DSM-V Part 3: Let’s talk about sex, baby

This is the third and final part of my gently-meandering look at the revisions that have been proposed for the 5th version of the DSM.  If you’re a real glutton for punishment, part one, which looks at changes to the parts of the DSM that relate most closely to mood-disordered me can be found here, and part two, which looks at the efforts of the revision committee to medicalise and pathologise normal variations in sexual desire, especially (for now) among women, can be found here.  In this part I’m going to look at the way the DSM is persisting in involving itself in the policing of consensual sexuality.  Gosh, that sounds thrilling, doesn’t it?  Actually, don’t answer that…

It’s proposed that the DSM-V will maintain the same list of ‘paraphilias’ (sexual behaviours that are classed as ‘deviant’) as exists in DSM-IV.  There are to be some behind-the-scenes changes – the revision committee are proposing a distinction between a simple paraphilia (a ‘non-normative’ sexual urge or behaviour) and a paraphilic disorder (a paraphilia that causes distress, and so requires treatment).*  Despite this, the decision to persist with the same lists means that, alongside several nonconsensual behaviours that are quite rightly regarded as wrong – paedophilia, exhibitionism (as in flashing, not dogging), frotteurism (rubbing up against a stranger), voyeurism (when spying on someone who doesn’t want to be spied on), necrophilia, zoophilia (bestiality), and telephone scatalogica (making obscene phone calls) – a whole range of consensual behaviours are also marked out as ‘non-normative’.

So, for example, the DSM disapproves of

recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer [Sexual Masochism]

Proving they can be equal-opportunity prudes, they also weigh-in against

recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the physical or psychological suffering of another person [Sexual Sadism]

Oh, and you don’t get off any easier if you like sucking toes, or licking armpits, or are turned on by bouncing up and down on a scrunched up ball of cellophane and listening to the squeaking sound

recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving either the use of non-living objects or a highly specific focus on non-genital body part(s) [Fetishism]**

And if you’re a man and you enjoy wearing women’s clothes then you get a whole disorder all to yourself

in a male, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing [Transvestic Fetishism]

Transvestic Fetishism even comes with a choice of flavours

With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)

With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

It’s interesting to note that transvestitism is only a disorder if you’re male.  I wonder, does it not apply to women because the DSM committee are smart enough to know that if they labeled women who wear jeans as paraphilic they’d be laughed at until the whole project was in ruins?  Or is it, as I’m fairly sure some of my feminist friends would suggest, because the committee subconsciously think it makes perfect sense for a woman to want to dress like a man – because men are powerful, and authoritative, and strong – but no man in his right mind would want to dress like a woman – because women are weak, and passive, and submissive?  (Yes, I still remember my Hélène Cixous.)

In the light of the second option, it’s also interesting to note that a man being turned on by the thought of himself as a woman is a disorder (assuming the state of mind even exists, which is a big assumption – most trans women see the theory as nothing more than an attempt to delegitimise their identity), but there’s no equivalent disorder – autoandrophilia? – for women.  Is that also because of the unacknowledged presumption that it makes perfect sense for women to want to be men, but for a man to want to be a woman is clearly evidence of mental instability?  I would be surprised if it’s because of a lack of evidence that potentially autoandrophilic behaviour exists – I’d have thought that pegging would be an obvious candidate for being described in just these terms.  (I’m not saying, by the way, that I think autoandrophilia is a real condition, or that there’s something wrong with pegging – I don’t, and there isn’t – just that it’s as likely to be real as autogynephilia.)

I think probably a part of the answer to these questions is that the DSM is reflecting a somewhat conservative version of current social mores.  For example, aside from a few hard-line religious fundamentalists, no-one bats an eyelid at the idea of women dressing in male clothing, but when men dress in female clothes it’s still seen by some people as provocative and shocking, and even in some cases wrong.  Now, it won’t come as a surprise to you to hear that I disagree with that assertion and that, in fact, I take a significantly more liberal view than the framers of the DSM do on all the consensual ‘paraphilias’; essentially, if people are enjoying themselves, and it’s all consensual, then why label some sexual practices as ‘normative’ and others as ‘non-normative’?  What may be stranger to hear coming from the mouth of a person like me who has liberal social values is that I also take what seems like a more conservative line on some things than the framers of the DSM do.

For example, and contrary to the criteria for ‘Sexual Interest/ Arousal Disorder in Women’ (see part two of this post for details), I don’t think that a woman (or a man, for that matter) who has a low interest in sex has a disorder or needs treatment – I’ve said before that having lots of partners, only one, or none at all are all equally valid choices so far as I’m concerned.  Neither do I think that someone (sorry – some woman) who, for cultural or religious reasons, thinks that it’s wrong to have sex – or certain kinds of sex – is mentally ill.  I might personally disagree with those who argue that any form of sex that isn’t explicitly aimed at procreation is sinful, but I would defend their right to believe that, and to act accordingly, without having the full might of the DSM directed against them.  On sexual matters, the only thing that matters is consent, and provided consent has been freely and meaningfully given, the only possible approach for an official document like the DSM is live-and-let-live.  Anything else is an attempt to impose a particular set of cultural and social values, and this is not what psychiatry should be in the business of doing.

Partly they shouldn’t be in the business of doing it because it’s wrong in and of itself.   In the shifting morass of social mores there is no fixed place to observe from and say “This is normal and this isn’t”.  The best example of this, of course, is the way the DSM has handled the issue of homosexuality, which up until pretty much the time I was born was a ‘paraphilia’, but is now regarded as so normal that the concept of psychiatrists offering to convert homosexuals to heterosexuality is routinely condemned by the American Psychiatric Association.  Nothing material has changed in the interim – in 1970 nobody knew why some people are gay (although there was speculation about upbringing and the social environment): in 2010 nobody knows why some people are gay (although there is speculation, and even a small amount of actual evidence, about genetics and pre-natal hormone exposure).  The only change has been in general social attitudes towards homosexuality, and it strikes me that popular opinion is not an especially good way of establishing whether certain sexual behaviours are permissible or impermissible.

The other reason the DSM revision committees shouldn’t be in the business of imposing a particular set of social and cultural values is that it brings the whole of psychiatry into disrepute.  One of the most frequently heard criticisms of psychiatry is that it has nothing to do with treating the sick, and is instead a means of social control.  Despite the undoubted flaws of psychiatry, I don’t think that’s a fair accusation, but it really doesn’t help the case when a significant proportion of the DSM is given over to regulating consensual sexual behaviour, which cannot possibly fit the criteria for disease.  It’s particularly unfortunate since the reasons for keeping the consensual paraphilias in the manual are so vague.  Under the ‘Rationale’ tab for all of the paraphilias (this one, for example), the revision committee explain that they want to

leave intact the distinction between normative and non-normative sexual behavior, which could be important to researchers

This seems to me to be a truly bizarre statement.

Surely the only valid reason for maintaining that there is a distinction between ‘normative’ and ‘non-normative’ sexual behaviour is because there actually is a distinction.  If the committee can identify no objective reason for stating, for example, that oral sex (a non-reproductive sexual practice engaged in simply because it brings pleasure to the participants) is psychiatrically ‘normative’, but shrimping (a non-reproductive sexual practice engaged in simply because it brings pleasure to the participants) is psychiatrically ‘non-normative’, then surely they’re honour-bound to strike out the distinction?  In fact, by making the comments they have about researchers, the committee have pretty much conceded that the division is not justified either by evidence or logic, but are insisting on maintaining it anyway, and just because they want to.  Such a dismissive attitude towards rationality and normal scientific practice does not reflect well on the revision committee, or the document they are producing.

* – see the ‘Rationale’ tab under any of the paraphilias (this one, for example) for details of the proposed separation between paraphilia and paraphilic disorder.

** – Amusingly, it seems that there are prohibitions against sexual acts with animals and non-consensual sex with humans, and insistences that fantasising about the use of non-living objects or the ‘wrong’ parts of people is ‘non-normative’, but on the issue of sex with plants the DSM is wholly silent  I can only assume, therefore, that if you get your rocks off by fiddling with a fuchsia or deflowering a dahlia then the American Psychiatric Association think that’s just fine and dandy…

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8 Responses to DSM-V Part 3: Let’s talk about sex, baby

  1. ACH says:

    I’m curious why you leave unchallenged the classification of the criminal paraphilias? Even in those cases, I think that regarding them as mental disorders is problematic. I think that it’s wrong to rob banks, but I certainly don’t think that bank-robbingism is a mental disorder. In non-clinical samples, it has been found that “paraphilic” fantasies are quite common (the criminal and non-criminal ones alike.) Of course, most people are perfectly capable of distinguishing between what they do in their imagination and what they do in reality, so people who act out their fantasies with non-consenting people, is it because they’re horny and can’t control themselves? That does seem to be the way that having the “paraphilias” in the DSM is viewed.

    Personally, I think that the absolute worst proposal for DSM-V, at least as far as the paraphilias are concerned is “Paraphilic Coercive Disorder.” The whole purpose of that one is to justify the “civil commitment” of sex offenders (under “sexually violent predator” laws) after they have completed their sentences. It’s profoundly disturbing from a civil liberties perspective, is extremely expensive and focuses on a tiny part of the problem of sexual violence, and reinforces the idea that “real rape” is committed by horny strangers hiding in bushes and parking lots.

  2. Autogynephilia is a load of bollocks, and was a prejudicial idea that was introduced by trans-phobic medics in the past to stigmatise MTF transpeople and deny them treatment (hormones and surgery if desired).

    A very good friend of mine is a transwoman and is very involved in the politics of it all, which has been eye-opening for me. The level of bigotry would seem to be like that faced by gay men 25 years ago.

    The NHS often goes to considerable lengths to prevent referral of transpeople to gender clinics (this because of cost – Cambridge PCT being a particular offender) and will use any pretext to deny treatment. Including accusing the transwoman of autogynephilia, a non-existent disorder.

  3. aethelreadtheunread says:

    Thanks for the comments.

    ACH – I’m curious why you leave unchallenged the classification of the criminal paraphilias?

    Because they are at least somewhat responsive to treatment (therapy) in some cases, and because it’s a good idea to try and treat them if at all possible. If we abandon the concept of treatment for, say, paedophiles, then we are faced with two options: 1) lock them up forever as a preventative measure; 2) release them back into the community knowing we have not done what we can to prevent them re-offending. I would argue that neither of these options offers an advantage over the admittedly imperfect status quo. That said, i do agree that the inclusion in the DSM is problematic: if the people who engage in the non-consensual paraphilias have a psychiatric disorder, then why isn’t that disorder treated within a secure hospital rather than the mainstream prison system?

    Paraphilic Coercive Disorder is indeed very worrying, for all the reasons you outline. Thank you for drawing attention to it. In my defence, there’s a lot in the DSM that’s worthy of discussion and comment, and i can’t cover it all! :o)

    DeeDee Ramona – The level of bigotry would seem to be like that faced by gay men 25 years ago.

    I’m old enough to have some memory of the kind of anti-gay bigotry that was around 25 years ago, and i’m certainly aware of the parallels, but, if anything, i think the bigotry faced by trans people today is worse. Trans people are almost completely invisible in popular culture except as the butts of bigoted jokes, and that wasn’t true for gay people (well, gay men, at least) 25 years ago – alongside the bigoted jokes there was also more positive coverage. For those kinds of reasons, i think it might be more accurate to say that the level of bigotry trans people face now is similar to that faced by gay people 35 or maybe even 40 years ago – basic legal rights have been granted, but very little else.

  4. ACH says:

    The problem with “pedophilia” is that it is currently being used to lock them up forever. About 20 states in the US have “Sexually Violent/Dangerous Predator/Person” laws that permit the “civil commitment” of sex offenders after completing their prison sentences. The whole point of this commitment is to get around the constitutional protections involved in criminal prosecutions–further punishment would violate the double jeopardy clause of the US constitution. Thus, they are not locked up for anything they have ever done but because of “risk” that they pose. Such commitment requires that they be diagnosed with a mental disorder. Pedophilia is the most common diagnosis used in these cases. Also, it is at all necessary to give people a diagnosis of pedophilia to provide treatment. Perhaps an impulse control disorder could be diagnosed or if the DSM had some sort of “sexual interest distress” that did not specify the particular interest, that could be used. I think there are plenty of ways of providing treatment without specifically listing the various things as mental disorders.

    You may find this articleAlice Dreger (and, more importantly, the comments) interesting.

  5. I believe an oft-quoted stat is that most child sexual abusers are not paedophiles. They are evil people who get off on hurting and dominating someone smaller and weaker than them nonconsensually and don’t give a shit about the effect it has. That’s not the same as someome who gets turned on by kids in and of themselves, apparently, who are a subsection of this group.

  6. Pingback: This Week In Mentalists (120): The Made With Extra Special Sauce Edition « Mental Nurse

  7. Adair says:

    Are there any numbers for how many mental health professionals take this stuff seriously?

  8. TheShrink says:

    Adair, if you’re in the UK then criminal “abnormal” behaviour is assessed using different frameworks (of which ICD-10 is but a part). If you’re in the USA they live and breathe DSM.

    So the number of mental health professions that take this stuff seriously in the UK might be about , what, 4?

    So the number of mental health professions that take this stuff seriously in the USA might be about, erm . . . pretty much all of them?

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