Pandora Replies to Dr Frances

In his recent David Letterman–like Top 19 list of DSM5 issues, Allen Frances¹ targeted a proposed revision of the  DSM-IV diagnosis of Pedophilia, and 2 proposed new diagnoses: Hypersexual Disorder (HD) and Paraphilic Coercive Disorder. He protests the inclusion of pubescent teenagers in the definition of the proposed revision of Pedophilia (including the renaming of it as Pedohebephilic Disorder) and criticizes the quality of writing of these criteria.¹ As the chair of the DSM5 Work Group responsible for those draft criteria, I need to address his poorly reasoned claims.

If Dr Frances were a thoughtful critic of the DSM5, he could at least have studied the detailed literature reviews and the stated rationales for the changes-easily accessible along with the proposed diagnostic criteria in the American Psychiatric Association (APA) Web site, www.dsm5.org. He could then submit his concerns in a Letter to the Editor of the Archives of Sexual Behavior, where all but one of the paraphilic reviews have been published online since fall 2009, or to the work group directly, through the Comments section of the Web site. He has ignored my invitation to do so,² and instead has chosen to fire off criticisms as quickly as his grandchildren might tweet their friends.

I also doubt that he has read Dr Blanchard’s³ lengthy report on the serious problems with the DSM-IV-TR diagnostic criteria for Pedophilia, which were detailed in his published report to the DSM5 Paraphilias Sub–Work Group-a report that can be downloaded for free from www.dsm5.org, thanks to a shared copyright agreement between Springer (the publisher of Archives of Sexual Behavior) and the APA. I have worked professionally with Dr Blanchard for almost 30 years, and he is the most careful writer I know. That Dr Frances would characterize Dr Blanchard’s proposed diagnostic criteria as poorly written is-to expropriate an adjective from my friend and colleague, Bob Spitzer-“absurd.” The Paraphilias Sub–Work Group has labored for months and for several hundred hours on their proposed products, and I am dumbfounded by Dr Frances’ characterizations.

In his commentary, Dr Frances (who was the editor of the DSM-IV) fails to mention the epistemological problems he created by clumsily implementing the requirement of distress and/or impairment to diagnose a paraphilia. In the versions of the DSM prepared under Dr Frances’ supervision, a person cannot have a paraphilia unless he is distressed by that paraphilia or he is harming other people because of it. A distinct but harmless paraphilia cannot exist, by definition. A man cannot be a fetishist, for example, even if he masturbates into rubber boots on a regular basis, unless he is bothered by this behavior or is impaired in his psychosocial functioning. In DSM-IV-TR, there is no such thing as a well-adjusted paraphile; such people are defined out of existence.

It is ironic that Dr Frances criticizes the wording of the proposed diagnostic criteria for the paraphilias, when the criteria prepared under his supervision contained such logical absurdities. He has often and ominously warned of future, possible “unintended consequences” of the wording details of the diagnostic criteria, but he has been strangely silent about clear errors in diagnostic criteria that should have been obvious in the DSM-IV.

To correct this problem, the Paraphilias Sub–Work Group has introduced the proposed distinction between ascertaining a paraphilia versus diagnosing a paraphilic disorder. In my view, this is an extremely creative distinction that might do well in distinguishing people who have paraphilic behavior from those who have a paraphilic disorder. He had his kick at the paraphilic can and missed it.

Regarding the proposed new diagnoses of Hypersexual Disorder and Paraphilic Coercive Disorder, Dr Frances ignores the detailed literature review by Kafka⁴ regarding the former and the advisor reports on the latter.^5-7 Regarding HD, all he can muster is an oversimplified morality lecture: “[HD] would be a gift to false positive excuse seekers. . . .”¹

For thoughtful readers of Psychiatric Times, the Paraphilias Sub–Work Group welcomes detailed feedback on its proposed diagnoses and diagnostic revisions. That is, after all, the purpose of the www.dsm5.org Web site-which is arguably the most transparent forum for feedback in the history of medicine.

Kenneth J. Zucker, PhD

Dr Zucker is chair of the DSM5 Work Group on Sexual and Gender Identity Disorders. He is psychologist-in-chief at the Centre for Addiction and Mental Health (CAMH) and head of the Gender Identity Service, Child, Youth, and Family Program at CAMH, Toronto. He is also professor in the department of psychiatry, University of Toronto. He can be contacted at Ken_Zucker@camh.net.

References

1. Frances A. Opening Pandora’s box: the 19 worst suggestions for DSM5. Psychiatric Times. 2010;27(2). http://www.psychiatrictimes.com/dsm-v/content/article/10168/1522341. Accessed February 22, 2010.
2. Zucker KJ. Reports from the DSM-V Work Group on Sexual and Gender Identity Disorders. Arch Sex Behav. 2009. Sep 17; [Epub ahead of print]. doi:10.1007/s10508-009-9548-9.
3. Blanchard R. The DSM diagnostic criteria for pedophilia. Arch Sex Behav. 2009 Sep 16; [Epub ahead of print]. doi:10.1007/s10508-009-9536-0.
4. Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex Behav. 2009 Nov 24; [Epub ahead of print]. doi:10.1007/s10508-009-9574-7.
5. Quinsey VL. Coercive paraphilic disorder. Arch Sex Behav. 2009 Oct 1; [Epub ahead of print]. doi:10.1007/s10508-009-9547-x.
6. Thornton D. Evidence regarding the need for a diagnostic category for a coercive paraphilia. Arch Sex Behav. 2009 Nov 26; [Epub ahead of print]. doi:10.1007/s10508-009-9583-6.
7. Knight RA. Is a diagnostic category for paraphilic coercive disorder defensible? Arch Sex Behav. 2009 Nov 3; [Epub ahead of print]. doi:10.1007/s10508-009-9571-x.

Dr Frances Responds

I thank Dr Zucker for accurately stating my position and then illustrating it with a particularly vivid and well-chosen example. I continue to find no reason to label as mental disorders sexual urges, fantasies, or behaviors that are harmless to others and cause no distress or impairment to the individual. As psychiatrists, we have our hands full taking care of the suffering and distress caused by real mental disorders. There is no need for us to expand our purview to cover sexual thoughts and behaviors that are private and harmless.

The behaviors captured by “paraphilic coercion” and “hypersexuality” are anything but private or harmless-but that does not make them mental disorders. There is no infallible definition guiding what should, and should not, be included in the official manual of mental disorders.

Many decisions can be tough calls. But it seems abundantly clear that these proposals from the Sexual Disorders Work Group have no place in DSM5. They offer little gain and would create significant problems. The construct “paraphilic coercion” has already contributed significantly to a grave misuse of psychiatry by the legal system in the handling of sexually violent predators-a misuse much opposed by the APA in a task force report and amicus brief to the Supreme Court.

Both constructs also medicalize undesirable sexual behavior and thereby provide a psychiatric excuse helpful to those who are attempting to evade personal responsibility.

Such obviously risky proposals would deserve serious consideration only if they fill an important need; are supported by a wide, deep, and high-quality base of scientific evidence; and would have containable blowback.

None of these conditions is met here. These proposals do not belong anywhere in DSM5-not even as Not Otherwise Specified examples.

Dr Zucker will no doubt respond that he is the expert on sexual disorders and that I don’t know what I am talking about. This would miss the point that the official diagnostic system is too important to be left exclusively in the hands of experts. Experts in any given area often have pet diagnoses that may have some value in their own hands but can cause unintended societal disasters when taken out of context and put to general use. Experts also tend to overvalue the quality and relevance of the scientific literature in their own field.

Every new diagnosis suggested for DSM5 requires (but has not yet received) a searching risk/benefit analysis and a thorough forensic review. I am confident that none of the suggestions for new diagnoses made by the Sexual Disorders Work Group would stand up to such scrutiny.

Allen Frances, MD

Dr Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.