Hypermedicalization Disorder

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I've been reading the sexuality-related proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Assocation and I'm troubled. In the move from DSM-IV to DSM-V It seems that larger and larger realms of sexual expression are falling under the rubric of psychiatric disorder. This is the wrong approach to the difficulties people have with sex.

My reading started with the newly proposed diagnosis "Hypersexual Disorder" because a reader asked me if I intended to post about it. The new diagnosis is a response to the increasing use of the loosly defined and largely bogus label "sex addict." The American Psychiatric Association subcommittee that put this new diagnosis together says, in its rationale statement:

There is a significant clinical need, even a “demand” from mental health consumers, for mental health providers to recognize and diagnose a distinct group of men and women who have been seeking and are already receiving mental health care such as individual psychotherapy, 12-step group support, pharmacotherapy, and specialized residential treatments. These men and women are presenting to clinicians because of recurrent, “out of control” sexual behaviors that are not inherently socially deviant (i.e., normophilic, not paraphilic). Persons afflicted with these conditions are currently diagnosed as Sexual Disorder Not Otherwise Specified, a diagnostic wastebasket that the DSM-V editors would like to see diminished in scope. Clinical and research-based interest in this set of problematic nonparaphilic sexual behaviors is sufficiently established to have birthed a peer-reviewed journal published since 1990 dedicated exclusively to research and treatment of “sexual addiction/ compulsivity.”

This, on its own, is troubling. The diagnostic criteria are even more troubling. Direct from the DSM-V Revision site, here are the criteria:

A.    Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

(1)   A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior. [15]

(2)   Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). [16]

(3)   Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events. [17]

(4)   Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior. [18]

(5)   Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. [19]

B.    There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. [20]

C.     These sexual fantasies, urges, and behavior are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication). [21] 

If a person meets four of the five critera in section A then clearly they are either troubled enough by their own sexual urges and desires that they are trying to curb them or they are recklessly engaging in sexual activity repeatedly. Either one of those issues alone is enough to justify a person's seeking help. But medical help is not necessarily the right approach. The problems that cause feelings of distress around sexual behavior are often not internal to the individual.

Imagine, for example, if in response to an ongoing stressful situation at work I've been using fantasy and masturbation (at home, in the evenings and on weekends) as a stress relief strategy. If I had been raised in an environment that made me feel guilty about masturbation, that guilt might cause me to try to stop using this otherwise-very-pleasant method of relieving stress and refocusing my mind. Still, I might be unable to stop because really, this is a very pleasant way of dealing with an otherwise-very-unpleasant life circumstance. In fact, I might be repeatedly unsuccessful. If such were my situation, I might feel a great deal of distress. Would I be suffering from a psychiatric disorder? No! I'd be suffering from the effects of being raised in a sexually repressive culture. I might need therapy of some sort, but the last thing I'd need is to be told that I'm sick.

Better than psychiatric treatment might be a copy of Sex For One by Betty Dodson and a referral to some sex-positive support groups and web sites that understand the benefits of masturbation and can help reduce the guilt or shame the hypothetical "I" above might feel about it.

The reality of US dominant culture is such that many people are distressed by their sexual desires. But I would be only a few of them are clinically sick. I think about Leonore Tiefer's writings, some of which are collected in her book Sex Is Not A Natural Act, in which she unpacks the many cultural and social factors that limit our ability to experience sexuality with pleasure. In the introduction to the second edition she imagines one way to counter the medicallization of sexuality:

I have a fantasy of little sex-ed-book-and-videomobiles parked near schools, ehalth clinics, libraries, malls, and laundromats, offering a cafeteria of information about sexuality to citizens of all ages. We have to enable people to get information about sex that doesn't come from the pharmaceutical industry, Hollywood, or Madison Avenue. (p. xii)

Earlier this week Ricci Levy, Executive Director of Woodhull Freedom Foundation, posted on the need for marginalized sexual subcultures to join together to resist the continued medicalization of sexuality, and Leonore Tiefer's fantasy gives me an idea: We need to rent a fleet of ice cream trucks and put those sex-ed-mobiles on the street!

(This is, hopefully, part 1 of a 2-part examination of the DSM-V revisions. Part 2 will examine the ongoing paraphila debate. I have not read the gender-related categories closely enough yet to comment on those, but that's also on the agenda. Stay tuned.)

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