualify as a mental disorder. This
diagnosis would be subject to the same misuses in SVP cases as has
been described above.
"GENDER <http://www.psychologytoday.com/basics/gender> INCONGRUENCE"
would replace the DSM IV term Gender Identity Disorder
<http://www.psychologytoday.com/conditions/gender-identity-disorder> .
The writing here is especially unclear, but there appears to be an ill
conceived suggestion to remove the requirement for clinically
significant distress or impairment. Presumably everyone with an
unorthodox gender identity
<http://www.psychologytoday.com/basics/identity> would now get a
diagnosis of mental disorder-even if they are happy and functioning
well. If, indeed, this is what is meant, the suggestion makes no sense
at all and resurrects the same unfortunate issues that psychiatry
resolved forty years ago when homosexuality
<http://www.psychologytoday.com/basics/homosexuality> was removed from
the manual. The DSM IV approach seems best - ie, to recognize that
gender incongruence becomes a mental disorder only when it is causing
significant problems.
All of these suggestions by the Sexual Disorders Work group share the
common problem of medicalizing one or another form of sexual behavior.
This would always be controversial, but might perhaps make some sense
if the following conditions could be met: 1)very narrowly defined
disorders that would not spread widely to the general or prison
population;2)the individuals described would clearly benefit from
medical treatment; 3)the diagnosis and treatment are deeply grounded
in research and clinical experience; and 4) the diagnosis is unlikely
to cause forensic or societal problems. Each of the above suggestions
falls very far short in each of these requirements. They all need the
most thorough risk/benefit analysis and forensic review. I am
convinced that none should be made official in the final draft of
DSM5.
--
Allen Frances MD was chair of the DSM-IV Task Force and is currently
professor emeritus at Duke.
--
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