DSM V Idiocy
There’s a piece in New Scientist about the controversy surrounding the development of the DSM V – the American Psychiatric Association’s Diagnostic and Statistical Manual (5th edition). The article and an accompanying editorial make for very interesting reading.
The DSM is one of the two major diagnostic manuals in use; the other is the ICD (International Classification of Disease) which is not limited to psychiatric illness/disorder. There are significant differences and similarities between these two books, but I won’t go into that, as it’s not relevant to this post/rant. What is relevant is to understand why we have these books at all; can’t we make a diagnosis without them? Well, yes. Yes we can. We used to, quite happily. However, there were marked differences in diagnostic (and therefore treatment) practice between Europe and North America – for example: more diagnoses of bipolar disorder in Europe, and more of schizophrenia in North America. Even within a country diagnostic practices were of uncertain reliability – and validity.
The DSM then, had as its aim the standardisation of diagnostic practice, by the development of empirically validated lists of symptoms that would allow the reliable delineation of various syndromes. Given that we don’t have any examination or lab test that can tell us specifically a patient’s diagnosis, we work with syndromes – much as internal medicine used to many years ago, with for example detailed description of all aspects of a patient’s cough; now we have throat swabs, and chest x-rays, and microbiology labs, that can tell us what’s going on – however we choose to describe the cough. As a cynical Antipodean I would say that the DSM more recently has another purpose: that of HMO cookbook, but that’s another topic for another day …
The DSM is revised (we’re on DSM IV TR (text revision) now) by a task force which examines the evidence around currently included disorders, and proposed new inclusions. It is a couple of proposed additions which concern me, and have prompted this post.
Hebephilia
First, we have Hebephilia:
Hebephilia refers to when adults are sexually fixated on teenagers around the time of puberty. This sets it apart from paedophilia, which refers to a focus on pre-pubescent children. The DSM-V work group on sexual disorders is likely to call for paedophilia to be renamed paedohebephilia, and include a hebephilic subtype.
Ok. I have kids. I get that we don’t want to think about dirty blokes having dirty thoughts about our young people – much less actually trying to do something about those dirty thoughts. But exactly how far are we going to stretch our concept of abnormal/ill? As quoted in New Scientist:
Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. “People didn’t used to live so long and mating started earlier,” she says.
But there’s another thing (so to speak) that I want to focus on. From where does this notion of hebephilia come?
The justification is the research of one work group member, Ray Blanchard of the University of Toronto in Canada. Working with sex offenders, Blanchard used a device that records blood flow in the penis to measure their arousal while they were listening to sexual material. He concluded that some men have a disorder that causes them to fixate on girls aged 11 to 14 (Archives of Sexual Behavior, vol 38, p 335).
… Dude. Srsly? First: you’re looking at a group of sex offenders. Looks like you set up the situation to maximise the chance of finding something abnormal. I suppose then you might have your name attached to something in the DSM … Just sayin’ …. Secondly: you took a bunch of men, and attached devices … to their penises… and checked to see whether there was any change in blood flow (aka a little chubby) and tried to correlate that with the material you were showing them. Srsly. Dude. You’re a dude. Right? Do you really think a little penile tumescence is that unusual? Bear in mind you’ve attached devices to the willies of sexually deviant men. Are you really surprised there was a bit of nether swelling? Really? – And are you really suggesting seriously that their little chubbies meant they were actually aroused by, and wanted to do stuff to, whatever it was they were looking at? Really?
I’m reminded of a patient way back at the beginning of my training. This man was psychotically depressed. He was wracked with guilty delusions about bestiality, which stemmed from an erection which developed while sitting in the sun stroking a cat which was lying on his lap. So: relaxed, warm, pressure on the groin, involved in a grooming activity … he didn’t want to have sex with the cat, and only an idiot (or a depressed and delusionally guilty person) would think so. Desire certainly can/does lead to physical arousal, but (at least minor) physical arousal Does. Not. Mean. Desire, or any likelihood of action. While I haven’t read the paper itself (I can access Archives of Sexual Behaviour through my employer, but oddly, only one article from that particular issue – dunno what that says about either the journal or my employer …), the fact that a device was needed to measure blood flow suggests that none of these subjects were sporting obvious erections. 
This really does suggest to me a basic lack of logic, and of understanding of how people work.
Paraphilic Coercive Disorder
The other proposed “disorder” mentioned is Paraphilic Coercive Disorder. They say less about it, only:
The work group is also considering whether some men are specifically turned on by rape – a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.
All I’ll say (in addition to the same points I made earlier about the devices on the willies) is that it strikes me that this would mena that half or more of the BDSM community would instantly have a psychiatric disorder.
A little more thought, and a little less puritanism might be in order. People’s bodies do all sorts of things that don’t mean they want to do dirty stuff; remember that our bodies are 50,000 years “older” than our society. People fantasise about all sorts of dirtys that they would never actually do – and large numbers of people do things (completely consensually) that many others would find highly disturbing – including power and coercion. Who can turn around and rightly say that that represents psychiatric illness?
Along with the other mentions of diagnostic creep, I await DSM V with considerable trepidation. At least it’s been pushed back to 2013 – heh, 2012 was probably not a good year to release it anyway
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