This also appeared on CarnalNation.com.
As some of you may know, The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a document produced by the American Psychiatric Association. It serves as the official list of how we define mental health and mental health disorders. In a nutshell, if it’s in the DSM, it’s officially a disorder.
The hope, at least for most ethical, well-trained, and compassionate professionals, is that the diagnoses are based on clinical evidence, scientific research, and fact. That’s a tall order, given that our understanding of mental health processes is constantly growing. So every few years, the APA gets a bunch of folks together and revises the document. It doesn’t happen often and it has been about 10 years since the last version (the DSM-IV-Text Revision) came out. The DSM-V is currently being developed and is scheduled to be published in 2012.
One of the goals is for the diagnoses to be both reliable and valid from a scientific perspective. Reliability means that different care providers assessing similar clients will come to the same conclusions regarding what diagnosis to make. Validity means that the diagnoses are consistent with mental health theories. Unfortunately, both of those are hard to ensure when it comes to mental health, for a number of reasons. For example, there are many different theories that people claim account for variations in mental health and until we develop a unified model of mental health, claims of validity are hard to back up. And each therapist tends to bring their own interpretation to their clients’ sessions, making reliability tricky.
But when it comes to the sexuality diagnoses, things start to get even messier than usual. (Isn’t that always the way!) Given the erotophobia and sex-negativity that runs through US and Western culture, it really doesn’t come as a surprise that the DSM diagnoses rely on a set of assumptions that re-create a model of “normal” sex. Less common sexual practices are held to a different standard than those that are more widely accepted and in many cases, there’s no way to distinguish between the behavior and the supposed problem. One of the ways that they’ve tried to work around that is by making one of the required criteria “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” In a nutshell, the intent is to make it clear that if the situation doesn’t cause distress to anyone, then it’s not a problem.
While there are clearly some good reasons for that, it also creates complications. After all, how do you decide that the solution is to change the behavior of the person with the presenting issue instead of changing their circumstances? If someone feels just fine about something that their partner has problems with, where does the solution lie? When does a strong interest become an obsession, and why do we have a different standard for sex than, say, football? After all, a football fan who organizes his life around his favorite team is much less likely to face stigma than someone who organizes their life around sex.
These are the sorts of issues that mental health professionals struggle with, and it’s especially challenging when the therapist has a negative reaction to whatever their client’s sexual desires are. I have a lot of compassion for them. It’s not an easy job and the best tool they have is their entirely fallible, human intuition. It’s no wonder that some of them are trying to standardize things and that’s why it’s important to have the DSM based on empirical evidence instead of prejudice and sex-negativity.
The National Coalition for Sexual Freedom is circulating an online petition to remove BDSM practices, fetishes and cross-dressing from the DSM. These sexual practices, preferences and desires are not, in and of themselves, the result of or the cause of mental health disorders. It’s true that some people with serious conditions also engage in these behaviors, but so do many millions of other people and the empirical evidence simply doesn’t support the erotophobic belief that these sexual expressions are inherently unhealthy or dangerous.
Further, quite often, the problem is with the lovers, family members and communities of the people who engage in uncommon sexual practices. The distress comes from the external sex-negativity rather than the sex itself. Until and unless the DSM makes it possible to distinguish between the behavior and the supposed disorder there is no reason to attach the stigma of a mental health disorder to people when it’s not warranted, especially given the impact that can have on child custody, employment, self-esteem and medical care.
The effects of the DSM on people’s lives are expansive in both scope and scale. We deserve diagnostic criteria that are accurate and scientifically valid. Otherwise, we’re letting the APA be the sex police and we are worth better than that. I invite and encourage you to go to the petition site and sign it. You can make your signature anonymous on this secure petition site so it doesn’t appear on the Internet or when the petition is delivered to the APA.
If you want more information, the National Coalition for Sexual Freedom has a wonderful document called the DSM Revision White Paper (catchy name!) The White Paper shows in great detail how the sexuality diagnoses are biased and how these sexual practices are held to a different standard than those that are more widely accepted and how the DSM makes no attempt to distinguish between behavior and dysfunction when it comes to sex. Check it out and pass it on.
This is only the beginning of the problems with DSM-V, which has seen regular defections and resignations of editors and researchers. I have blogged about this a few times, including linking to this article about unintended consequences in Psychatric Times. In short, while I wouldn’t stop anyone from signing the petition, I wouldn’t recommend holding your breath until the changes are made either.
clearly BDSM, consensual practices and cross-dressing are not pathological, are not “diagnoses” and should never have been construed as such. however, i do lean towards the idea that some fetishes – those that imply non-consensual relations, such as bestiality, pedophilia, rapism, should still be included in the DSM. it’s a fine line, but i think that line can be drawn at the place where personal desire becomes violations of anothers’ boundaries.
Interesting point by Lia about pedophiles. Does willpower come into it? For example are there good and bad pedophiles out there? The good ones would realise what they are but resist, the bad ones indulge.