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Dr. James M. Cantor |
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“Depathologize!”:
A follow-up. If I had to pick
the top theme that sexologists and sexuality interest groups were discussing
in the lead up to the proposed DSM changes, that would be it: Depathologize, depathologize,
depathologize. From blogs to
letters to editors of research journals, there have been demands that the DSM
declare as officially normal
various sexual phenomena, ranging from purely consensual situations (like
transsexualism and BDSM) to those that motivate sexual offenses (such as
pedophilia and hebephilia). With the release of the DSM5 proposals from their
various workgroups, I thought it was worth revisiting. I was actually quite surprised by which of
the DSM committees did and did not remove the label mental illness and from whom: 1. Despite
being under the most pressure (probably) to remove the diagnosis of Gender Identity Disorder (GID), the gender committee of the DSM
(composed of Drs. Jack Drescher, Heino F. L. Meyer-Bahlburg, and
Friedemann Pfäfflin and
chaired by Dr. Peggy Cohen-Kettenis) has, in
effect, widened that
diagnosis. In the DSM5 proposal, Gender Incongruence (the new name)
also includes people born with physical Disorders
of Sex Development (DSD)—such as people who are born with ambiguous
genitalia and who dislike the gender to which they were assigned at
birth. In the old DSM (DSM-IV-TR),
people with DSD were specifically excluded
from being diagnosed with GID. (Although they rarely received any DSM
diagnosis in practice, they could be diagnosed under what amounted to an
“other” category.) 2. In contrast, the
paraphilias committee of the DSM (Drs. Martin Kafka, Richard B. Krueger, and Niklas Långström, and
chaired by Dr. Ray Blanchard) greatly narrowed
the range of what is deemed a mental illness. In the DSM5 proposal, people
with atypical—but otherwise consensual and unproblematic—sexual activities
such as cross-dressing and BDSM would no longer be diagnosed with a disorder
at all. 3. The remaining depathologization discussions have pertained to
paraphilias associated with nonconsensual
behaviors. Although there have been people at the extremes, writing that even
the sexual preference for children should be deemed normal by removing it
from the DSM, the paraphilias committee kept the basic scope roughly the same
as before, but repaired contradictory criteria that were in DSM-IV-TR.
Whereas DSM-IV-TR used the diagnosis Pedophilia
very broadly (applying it to people whose sexual preference is for children
up to age ~13), the DSM5 proposal uses more homogeneous groups: Pedophilia (the sexual preference for prepubescent children, up to age 10)
and Hebephilia (the sexual
preference for pubescent children,
ages ~11–14), bringing it into line with the definitions most often used in
current research studies.* So, some
diagnoses were widened, some narrowed, and some left the same. To me, the most
surprising of these changes was the expansion made by the gender committee,
widening Gender Identity Disorder
to include people with Disorders of Sex
Development (called Intersexes
in DSM-IV-TR). The life experiences of people with DSD are very different
from those of transsexuals.
Transsexuals struggle terribly trying to convince society of
their compelling need to change their bodies, despite having no visible
evidence of a physical disorder.
People with DSD, however, suffer the very opposite: Born with very
clear evidence of a physical disorder, society
compels them to change their
bodies, even before the infants grow to an age to express what those changes
should be (if any). Combining very different situations decreases rather than
increases the precision of the manual’s terminology. In the years
leading up to the DSM5, the primary arguments for removing versus retaining
transsexualism have been: (for removal) that being listed in the DSM conveys
an unnecessary stigma; and (for retention) that medical insurance will cover
only medically necessary treatments, and in the absence of physical evidence
of a physical pathology, recognizing transsexualism in the DSM establishes it
as a bone fide medical condition with a bone bide medical resolution
(hormonal and surgical sex reassignment), despite the lack of physical
evidence. The gender committee’s proposal suggests that they believe
transsexuals indeed receive greater benefit by remaining in the DSM. Obviously, the
gender committee felt that Disorders of
Sex Development merited reclassification, but it is less clear why it
would be reclassified rather than entirely depathologized.
Unlike with Gender Identity Disorder,
no medical care becomes available to people with DSD from being in the DSM
that is not already available to them under their physical diagnosis (e.g., Congenital Adrenal Hyperplasia, etc.).
No government-issued identification or other document becomes changeable that
could not already have been changed on the basis of the physical diagnosis.
To me, having DSD in the DSM is all cost and no benefit. Rather than depathologize DSD, however, the gender
committee is elevating the status of DSD from one of several possibilities in
a DSM “other” category, up to a specifier of the
primary diagnosis. In one
discussion among professionals on the proposed changes, Dr. Randall Ehrbar, a clinical psychologist and openly trans man, saw
an ideological overtone to the combining of transsexualism and DSD. “I agree
that the addition of the DSD specifier is a
mistake....Because many trans people and providers strongly believe that
being trans is per se reflective of
a neurological intersex condition, I fear the use of this specifier
would reflect the ideology of providers rather than the presenting concerns
of clients.” Another critic
of the proposed change is Dr. Allen Frances, who was the head of the prior
DSM. Although I disagree with other
things he has written on the DSM5, I believe his comment regarding the new Gender Incongruence criteria was quite
apt: 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 they are happy and functioning
well. [The previous] approach seems
best—i.e., to recognize that gender incongruence becomes a mental disorder only
when it is causing significant problems. [Ref1] I have not yet seen any
reaction from DSD community or family groups about the proposed changes. I suspect that they have been caught by
surprise (as have I). Although
transgender and other groups have been following the DSM discussions very
closely for many years, the widening of the primary gender-related diagnosis
was not discussed by DSD groups. The issues of interest to DSD advocates
usually pertain to how infants are treated, what sex they should be raised
as, and whether any surgeries should be conducted in infancy or later in
life, when the persons are able to make decisions for themselves. This change to the DSM seems (to me) to
have come out of nowhere. It will be
very interesting to see what the DSD communities’ responses will be, as they
organize their reactions. The change to the criteria for
paraphilias involving consenting
sexual behaviors, such as cross-dressing and BDSM (e.g., bondage/discipline),
provides a clear split: Persons who sexually prefer such activities may be
said to have a “paraphilia” but would not
be diagnosed with a mental illness (now called a “paraphilic disorder”) when
those activities cause no harm or distress. This change has garnered explicit
community support. According to the National
Coalition for Sexual Freedom: In the new proposals for the
DSM-V, alternative sexual behavior has been depathologized….NCSF
has worked very hard with its DSM Revision Project to make sure these changes
take place, and will continue to strongly advocate for clear language of what
exactly constitutes a mental disorder.
[Ref2] The proposed changes to the
diagnoses about having sexual preferences towards children appear to have
been structural only. Although there have been individual authors—such as
Karen Franklin [Ref3]
advocating for the depathologization of Hebephilia (the sexual preference for
11–14 year old children), and Richard Green [Ref4], for
the depathologiziation of Pedophilia (the sexual preference for children under 11)—the
criteria have been “cleaned up” rather than broadened or narrowed. The DSM-IV-TR said on the one hand that
pedophilia was a sexual attraction towards prepubescent children, but it
nonetheless used age 13 (which is long after the mean onset of puberty in the
The DSM5 criteria resolve that
inconsistency: The term Pedohebephilia
will refer to sexual attraction to pubescent or prepubescent children
generally, with “pedophilic type”
used for those whose sexual interests are limited to prepubescent children (Tanner Stage 1 of physical development,
usually under age 11), “hebephilic
type” used for those whose sexual interests are limited to pubescent children (Tanner Stage 2 or
3, usually ages 11–14), and “pedohebephilic
type” for those whose interests span both stages of development. There has been little community
input on this aspect of the DSM5. Although there exist groups advocating for
increasingly punitive reactions to sex offenders against children, there has
been little discussion (that has reached my own desk, anyway) about what the
general community believes would be the optimal cut-off for how young a
sexual interest has to be before one might consider it a mental illness (if
at all). In fact, that would make for an interesting, if overdue, survey. Given the many expressions that the
DSM should pathologize less, I would certainly have predicted that the sex
and gender workgroups would reduce the range of situations receiving a
diagnosis. I would not have predicted,
however, that it would be the
paraphilias committee rather than the gender committee which actually did
so the most. For those
interested, the full text of the proposed DSM5 diagnostic criteria are
available from the website of the American Psychiatric Association, and they
are requesting public input: DSM5
Criteria for the Sexual and Gender Identity Disorders (proposed) — James M. Cantor, PhD, *In the interests of full
disclosure, I should point out that I am a co-author or lead author on many
of the published studies that explicitly included a group of hebephiles. Although there are writers who inaccurately
refer to hebephilia as a sexual interest in “teenagers” (ages 13–19) or
“adolescents” (approx. ages 11 to early 20’s), the work from my own team is
very specific in referring to the sexual preference in pubescent children, ages 11–14. |
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Last updated 17
March 2010 |