Constructing Perversions: The DSM and the Classification of Sexual Paraphilias & Disorders

1. Constructing Perversions: The DSM and the Classification of Sexual Paraphilias & Disorders Robert Scott Stewart Cape Breton University, Sydney, NS Canada Scott_stewart@cbu.ca

2. Outline History of Perversion Thomas Nagel: a Philosophical Account of Perversion Nagel and DSM: Perfectionist accounts of sexual desire Problems with perfectionist accounts for the APA and DSM ‘Disease creep’ and over-diagnosis and over-treatment Big Pharma’s influence Designer Drugs and Worrying Precedents A Cautionary Tale Conclusion

3. Perversion: Background Aristotelian teleology Aquinas, teleology and sin Nagel: sexual desire as “multi-level interpersonal awareness” of escalating desire Perversions as incomplete versions of sexual desire Overlap with the DSM

4. The APA and the DSM on Paraphilias “The Paraphilias are characterized by arousal in response to sexual objects that are not part of normative arousal-activity patterns and that in varying degrees may interfere with the capacity for reciprocal, affectionate sexual activity (APA, DSM III-R, 1987, 279: emphasis added). “Sexual arousal brings people together to have interpersonal sex. Sexual arousal has the function of facilitating pair bonding which is facilitated by reciprocal affectionate relationships” (Spitzer, 2006, 114).

5. Description vs. Prescription • Nagel admits that his view of non-perverse sex is “evaluative in some sense,” though the type of evaluation is not clear. “It is not clear that unperverted sex is necessarily preferable to the perversions. It may be that sex which deserves the highest marks for perfection as sex is less enjoyable than certain perversions; and if enjoyment is considered very important, that might outweigh considerations of sexual perfection in determining rational preference” (Nagel, 1969, 16-17) • The DSM provides no such caveat.

6. “Perfectionist” Conception of Sex Is not meeting the ideal a perversion? an analogy the “judgment of what constitutes reciprocal, affectionate sexual activity is clearly value laden and suggests an underlying, implicit, theoretical orientation. There are no data to suggest that individuals diagnosed with a paraphilia have any more difficulty maintaining relationships than “normal” heterosexuals, who have staggering divorce rates.” (Moser and Kleinplatz 2005, 102)

7. Inconsistency in the DSM DSM criteria: all mental disorders must “… be associated with present distress … or disability … or significantly increased risk of suffering death, pain, disability, or an important loss of freedom, DSM IV-TR, 2000, xxx1). Yet some paraphilias don’t require this: criminality vs. mental illness?

8. Slippery slope worries Sexual Disorders Not Otherwise Specified: (i) "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used," and (ii) “compulsive sexuality in a relationship” (APA, DSM IV TR, 2000, 582).

9. Sexual addiction? In and out – and in? “The results of the review reveal abundant clinical evidence of sexual activity that can be characterized as excessive” but there was “no scientific data to support a concept of sexual behavior that can be considered addictive” (Schmidt,1995, 254). Manley and Koeler (2001,260): a new nosology: “Sexually Excessive Behavior Disorders” including sex addictions (excessive masturbation, affairs, and attendance at strip clubs and peep shows).

10. “All the World’s A Hospital” “The world we now live in is … so thoroughly indoctrinated in the ideology of therapy that society has remade itself in therapy’s image” (Gordon, 2000, 229). “The nineteenth century marked a shift to scientific investigation of sexual matters. The medical profession usurped moral and religious authority in the area of sexuality, generated new and highly visible discourses, and promulgated the diversification of new sexual identities. Sexuality, then, represented a site of expansion and control by the medical profession. Physicians were consolidating their power to regulate and define large areas of human experience, even those, as later critics would note, that fell outside of their training and expertise (Irvine, 1995, 430).

11. Designer Drugs Ritalin and ADHD Viagra and Erectile Dysfunction SSRI’s and depression (Jump in adolescent depression from 0-15/20% in 15 years) “Listening to Prozac” Easy to fulfill criteria

12. Big Pharma’s long reach Cosgrove et al., 2006: Half the experts sitting on panels for DSM V have “financial ties” with Pharma Elliott (2004): Half the papers on SSRI’s Pharma sponsored (or written) Direct Marketing – $11.4M-$29.9M in 10 years (Donohue, et al., 2007) Steven Sharfstein (2005, 3): “as a profession we have allowed the biopsychosocial to become the bio-bio-bio model.”“a pill and an appointment” is too often the preferred (or only) treatment offered.

13. SSRI’s and Sexual Parpaphilias/Disorders Side effects: reduced sexual drive, erectile dysfunction, difficulty reaching orgasms SSRI’s ‘success’ might “merely reflect their side effect profile” (Greenberg & bradford, 1997, 357)

14. A cautionary tale Daniel Bergner, The Other Side of Desire The tale of Jacob: foot fetishism, chemical castration and Viagra A different ‘treatment’ option? No treatment as an option?