Making Sex Sick: the DSM and the Errors of Psychology
Posted on | February 23, 2010 | 3 Comments
How embarrassing. I posted something yesterday evening on the DSM-V revision where I expressed an opinion based on a complete misread of the DSM text. One of my most alert and intelligent readers, Elmo Iscariot, whose comments you can find in several previous posts, pointed out this misread and I’m quite grateful for it. In the post below, I correct my error and outline, accurately this time, the objection of the sex-positive community to the proposed revised text of the DSM:
A friend, Emily Prior, who I met while teaching sex ed at Planned Parenthood and who now runs the Center for Positive Sexuality, sent me the link to the DSM-5 Development site.
The Diagnostic and Statistical Manual (DSM) is the tool that psychiatrists use to diagnose patients. It describes symptoms in a specific, quantifiable way so gives practitioners an ethical guideline for declaring that a patient has, for example, personality disorder.
Lay people (like me and you) are allowed to make comment on this, the fifth revision to the book. I have registered to do so and will more or less “comment out loud” by reproducing my criticisms of the DSM revisions (or lack of) right here. (The deadline is April 20, so if you want to comment, hurry up.) Revisions to the DSM have always caused controversy and it’s a credit to the American Psychiatric Association (APA) that they are conducting this revision with an unprecedented amount of transparency.
To those unaware of why the DSM should raise any suspicion or interest in the general population, I’ll point out the famous case of homosexuality being in the DSM until 1974 (and I mean consentual adult homosexuality). For another case, Attention Deficit Disorder (ADD) and Disruptive Behavior Disorder, which are, unfortunately, not being revised at all, have been in use for decades as a facile justification for drugging up any child that cannot be controlled by its caretakers (read any boy who is annoying his mother or teacher).
In sum, there is this creepy element of the DSM that acts as a crude cover for things that the mob thinks of as weird or inconvenient. This is not morally acceptable. The DSM is an important ethical and professional guide for mental health professionals, but parts of it have been and continue to be a weapon of intollerance and cruelty. I am interested in de-weaponizing the DSM.
It is fitting that the genpop is allowed to comment on the DSM, because in a very real way, the genpop has made it. Freud is Freud because wealthy Viennese fathers and husbands brought him their wives and daughters and asked, “What’s wrong with her?” This was a question that demanded an answer and not only Freud, but his colleagues, formed an entire profession dedicated to coming up with answers in the forms of diagnoses. Oedipal complex, neurosis, etc. are not characteristics pulled from a scientific study of the general population, but are rather answers TO OUR QUESTIONS. Not our questions about people in general but about people we think are strange or who do not fit in. We are collectively responsible for this book, so we are morally obligated, in my view, to comment and guide the good people of the psychiatric profession as they make a good-faith effort to meet OUR demand for psychiatric diagnoses.
I’ll spend the rest of this blog on my criticisms of the diagnoses of masochism and sadism:
The proposal for Sexual Masochism is as follows:
A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The diagnosis for Sexual Sadism is essentially the same, just inverse:
A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the physical or psychological suffering of another person.
B. The person is distressed or impaired by these attractions or has sought sexual stimulation from behaviors involving the physical or psychological suffering of two or more nonconsenting persons on separate occasions.
[All the above is exactly as I had posted in the first place. Where I stumbled was in misreading A and B to each be sufficient conditions for calling someone mentally disturbed, where A is nothing more or less than an accurate description of a practicing sadist or masochist. In fact that's exactly what was intended by the DSM review committee, which is sensitive to the problem of calling fetish practitioners ipso facto disturbed. Part A is intended to establish that the person had masochistic thoughts, which would NOT be sufficient for any psychological diagnosis, and then Part B is to be the trigger for a diagnosis of a disturbance.]
Once I’d been alerted to the misread, I called my friend Emily to have her educate me about what the objection was to the DSM revisions. Ironically, the first objection she mentioned is that not just me but practitioners might also misread these diagnosis guidelines and would start treated an ethical masochist or sadist as a mental case based on their fitting the A criterion.
Secondly, at the beginning of the DSM, they promise that all diagnoses are based on empirical evidence, yet there have not been nearly enough studies done on the general population about whether self-identifying sadists, for example, are any more at hazard than the rest of the population of injuring others.
The DSM entry seems to imply that everyone in the world who ends up criminally violating someone else in a sadistic way is a subspecies of people who have sadistic fantasies. (A practicing sadist might well make the opposite argument by the way: that people who don’t openly fantasize about it or act it out in an ethical setting are more at hazard than they of inappropriately taking out their aggression on others.)
Many studies done on “sadistic” men are prison populations studies. It’s obviously hazardous in the extreme to take these studies and extrapolate into the gen-pop. The few studies done on the gen-pop find what you’d expect them to: that a group of taxidermists and a group of self-identifying sadists and a group of CPAs have non-distinguishable profiles in terms of their acting out on non-consenting folks.
I’ll ask Emily for references on those studies, but in the meantime I can give an example from one of my favorite books on sex health, The Causes of Rape. After a discussion about how it’s very difficult to make reliable associations between sadists and rapists, the authors say the following:
“Perhaps some rapists do have a paraphilia, but one that is better described by phrases such as hyperdominance. That is, such a paraphilia would be characterized by intense sexual interest in the exercise of power, physical control, and physical and emotional dominance (rather than the inflicting of pain and injury itself).”
So by characterizing sadistic disorder as a discreet field variety of sadism the DSM misses the greater probability that someone who commits a sadistic act on a non-consenting person is engaging in a broader spectrum behavior, perhaps one involving control. A person who wants to control you may or may not want to give you physical pain. Causing a non-consenting person pain might simply be a means to an end.
Thirdly, there is an argument correctly pointing out that you could fill a library with the volumes of the DSM by constructing a description of any and every human activity (sexual and non) in the A/B structure used to describe the sexual disorders. Here’s a hypothetical entry on Dog Saving:
A. Over a period of at least six months, recurrent and intense fantasies, urges, or behaviors involving the rescuing of abandoned dogs.
B. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
I know someone who saves dogs who could talk herself into a year’s supply of Prozac if this was in the DSM.
Sorry again for the miscue. Thanks not just to Elmo but to everyone who has raised an objection or corrected something in any of my blogs. I consider this space to be very much of a dialogue. As I work out my thinking on items in the area of sexual health, I do rely on your input. Please keep it up.
Tags: ADD > American Psychiatric Association > bdsm > Diagnostic and Statistical Manual > DSM > homosexuality > kink > masochism > psychology > sadism > the mob
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3 Responses to “Making Sex Sick:
the DSM and the Errors of Psychology”
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February 24th, 2010 @ 9:08 am
Speaking as somebody who engages in both of the above on a fairly regular basis, I’m not sure I understand the problem. The diagnosis requires that both conditions be met, right? So why does it matter what one of the conditions says when separated from the other? In the presence of both clauses, I’d absolutely agree there’s a serious problem that needs addressing.
As a f’rinstance on a different topic, let’s say we have a law that says it’s a felony to:
A – Fire a gun at another person, while/ B – that person isn’t posing a threat to the shooter.
Should I, as a gun rights advocate, be upset that the first clause without the second would condemn self defense?
Or if our current bigamy laws (which flatly prevent me from marrying both my partners on the grounds that we might be exploiting one another, traditional-polygamy style) were amended to say it’s illegal to:
A – Marry a person while already married to another person/ B – if the second spouse isn’t capable of giving meaningful consent.
Should I reject that change because the first clause _would_ condemn my family if taken by itself?
Basically what I’m saying is that both my partners and I would be tarred by the A clauses in those DSM entries if it didn’t also have the Bs, and you can color me unoffended.
February 24th, 2010 @ 9:43 am
I should have been clearer. It’s an either/or thing. As I understand the DSM, a psychiatrist can diagnose based on A alone or B alone. I’ll double check with someone who studies this more deeply than I do. If I’m wrong I’ll retract, if it is A or B, I’ll clarify. It’s exactly that: the tarring of the A diagnosis that I, and most fetish practitioners, object to.
February 25th, 2010 @ 5:04 am
One of my most alert and intelligent readers, Elmo Iscariot…
Flatterer.
Incidentally, I agree with the revised post with one reservation:
…you could fill a library with the volumes of the DSM by constructing a description of any and every human activity (sexual and non) in the A/B structure used to describe the sexual disorders.
I don’t actually have a problem with this. In a vacuum, it would be silly to single out sexual behavior for the “unhealthy when it gets too obsessive” treatment. But as you point out, the mental health field has a _long_ track record of pathologizing alternate sexual behavior. When the DSM has spent decades telling doctors to treat sadism and masochism as diseases, it seems reasonable to explicitly state in the new revision that their recommendation’s changed.