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
Homosexuality.
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.
.