Friday, June 3, 2011

DSMocking!

May 2013! Blue cover, maybe! No famous actress or model on the cover because that would be really weird! The major resource codifying the diagnosis of psychiatric disorders! Yes, folks, it's the proposed draft of the DSM-V! This being the Pervocracy, let's look at the sexy parts!



In my opinion, the entire Paraphilias section is coming at things wrong by listing out specific fetishes. I don't think it matters whether you're an exhibitionist or a masochist; what matters is the problems it causes. In my perfect world, all the specific paraphilias would be out of the DSM and replaced with:

Sexual Adjustment Disorder: A person has difficulty accepting their fetish, orientation, or form of sexual expression (often but not always exacerbated by the attitudes of their friends, family, and community). They experience significant distress or impairment not from the fact that they have the fetish, but from the fact that they haven't healthfully integrated the fetish into their identity.

Sexually Abusive Disorder: A person has a persistent desire to sexually coerce, exploit, or abuse others--the specific form of the coercion is not as significant as the fact that it is coercion.

I realize that the DSM is only intended for diagnosis and not treatment, but diagnosing someone as "your problem is that you have Fetishistic Disorder" suggests that the treatment is to get rid of the fetish, rather than to help them express the fetish in healthy ways.

The particular shame of the Paraphilias section is Transvestic Disorder.
A. Over a period of at least six months, recurrent and intense sexual arousal from cross‑dressing, as manifested by fantasies, urges, or behaviors.
B. The person has clinically significant distress or impairment in important areas of functioning.

The concept that there are "right" and "wrong" ways for people to dress according to gender is bad enough without codifying it into the medical literature.

It's also sexist, in that I wear "men's" clothing all the time, but I'm unlikely to be considered a transvestite because it's only weird when men do it. Which is sexism against men in limiting their clothing options; and sexism against women in saying that our clothes are so weird that you'd have to have some kind of funky fetish to want to wear them.

I realize that the language includes the "significant distress or impairment" loophole that almost everything in the DSM does, but this loophole isn't a "get out of bad idea free" card. For example, many people are significantly distressed or impaired by being gay, but we don't list homosexuality as a disorder with the "but don't worry, that's only if it's hurting you!" caveat, because the sexuality itself isn't a disorder. It's a matter of, as I described above, adjustment, and should be diagnosed as such.

I also wonder--and this isn't an accusation but a question--how much the "sufferers" of each condition have been included in the construction of the DSM-V. I get the impression that much of it is written from the perspective of "these are some patients that, I, a totally normal person who never does anything weird at all, have objectively observed," verus how much input was received from people willing to say "as someone with a thorough education in psychology who also happens to like wearing frilly panties, these are my experiences."



And then we have the minefield that is Gender Dysphoria. Unfortunately, this can't simply be tossed out with "being trans isn't a disorder!", because currently a diagnosis is often necessary for trans people to get drugs or surgery or alter legal documents listing their sex. And the wording has certainly improved from when it was "Gender Identity Disorder."--referring to "assigned gender" rather than "his or her sex," and being considerably more specific of what the manifestations of gender dysphoria might be.

Nonetheless, it still calls being transgendered a disorder. It still veers close to the "identifying the wrong part as the problem" issue present in the paraphilias section. And it also necessarily buys into gender roles and the concept of two fixed genders.

Being cis myself and not having a full view of either the legal or the psychological implications of a Gender Dysphoria diagnosis, I don't have specific alterations to propose, but I do want to point out that it's problematic.

Reading through this section, I couldn't help noticing that I would have handily qualified for a diagnosis of Gender Dysphoria in Children. Which is weird, because I'm cis; I'm somewhat masculine and rather uncomfortable with the entire idea of gender as a package deal, but ultimately I'm okay being called a lady and having lady parts. But I played "male" roles extensively as a child, to the point of asking to be called by various male names (including Batman, okay, but woe betide anyone trying to make me be dumb ol' Batgirl) and refusing to play with any toys or games I considered "girly." How much of this was true gender dysphoria, how much was internalizing the sexism of "boys are tougher and awesomer, so I want to be a boy!", how much was reaction to the fact that due to sexism a lot of boy games were awesomer, and how much was simple preference independent from gender? Shit, I still don't know.

I do know that "treating" me, either to make me into a proper girl or to transition me to a boy, would probably not have been a good course of action compared to simply allowing me to grow up as a masculine girl. I'm not saying this is the case for all non-gender-conforming kids, but it illustrates the difficulties in a diagnosis that hinges on accepting traditional gender roles.

The good news is that the people writing the DSM-V are accepting public comment, and they are still very actively in the process of revising the diagnoses. If you disagree with the way they're defining identities as disorders, you can do more than shake your fist at the sky; you can up and tell them. I'm going to.

29 comments:

  1. The DSM website hates my computer. BLEH.

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  2. You're not the only one, I can't get to it either.

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  3. great post!!

    "How much of this was true gender dysphoria, how much was internalizing the sexism of "boys are tougher and awesomer, so I want to be a boy!", how much was reaction to the fact that due to sexism a lot of boy games were awesomer, and how much was simple preference independent from gender?"

    Excellent questions to ask. I think people sometimes overlook the complexity of what creates gender identity, behavior, etc.

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  4. I'm curious about how "Transvestic Disorder" and things like that are diagnosed in the actual clinical setting. If you go in with depression and also mention your frilly panties, does that change your treatment? Or is it more of a relic? Does it depend on the type of practitioner? For that matter, if the new DSM had Holly's definitions, would psychiatrists who'd been trained under the old system actually change the way they treated people?

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  5. I actually LOATHE that trans is still a disorder and that I have had to jump through so many therapeutic hoops to get the medical procedures I wanted, when had I wanted "gender appropriate" surgeries such as breast implants, I wouldn't have had to do shit.

    Plus, I still have to deal with people who insist that being trans is a disorder, and therefore, I'm seriously mentally ill and need to be cured of my disorder.

    And I STILL can't get it covered by medical insurance! Seriously, I'd rather have to pay out of my own pocket and crap and NOT have to have a shrink give me my surgical hall pass.

    --Rogan

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  6. It's because of shit like this that I am afraid to tell my shrink about my fetishes. I'm also seeking gender transition, and I'm terrified that if my therapist found out that I fantasize about affectionately torturing my partner before falling asleep in her loving arms that she'd tell my endocrinologist not to give me hormones because clearly I'm a crazy pervert, not a trans woman who also happens to be pretty domme.

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  7. "For example, many people are significantly distressed or impaired by being gay, but we don't list homosexuality as a disorder with the "but don't worry, that's only if it's hurting you!" caveat, because the sexuality itself isn't a disorder."

    Actually, the language for a lot of these disorders looks a hell of a lot like "Ego Dystonic Homosexuality" which is the last form in which homosexuality appeared in the DSM, before it was removed for being horribly biased crap.

    The sense that I've gotten in doing research on the paraphilias is that a lot of the distinctions exist to create structure for forensic psychologists to get grants to study different theoretical criminal populations. Which is, needless to say, scary and problematic, but does explain some of the weirder distinctions within the category.

    Also, Holly, while I like your thought process on this, I'd kinda like to take it a step farther. Why does sexual adjustment disorder need to be separated out from other adjustment disorders? The DSM has a separate category known as "V Codes," which are sort of the non-pathologizing dianoses for people needing some support in dealing with difficult moments in life and the like. I think that integrating a new sexual identity or interest probably belongs there.

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  8. Transvestic Fetishism (now Transvestic Disorder) is more along the lines of a guy dresses up as a woman and jerks off to it than a guy likes to dress up as a woman, but that doesn't make it better. I suppose they felt there was some weird reason for adding this as a separate entry but I have no idea what it might be. I agree that it's probably more than just a tiny bit sexist.

    I'm currently in school to become a counselor and in studying the paraphlias I've just been annoyed the entire time. You're correct, the view for forming the DSM criteria is often come at from the "I'm normal and would never do this!" stance. It comes across as very judgmental.

    I know that in the current DSM there's a caveat about Gender Dysphoria can't come from thinking that the other gender just has it better.

    @roseblack: The problem with "V Codes" is that very few insurance agencies will cover those sessions. That's why so many divorced people complain about how expensive it is to go to a marriage counselor--it's because marital problems are under the V codes so insurance won't pay a dime.

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  9. @Anon 1:45 - Not that it's of much use if you've already got a shrink, but https://www.ncsfreedom.org/ has a resource list of kink-aware professionals, which includes a whole lot of therapists. Mileage may vary depending on where you live, but sometimes useful nonetheless.

    @Jak - You make a good point, but to me the issue there is that insurance isn't covering V Codes. It strikes me as the psychological equivalent of refusing to cover severe flu symptoms.

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  10. This is something I've been following for quite a while. I regret not having written in way back when they were taking public comments, although I'm sure it would have accomplished fuck-all anyway.

    Over all I'd have to say it's an improvement, but there are some trouble spots as well.

    This blog mentions some of the same parts that worry me. The DSM site isn't working for me either, so I can't double check if any of that has changed in the current draft, but it hadn't as of last time I looked.

    I do like the fact that they now acknowledge that a paraphilia is not always a disorder. But more drastic changes like Holly suggested are needed in the long term.

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  11. Another major one is that asexuality and hypoactive sexual desire disorder.

    bdelli

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  12. "But I played "male" roles extensively as a child, to the point of asking to be called by various male names (including Batman, okay, but woe betide anyone trying to make me be dumb ol' Batgirl) and refusing to play with any toys or games I considered "girly." How much of this was true gender dysphoria, how much was internalizing the sexism of "boys are tougher and awesomer, so I want to be a boy!", how much was reaction to the fact that due to sexism a lot of boy games were awesomer, and how much was simple preference independent from gender? Shit, I still don't know."

    Oh, yes -- this. Totally this, for me, too. I'm a very happily cis female and a big fat zero on the Kinsey scale, but I grew up wanting to be a boy and even today won't wear anything pink if I remotely have a choice. I still don't understand how all that maps out . . .

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  13. Really, the issue shouldn't be "what do you do in bed", but does what you do in bed satisfy you and is it voluntary with other people?"

    I mean a person with a fetish having vanilla sex is going to be unsatisfied- a problem- and a person involving another person in their fetish without discussion and permission is sexually aggressing against that person.

    as long as it's all consensual and satisfying, what does the DSM care?

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  14. Is there any validity at all to the theory that expression of some difficult fetishes (in porn or fantasy form) causes an uptick in fetish behavior? The context I've heard this in is for pedophilia.

    In a more general sense, is a fetishist in fact stuck with what they have; if there's nothing that's both possible/ethical and satisfying, is there any hope?

    It would be nice if there's a consenting adult partner with some child-like traits for the pedophile... but it seems overly optimistic to count on that sort of expression being possible for all difficult fetishes.

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  15. What about 'Call Me Asshole' in this column:
    http://www.thestranger.com/seattle/SavageLove?oid=8194197

    Dan does not suggest therapy, but do you think in a world of ideal open-minded therapists, they have anything to offer him?

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  16. Corresponding to the US DSM on an international plane, there's the World Health Organization (WHO) and its International Classification of Diseases.

    Encouraging news articles about countries chucking sexual preferences (such as sadomasochism), sexual identities and gender expressions off their lists of illnesses can be found on the front page of Revise F65.

    www.revisef65.org

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  17. sexism against women in saying that our clothes are so weird that you'd have to have some kind of funky fetish to want to wear them.

    Well, I do think you'd have to be somewhat crazy to voluntarily wear clothes without any pockets.

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  18. On the issue of patient input, there is some interesting stuff going on with a patient-advocacy group called B4U-ACT Inc., which aims to make compassionate mental health care available for minor attracted people (MAPs). Virtually all of the information about pedo(hebe)philia that the DSM is relying on is based on forensic populations, with the result that law-abiding people with similar attractions are entirely excluded, which reinforces stigma and prevents the accessibility of compassionate mental health care for MAPs.

    With your Sexually Abusive Disorder, I understand where you’re coming from, but the consequences of this would be horrific in light of so-called Sexually Violent Predatory (SVP) commitment that, in the US, 20 states and the federal govt. have, which allows them to lock up certain offenders after completing their sentences. To do so, they need some “mental disorder” and they’ve just been making shit up to lock people up in these gulags. For more information, check out DSM-5 Paraphilia Bibliography.


    @anonymous, hypoactive sexual desire disorder is listed among the sexual dysfunctions, not the paraphilias, and the politics there is quite a bit different.

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  19. ACH - I think the problems you bring up have less to do with the definitions in the DSM, and more with the way it's used. The DSM seems to be created to diagnose and used to condemn--the same process used to determine "this person has a desire to sexually abuse others, and should be helped to resist and reduce that desire" is simultaneously used to determine "this person has a desire to sexually abuse others, and is a bad person who belongs on the other side of the moon."

    I think we need forensic criteria that are just completely separate from the diagnostic ones. (And that the forensic criteria need to acknowledge "desires the patient has, but is absolutely determined to never act on" as possibilities.) The purposes are so wildly different.

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  20. RE: perlhaqr

    We have a dress with pockets! It's just some of them that don't. O_o I don't know why. I think the more pocketastic, the better! :D

    --Sneak

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  21. I have a couple dresses with pockets, and they are absolutely the best. The only problem is with the strapless one - there's a weight limit on how much I can hold up by the power of my boobs alone. Talk about clothing designed to be impractical!

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  22. Hershele OstropolerJune 4, 2011 at 11:14 PM

    You're correct, the view for forming the DSM criteria is often come at from the "I'm normal and would never do this!" stance. It comes across as very judgmental.

    I wonder how much less judgmental it would seem if we could remove the stigma on the mentally ill.

    That's not easier, necessarily, but I think it attacks the problem on a much more fundamental level.

    One way to do that -- not the only way, or even necessarily the best way -- would actually be to cram more stuff in there. If everyone does something that, if it causes distress, is a disorder, than no one can really throw stones.

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  23. @roseblack: You're right, most of the V Codes are things that can lead to greater health problems (both psychological and physical). That's an insurance issue, though, not a psychological one. Psychologists can't really do much about V Codes, and if they try to code the person somewhere insurance will cover it they can be punished for insurance fraud.

    @Hershele: I think the other side of the problem is that we want to assume there's some sort of normal and if you're not normal YOU MUST BE FIXED, DAMMIT! Take away the judgement, and make sure to think that nobody is really normal in this aspect, and that after you've worked through trying to find a partner and expressing it in a good and safe way you are still significantly distressed by your difference then that is the time to go in and attempt to find someone to talk to.

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  24. Aaaaand the DSM is also considering revising the diag for DID as YOU ACTUALLY HAVE TO BE UNHAPPY OR INCONVENIENCED BY IT!

    :D Hooray! We might actually be able to argue with non-sympathetic shrinks that we can't be diagnosed now!

    --Rogan/Sneak

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  25. I basically agree with you, especially about the part where psychologists are orienting their literature in such a way that it assumes a "normal" person is observing an "abnormal" person and therefore has greater authority to judge. However, I think the problems caused by sexual disorders can go beyond questions of whether you're 1)comfortable with your sexual desires or 2)sexually assaulting someone.

    There's a difference between being kinky and having a fetish that restricts your sexual repetoire to one thing, and one thing only, no matter what you might otherwise want. That's where the "distress and impairment" stuff gets serious. Paedophiles were an example another commenter gave above, but so are people who fetishise anything else they can literally never have, or people who are unable to have "normal" dating and sexual relationships with others because the only thing that arouses them is a fetish object, or people who were physically or sexually abused as children and got locked on a pattern of re-enacting that abuse in a way that continues to traumatise them instead of making it better. In those types of situations I do feel like it's fair to say, "Something has gone awry here, because you're compulsively fixating on something you don't want to fixate on." And, in that case, having the fetish would be what's causing their distress.

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  26. I'm learning so much here... I've never been in an environment where these things have been discussed, and English is not my language, so I won't try to add anything. I just wanted to thank you for writing, and tell you how glad I am I've found your blog. Not only because I've experienced obstacles both from within and from without, so to speak, when exploring my own sexuality, but also because I as a parent have struggled to find ways to support our little boy, who doesn't "fit in". I want him to have a safe haven at home, but I'm still uncertain as to how much we should fight for his rights at school - and how much we should just teach him to handle the fact that some people will never treat him with the respect he deserves. It's hard to find people to talk with about this - some of those we've told, thinking they might be helpful, have simply been upset with us for not "setting him straight", "drawing the line"... he's 6 yrs old. Anyway, thank's for making me understand it a little better.

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  27. "It's also sexist, in that I wear "men's" clothing all the time, but I'm unlikely to be considered a transvestite because it's only weird when men do it. Which is sexism against men in limiting their clothing options; and sexism against women in saying that our clothes are so weird that you'd have to have some kind of funky fetish to want to wear them."

    Possibly the best line that ever came out of my husband's mouth was "It's not women's underwear; it's MY underwear." (In reference to the lacy panties he had, for whatever reason, chosen to wear to the party that night.)

    "Is there any validity at all to the theory that expression of some difficult fetishes (in porn or fantasy form) causes an uptick in fetish behavior? The context I've heard this in is for pedophilia.

    In a more general sense, is a fetishist in fact stuck with what they have; if there's nothing that's both possible/ethical and satisfying, is there any hope?

    It would be nice if there's a consenting adult partner with some child-like traits for the pedophile... but it seems overly optimistic to count on that sort of expression being possible for all difficult fetishes."

    Not something I talk about much, for obvious reasons, but a close friend of mine is currently in therapy for pedophilia. From what I can gather, being sexually attracted to children doesn't mean he's not also attracted to adults (and not even particularly "child-like" ones.) The knowledge that he can't act on a particular sexual desire doesn't mean that he can't enjoy other, fully consensual relationships.

    "Reading through this section, I couldn't help noticing that I would have handily qualified for a diagnosis of Gender Dysphoria in Children."

    Heh, probably me too. As one of those fruity reincarnationist people, I have a pretty good idea that most of my incarnations have been male. I'm enjoying my life as a woman, but I tend to think of it as a ~70 year long vacation - a nice place to visit, but I wouldn't want to live here. (Does that make sense? Have I just outed myself as a weirdo? Reading through the comments, I get the idea that if I were going to do so anywhere, here might be the best place.)

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  28. Y'know, I'm sick of transgender people thinking everything is about them.

    Gender Dysphoria/ GID, whatever is a diagnosis that's supposed to be for TRANSSEXUAL people. No, it's not a disorder to dress how you like. It's not a disorder to assert your gender. But it's not a disorder to be sad. It's not even a disorder to be MISERABLY sad. So why do we have "Depression" as a disorder? We have it because depression is seriously linked to morbidity. Transsexuality is seriously linked to morbidity. We kill ourselves because we cannot exist within our bodies. We become unable to have sexual relationships because we cannot exist within our bodies. We cut organs off or flay skin because we cannot exist within our bodies.

    When this happens, THERE IS SOMETHING WRONG. To say that transsexuality exists and that by virtue of its strong link to morbidity it deserves attention to ensure that each transsexual person has a decent shot at living as heathfully as possible in as healthy a body as possible is NOT the same thing as saying that being TRANSGENDER and playing with drag is wrong.

    PLEASE - Don't make this about transgender people when it's not. There's are so many transgender people around right now that it's easy to think that the only way to be trans is to be transgender. It's not true. And listening to transgender people say that GD shouldn't be in the DSM is like listening to people who keep their houses clean say OCD shouldn't be in the DSM. Yes, there's a relationship, but really, seriously, it's not like everything is about you. Maybe, just maybe, what's happening in the DSM is about someone else.

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  29. The DSM has come a long way, but still has a way to go. The problem is that they're focusing on "abnormal" as opposed to "unhealthy".
    On an entirely different note, how could you not like bat girl? Cassandra Cain is such a badass!

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