Kleinplatz, P.J & Moser, C. (2005). Politics versus science: An addendum and response to Drs. Spitzer and Fink. Journal of Psychology and Human Sexuality, 17(3/4), 135-139.
Politics versus Science: An Addendum and a Response to Drs. Spitzer and Fink
Our article, “DSM-IV-TR and the Paraphilias: An Argument for Removal,” highlighted problems of logic, internal consistency, and validity of the statements presented in the DSM. The usual scholarly response to such an article is an academic discussion of the ideas presented and why they are or are not justified. With the exception of four points, which we will discuss below, this is not what Drs. Spitzer and Fink presented. They do not dispute most of the points made in the article, do not present contradictory data, and do not argue that we misinterpreted either the actual words or even the intent of DSM. In fact, Dr. Spitzer states, “I am certainly not going to argue that the particular DSM-IV criteria for the paraphilias and for GID are without problems and I am not going to argue that use of the diagnostic criteria by clinicians and researchers results in no false positives.” It is noteworthy that neither Drs. Spitzer nor Fink suggests any solutions to the problems we identified.
We believe some history is important
to help understand the context of their remarks. On May 19th, 2003, one of the
authors (CM) presented an earlier version of this paper at a symposium entitled
the “Sexual and Gender Identity Disorders: Questions for DSM-V” at the Annual Meeting of the American Psychiatric
Association (APA) in
Soon after the presentation, in a blatant attempt to politicize this debate, someone released a copy of the paper to various politically conservative organizations. They in turn published misleading statements concerning our conclusions. Carefully selected excerpts were posted on the Internet without our knowledge or authorization. These versions flagrantly misrepresented our statements and intents, the symposium where the paper was presented, and the APA itself. Specifically, it was alleged that we were defending pedophilia or at minimum, advocated the decriminalization of child sexual abuse. These points were specifically discussed and refuted clearly in the paper. The result was that the focus of the debate shifted; the substance of our paper, that is, the real flaws in the Paraphilia section, was ignored.
Nonetheless, the controversy garnered the attention of the mainstream press. To put it mildly, a media frenzy ensued. We were deluged with numerous requests for interviews, comments, and offers to debate Dr. Spitzer in the media. Many of these offers were withdrawn when the pertinent – and omitted – sections of the paper were faxed to the news media in question. As a matter of policy, we decline to discuss complex psychiatric issues in the media. We prefer to debate these issues in scientific or professional forums.
The APA responded to the media frenzy with its own press release. The official statement, APA release number 03-28, dated June 17, 2003, quoted Dr. Darrel A. Regier, Director of the APA’s Division of Research: “There are no plans or processes set up that would lead to the removal of the Paraphilias from their consideration as legitimate mental disorders.” This statement is inconsistent with the revision process already in place, and described in the DSM (APA, 2000, pp. xxvi-xxx) itself. The APA’s press release seems more indicative of a concern for public relations than the validity of the DSM. Their response, presumably intended to quiet the storm, demonstrates the influence of the sociopolitical environment on the APA and the DSM.
Similarly, Dr. Spitzer acknowledges that one reason, perhaps the main reason, for keeping the Paraphilia category in the DSM is public opinion rather than science. He states, “First of all, [the removal of the Paraphilias from the DSM] is not going to happen because it would be a public relations disaster for psychiatry.” Dr. Fink takes the position that the diagnoses are included for the convenience of the clinician, who wants to treat these individuals. By virtue of its own actions, the APA has demonstrated and Drs. Spitzer and Fink have affirmed that the DSM is a political document. The claim that the DSM is to be a dispassionate, scientific document with an empirical basis is inconsistent with the APA’s actions. The credibility of the DSM as the definitive, objective reference for the diagnosis of mental disorders has been brought into question. All those who are concerned about the scientific basis of psychiatry should be watching these events.
Concerning Dr. Spitzer’s specific criticisms, he faulted us for suggesting that the Paraphilias should be distinct from other mental disorders. He believes that all mental disorders should be considered in terms of points on a continuum. We agree with him but that is not how the DSM is organized. The editors state, “DSM-IV is categorical classification… [which] works best when all members of a diagnostic class are homogeneous, when there are clear boundaries between classes, and when the different classes are mutually exclusive” (APA, 2000, p. xxxi). Unless and until the DSM is reorganized, there is no discernible basis for this diagnosis.
Dr. Spitzer states that we believe, “there is no such thing as pathological sexual behavior.” Actually, we pointed out the lack of empirical evidence for designating sexual behaviors pathological a priori. Without such data, these determinations are made on the basis of sociocultural criteria rather than science.
Dr. Spitzer also faulted us for not presenting any case of harm resulting from these diagnoses, though he admits that individuals with these diagnoses, “…are denied [child] custody because of their atypical sexual behavior and without any evidence that their sexual behavior hurts anyone.” If denial of child custody does not qualify as harmful, we wonder what Dr. Spitzer would define as harm. We are aware of at least two forthcoming articles which document the damage caused by these classifications (Keely, Stock, Moser, in press; Wright, in press), but this is not the appropriate venue to present that data.
We advocated the removal of the Paraphilias from the DSM because of extensive problems in logic, lack of empirical data, and lack of internal consistency in this section. Why are Drs. Spitzer, Fink, and apparently the APA resistant to recognizing and remedying these problems? We allowed for the possibility that the APA would choose to fix the Paraphilia section but question the viability of such an endeavor.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition-text revised.
Fink, P.J. (2005). Sexual and Gender Identity Disorders: Discussion of Questions for DSM-V. Journal of Psychology and
Human Sexuality, 17(3/4), 117-123.
Kolmes, K., Stock, W., & Moser, C. (in press). Investigating bias in psychotherapy with BDSM clients. Journal of
Moser, C., & Kleinplatz, P.J. (2005). DSM-IV-TR and the paraphilias: An argument for removal. Journal Psychology and
Human Sexuality, 17(3/4), 91-109.
Spitzer, R. L. (2005). Sexual and Gender Identity Disorders: Discussion of Questions for DSM-V. Journal of Psychology
and Human Sexuality, 17(3/4), 111-116.
Wright, S. (in press). Persecution of SM-identified individuals. Journal of Homosexuality.