DSM-IV-TR and the Paraphilias - An argument for removal

Abstract: The DSM-IV-TR (2000) sets its own standards for inclusion of diagnoses and for changes in its text. The Paraphilia section is analyzed from the perspective of how well the DSM meets those standards. The concept of Paraphilias as psychopathology was analyzed and assessed critically to determine if it meets the definition of a mental disorder presented in the DSM; it does not. The Paraphilia diagnostic category was critiqued for logic, consistency, clarity and whether it constitutes a distinct mental disorder. The DSM presents "facts" to substantiate various points made in the text. The veracity of these "facts" was scrutinized. Little evidence was found in their support. Problems with the tradition of equating particular sexual interests with psychopathology were highlighted. It was concluded that the Paraphilia section is so severely flawed that its removal from the DSM is advocated. [end abstract]

All societies attempt to control the sexual behavior of their members. One mechanism of exercising this control is to define a specific sexual interest as pathognomonic for a mental disorder. Historically and cross-culturally, even an accusation of interest in specific sexual practices could result in death, imprisonment, loss of civil rights and other social sanctions. Similarly, being classified as mentally ill could result in death, imprisonment, loss of civil rights and other social sanctions. Thus, the confounding of mental illness with unusual sexual desires is understandable.

Which sexual interests are proscribed often changes; masturbation, oral sex, anal sex and homosexuality were once considered mental disorders or symptoms of other mental disorders but are now typically accepted as part of the spectrum of healthy sexual expression. [...]

The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual (DSM); it describes the diagnostic criteria and defining features of all formally recognized mental disorders. It serves as a definitive resource for mental health professionals. Although its primary influence is in the United States, its impact is global. [...] The power and impact of the DSM should not be underestimated. [...]

The problem here is that engaging in "Paraphilic" behavior qualifies the participant a priori as a candidate for diagnosis. In addition, when individuals have unusual sexual interests, there is often speculation that any presenting problems are related to their sexuality. When a behavior per se signifies a diagnosis, then by definition the behavior is symptomatic of the disorder. This confound obscures the possibility that for at least some individuals, their specific sexual behaviors are healthy expressions of sexuality and beneficial to them. The fact that specific sexual behaviors are socially unacceptable or illegal is, and should be, irrelevant to the diagnostic process.

Historically, this was the situation that confronted homosexuals. When homosexual patients presented to a psychotherapist with any problem, it was often assumed that the problem was caused or exacerbated by their homosexual interests.

(Editor's Note: The following is an extract of a report presented at a May 19, 2003, symposium sponsored by the American Psychiatric Association entitled "DSM-IV-TR and the Paraphilias: An Argument for Removal.") [The quotes above are from this extract.]

source: Article 'DSM-IV-TR and the Paraphilias - An Argument for Removal' by Charles Moser (PhD, MD) & Peggy J. Kleinplatz (PhD); Journal of Psychology & Human Sexuality, Volume 17, Issue 3-4, Pages 91-109; 2006