DSM5 and Sexual Disorders - Just Say No

A major general problem in the preparation of DSM5 is that the various Work Groups have been given far too little guidance and support. This explains why: 1) most of the criteria sets are written so obscurely and inconsistently; 2) the rationales for change vary so widely in depth and quality across Work Groups,and; 3) so many suggestions that should have no chance at all have made it this far without being tossed.

The Sexual Disorders Work Group has strayed furthest off the reservation. It has made a series of radical and dangerous suggestions that need to be dropped.

Sexuality is an inherently difficult arena for psychiatric diagnosis because:
o The field has generated remarkably little research and few researchers
o There are no consensus norms in sexual behavior to provide a useful boundary in deciding what constitutes a sexual mental disorder
o Individual and cultural biases play a large and difficult to sort out role
o Decisions regarding the diagnosis of sexual disorders can have profound and unanticipated forensic and societal implications.

For all these reasons, changes in the definition of the Sexual Disorders should be especially cautious and evidenced-based. Instead, the Work Group has taken full and reckless advantage of the DSM5 spirit of innovation. To get a flavor for this, review their postings yourself (at www.DSM5.org) Each of the Work Group's suggestions is based on the thinnest of research support-- usually a handful of studies often done by members of the committee making the suggestion. None has been subjected to, or could possibly survive, anything resembling a serious risk/benefit or forensic analysis. I will discuss separately the problems with each proposal, but will not keep repeating that none of them has anything but a veneer of research support.

HYPERSEXUALITY DISORDER is the strangest of constructs. The Work Group explicitly states that it is not meant to be equated with "Sexual Addiction" (which apparently, and fortunately, was rejected by the DSM5 group working on the "addictions") -- but then goes on to base its proposed definition exclusively on items that are borrowed directly from those used to define substance dependence.

The fundamental problem with "hypersexuality" is that it represents a half baked, poorly conceptualized medicalization of the expected variability in sexual behavior. The authors have not thought through how difficult it is to distinguish between ordinary recreational sexual misbehavior (which is very common) and sexual compulsion (which is very rare). Humans (especially males)frequently misbehave sexually because our brain wiring tends to favor short-term pleasure regardless of long-term consequences. Sexual misbehavior should be considered "sexual addiction" only when it is compulsive, no longer pleasure-driven, and continues despite great costs that obviously outweigh any gain.

The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive -- but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure-driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire. Making an official mental disorder category of "hypersexuality" would also have serious unintended forensic consequences in the evaluations of sexually violent predators (SVP). For more on this, please read on.

PARAPHILIC COERCIVE DISORDER is based on the idea that some (probably a small proportion of) rapists qualify for a diagnosis of mental disorder. They rape not opportunistically, or as an exercise in power, or under the influence of substances or peer pressure-but specifically because it is their preferred form of sexual excitement. This proposal was explicitly rejected for DSM-IIIR and was given no serious consideration for DSM IV. The problem is the impossibility of reliably distinguishing between the small group of hypothesized "paraphilic" rapists (who would be given a mental disorder diagnosis) and the much larger group of rapists who are simple criminals.

The distinction has taken on huge significance because of an aberration in the way the criminal justice system handles rapists. Twenty states have passed SVP statutes mandating indefinite (usually in practice lifelong) inpatient civil psychiatric commitment for individuals who have completed their prison sentence for a sexually violent crime;have a diagnosed mental disorder, and are deemed likely to repeat. The statutes are a well meaning effort to reduce the threat to public safety posed by those recidivist sexual offenders who have received prison sentences that are judged to be too short. Although the SVP statutes have twice passed Supreme Court tests, they rest on questionable constitutional grounds and may sometimes result in a misuse of psychiatry.

Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis -- Paraphilia Not Otherwise Specified -- has become a frequent justification for the psychiatric commitment of rapists who are really no more than simple criminals. Raising this diagnosis to official status would greatly compound this misuse of civil psychiatric commitment.

PEDOHEBEPHILIA is a new category that would extend the traditional definition of Pedophilia (ie,requiring that the desired sexual target be a prepubescent child) to include pubescent teenagers. Clearly, sex with underage teenagers is reprehensible and deserves appropriate punishment under the penal code. It is, however, anything but clear when (and if) sexual behaviors with teenagers should qualify as a mental disorder. This diagnosis would be subject to the same misuses in SVP cases as has been described above.

GENDER INCONGRUENCE would replace the DSM-IV term Gender Identity Disorder. The writing here is especially unclear, but there appears to be an ill-conceived suggestion to remove the requirement for clinically significant distress or impairment. Presumably everyone with an unorthodox gender identity would now get a diagnosis of mental disorder-- even if he or she is happy and functioning well. If, indeed, this is what is meant, the suggestion makes no sense at all and resurrects the same unfortunate issues that psychiatry resolved 40 years ago when homosexuality was removed from the manual. The DSM-IV approach seems best -- ie, to recognize that gender incongruence becomes a mental disorder only when it is causing significant problems.

All of these suggestions by the Sexual Disorders Work group share the common problem of medicating one or another form of sexual behavior. This would always be controversial, but might perhaps make some sense if the following conditions could be met:
o Very narrowly defined disorders that would not spread widely to the general or prison population
o The individuals described would clearly benefit from medical treatment
o The diagnosis and treatment are deeply grounded in research and clinical experience
o The diagnosis is unlikely to cause forensic or societal problems.

Each of the above suggestions falls very far short in each of these requirements. They all need the most thorough risk/benefit analysis and forensic review. I am convinced that none should be made official in the final draft of DSM5.