My Rx for hypermedicalization disorder

Elizabeth's picture

This is the second of at least two posts exploring the continued medicalization of sexuality as seen through the revisions of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). See part one here.

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 Imagine a person who is deeply conflicted about his sexuality. Instead of acknowledging his problem and working through it, this person lashes out at others, sending them confusing and judgmental messages about their own sexual behavior. He then tells them they are sick because they are confused. Imagine further that this person is a person of power and consequence and so the people around him start to feel ashamed of their own sexual desires and behaviors. They stop talking to each other about sex, and look to therapists and doctors to help them cope with their own shame and confusion. Hardly seems fair or right, does it? One person's conflicts get internalized by many, and the many all then think there is something wrong with them.

That is kind of like what's happened in the United States in terms of sexual diversity. We get so many confusing messages, and one outcome is that we simply don't talk about our own desires and behaviors and many of us end up feeling abnormal, ashamed, or ill. Meanwhile the American Psychiatric Association continues to supply new diagnostic categories for those of us who are made anxious or disturbed by our sexual urges. 

I'm thinking of the proposed distinction between "paraphilias" and "paraphilic disorders" in the forthcoming DSM-V. The Diagnostic and Statistical Manual (DSM) is the book that defines the diagnostic criteria for mental illnesses so that they can be studied and treated by mental health professionals. From the Rationale page for one paraphilia, fetishism, we get the APA's statement of the difference:

A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.

This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological.

While I'm glad to see that "non-normative" no longer means "psychopathological" I'm not sure I see what good comes from labeling some sex "normative" and other sex "non-normative" in the first place. In a realm of behavior as full of variation as sexual expression, what sense is there in reinforcing a sense that some sex is normal while other sex is deviant? Research does not require those categories. We can easily research the prevalance of behaviors without a two column distinction between "normative" and "nonnormative." Indeed, the people that clinicians hope to use research to help might be better able to assuage their clients anxiety if they avoided that kind of thinking themselves.

I'm also unhappy to see that "distress and impairment" are deemed evidence of individual illness when those very real experiences often do not originate in the individual but rather in the society that sends them messages about their desires. If the distress is in reaction to a repressive sexual culture why should we designate the individual as sick? Why not diagnose the society?

Instead of therapy and medication the prescription needs to be one for social change. Research and development money should be spent figuring out how to create a more open, less judgmental cultural context for individual sexual expression. Consciousness raising efforts need to be respected in the way that private counseling is respected. And perhaps all this needs to be placed into the context of our national discussions of health care reform. Imagine the cost savings associated with changing society such that individuals no longer needed expensive treatment to make them feel okay!