The DSM Needs to be Based on Research


I’ve been following the developments surrounding the upcoming changes to The Diagnostic and Statistical Manual of Mental Disorders (DSM). If you’re not familiar with it, the DSM is a document produced by the American Psychiatric Association and it effectively serves as the dictionary of mental health. If a doctor, therapist, psychiatrist or other mental health professional wants to submit paperwork for insurance reimbursement, they need to include a diagnosis code from the DSM. In fact, that was the original intent when the DSM was first created. However, it has evolved to the point where inclusion in the DSM is pretty defines what mental health means.

That would be fine if everything included in the DSM was based on actual research. And for many of the diagnoses, there is plenty of clinical evidence to support the definitions. But when it comes to the sexuality diagnoses, the criteria are often based on prejudices and misconceptions rather than facts. There’s generally some grain of truth to some of them, but they’re still rooted in sex-negative definitions of pleasure that don’t take sexual diversity into account.

In all fairness, the DSM includes some version of “[t]he problem causes clinically significant distress or impairment” in the diagnostic criteria because there’s a general recognition that if everyone is happy with their sexual desires and practices, there’s no problem. But it’s all too easy for a therapist to decide that the problem in a relationship rests with the person who wants to try BDSM, cross-dress, or what have you. Since most therapists get less than 10 hours of sexuality training, plenty of them fail to distinguish between problematic sexuality, sexuality that a partner has a problem with, and sexual practices that the therapist has problems with.

One of the best ways to ensure consistent, fair, and compassionate care would be for the diagnostic criteria to be based on research instead of sex-negativity and erotophobia. So I think it’s really great that the Society for the Scientific Study of Sexuality sent the letter below to Ken Zucker and the rest of the folks working on the changes to the sexuality section of the DSM. We need more of this in the world:

March 18, 2010

Ken Zucker

DSM-V Sex and Gender Disorders Workgroup

Dear Dr. Zucker:

We, the Board of Directors of The Society for the Scientific Study of Sexuality, support the American Psychiatric Association’s (APA) own goal of making its Diagnostic and Statistical Manual (DSM) a scientific document, based on empirical research and devoid of cultural bias. A diagnosis of a mental disorder, especially in the Sexual and Gender Identity Disorders section, can have a severe adverse impact on employment opportunities, child custody determinations, an individual’s well-being, and other areas of functioning.

Therefore we urge the APA to remove all diagnoses of sexual pathology that are not based upon peer-reviewed, empirical research, demonstrating distress or dysfunction, from the DSM. The APA specifically should not promote current social norms or values as a basis for clinical judgments, such as the pathologization of some erotic minorities who are not doing harm to themselves or others, but who may feel ego-dystonic due to societal stigma placed onto them by a naive or unkind culture.

On behalf of the Board of Directors, thank you for your time and consideration,

Herbert P. Samuels, Ph.D.
President SSSS

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5 Responses so far.

  1. Jeffry says:

    How silly Charlie. The DSM is written so doctors can get paid for their services. It’s really kind of ridiculous that it even needs to exist. Got to have those numbers so forms can be filled out so someone with a high school education can determine (better than the doctor or the patient) whether therapy was “medically necessary.” The insurance industry sucks, and not in a good way. The current health care bill will probably make it even more intrusive and more difficult to work with. Sigh!

  2. Charlie says:

    I get what you’re saying. And given that this is the system we’ve got, I still think that it’s better to have the DSM based on clinical evidence rather than prejudice and misinformation.

  3. Jeffry says:

    OK, read the letter, but what it leaves out is why the patient went to the psychiatrist in the first place. Did they go because their sexuality is causing harm to them, their relationship or third parties? Then it’s pathology and they need to have a “number” for it so it has to be in the DSM. If it’s not pathological than a Dr. isn’t likely to treat it. Know what I mean? Inclusion in the DSM doesn’t mean someone is demonized in therapy because they live it. YMMV. Maximum flexibility is what the doctor needs in today’s crappy fee for service system. If someone in this equation gets screwed out of their money, it’s almost always the doctor. If we want doctors to be there when we need them, we need to make sure they can get paid when they do their work.

  4. Jeffry says:

    Since my wife taught seminars to medical students on transexuals, I’ll bet she got a whole lot more than ten hours of sexuality training. I’ll ask her. I’m pretty sure prejudice and misinformation is not what informs the DSM, but complaints of patients throughout history do. Perhaps you could mention some specific sections and support your notion they aren’t based upon evidence and information. In general I support what you want to do, specifically I don’t see the problem.

  5. Charlie says:

    Most MSW students in California get 1 unit/10 hours of class time in sexuality. I know because I taught for a few years at JKFU and they were proud to offer 2 units (20 hours) on the topic. And CA has higher requirements than many states.

    BDSM has been in the DSM for years despite any evidence that BDSM practitioners can be distinguished from anyone else. The same applies to cross-dressing and other sexual practices- the assumption has always been that the sexual behavior is the problem rather than the possibility that there are some deeper issues that show up through sexual behaviors. Other people can engage in the same sexual practices without it being a manifestation of a disorder.

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