Have the Lunatics Taken Over the Asylum? Part 3
The, er, dramatic conclusion to my DSM5 series for The 21st Floor.
Part 3: The medicalisation of rape? (with apologies)
The DSM-IV makes an interesting definitional decision which may seem a bit peculiar at first. A mental condition is normally only defined as a ‘disorder’ if it causes the sufferer ‘clinically significant distress’. Normally at the end of each list of symptoms, this proviso is mentioned – if it doesn’t cause distress, it’s not a disorder. There’s an interesting philosophical argument to be had on this issue – what exactly IS a disorder? – but for now we’ll look at one specific example.
A paraphilia, defined as ‘recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) nonhuman objects, 2 ) the suffering or humilation of oneself or one’s partner 3) children or other nonconsenting persons’. That proviso is here, too – if you haven’t acted on these, or they’re not causing you any distress, they’re not paraphilias. This does seem absurd to some psychologists – Kenneth Zucker, chair of the DSM5 Work Group on sexual disorders, has noted:
A distinct but harmless paraphilia cannot exist, by definition. A man cannot be a fetishist, for example, even if he masturbates into rubber boots on a regular basis, unless he is bothered by this behavior or is impaired in his psychosocial functioning. In DSM-IV-TR, there is no such thing as a well-adjusted paraphile; such people are defined out of existence.
The DSM5 group, then, make the distinction between ‘paraphilias’ and ‘paraphilic disorders’, the latter being the ones which cause distress. One would assume that paraphilias, as opposed to the disorders, wouldn’t be acted on in the same way by psychiatrists.
In the 1980s, it was suggested that DSM-III should include a category of ‘Coercive Paraphilia’, a particular subset of rapists who have a disorder which causes them to become aroused at the coercive (but not necessarily the sadistic) element of their crime. At the time, the evidence wasn’t judged sufficiently strong enough, so there’s no such category in the DSM-IV. However, the science has moved on, and there are now repeated calls for the inclusion of Coercive Paraphilic Disorder in DSM5.
We need to be careful to separate moral judgments from empirical facts on this issue which, of course, is an incredibly sensitive one. Allen Frances, chair of the group who wrote the DSM-IV, gives a harsh criticism in this article:
Paraphilic Coercive Disorder would expand the pool of sex offenders who are eligible for indefinite civil commitment because they have a “mental disorder” to include cases of sexual coercion. … Given the facts…that most rapists are savvy enough to deny sexual fantasies and the unreliability (and unavailability) of laboratory testing, the diagnosis will inevitably be based only on the person’s behavior, leading to a potentially alarming rate of false positives with consequent wrongful indefinite commitment.
While this argument seems quite appealing on the surface, you must note that it is moral/political, and not scientific. It could be the case that the inclusion of Paraphilic Coercive Disorder in DSM5 might cause more indefinite civil committment (he is thinking, by the way, of the sort of indefinite commitment the sex offenders Louis Theroux met in a recent documentary were undergoing). In other jurisdictions of course, it may go to the other way – lawyers can argue that their rapist client is disordered and therefore warrants a reduction in punishment severity. However, this has no bearing on the reality of Paraphilic Coercive Disorder, if it does in fact exist. I would argue that, whatever the consequences, it is important to know if a subset of rapists are indeed acting on a compulsion to coerce their victims into sex, and we should research such matters thoroughly. So where does the evidence currently point?
The argument hinges on two theories, which we have to decide between. 1) Some rapists have a brain problem, related to psychopathy, in which the screams, struggling, and resisting of the victim don’t give the rapist’s brain the ‘stop’ signals they would give to you or I, so they can get aroused by pretty much any sexual situation. In other words, the rapist has a failure of normal sexual inhibition. 2) Some rapists have a brain problem which gives them extra positive feelings and sexual arousal when they experience screams, struggling, and resisting. This is what would be called Coercive Paraphilic Disorder.
Theory 1 is the view of Raymond Knight, who, in this paper, concludes that:
The empirical data do not… support the hypothesis that a distinct syndrome exists that comprises males who are sexually aroused by the coercive elements of rape per se. … In addition, sexual fantasies about forcing sex and about struggling victims are highly correlated with sadistic fantasies and have not been shown to identify a syndrome that can be discriminated from sadism.
However, he may be missing something. David Thornton, here, points out that Theory 1 doesn’t necessarily fit with all the evidence. He points to some studies, including two recent ones from 2009, which were specifically set up to disentangle the sexual responses of rapists (measured, admittedly, by the slightly dodgy penile plethysmograph):
Taken together, these results are not consistent with the idea that preferential sexual arousal to rape is simply an expression of more general sexual sadism. Rather, there seems to be more than one paraphilic focus that is relevant here.
Clearly, this is an area which needs substantially more research. However, it seems there might be some utility for the construct of Paraphilic Coercive Disorder, despite the criticism. Since DSM5 is delayed, we should focus our research on trying to work out if constructs like this, which are genuinely ambiguous, are worth our time.
(Disclaimer: you must note that everyone proposing that this disorder should be included in the DSM5 is saying that it will only apply to a small subset of rapists. This is not about psychologists excusing rape, or anything like that. If it’s ‘medicalising’ rape, it’s only medicalising some rape, which is not necessarily a bad thing. Think of it this way: just because some people start fights because they’re dicks, doesn’t mean there aren’t also people who start fights because they have a brain disorder.)
So. Here ends our tour of some of the DSM5 issues. There are many more, of course, which I may return to in future. Are disorders like hoarding and skin picking disorder real? We’ll see. But for now, take this lesson: everyone benefits from an evidence-based approach, whether it’s teachers and their students, politicians and their voters, or psychiatrists and their patients. Received wisdom, even if it seems obvious (think Post-Traumatic Stress Disorder) should always be questioned, and should always be tested. The alternative would just be… crazy…
Knight, R. (2009). Is a Diagnostic Category for Paraphilic Coercive Disorder Defensible? Archives of Sexual Behavior, 39 (2), 419-426 DOI: 10.1007/s10508-009-9571-x
Thornton D (2010). Evidence regarding the need for a diagnostic category for a coercive paraphilia. Archives of sexual behavior, 39 (2), 411-8 PMID: 19941047