Home > Psychology, Science > Have the Lunatics Taken Over the Asylum? Part 3

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.

Shiny, shiny... all this talk of boots, I just had to get a photo.

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

  1. April 8, 2010 at 2:31 pm

    Very thought-provoking.

  2. ACH
    April 8, 2010 at 6:29 pm

    Having read Knight and Thornton’s papers, if I didn’t know much about the background to this, I think that the latter would seem more convincing. However, on further reflection and with more background info, there are some extremely troubling issues. First of all, lack of attention to wording: In DSM-III-R, all the paraphilias required that the sexual interest involve “recurrent intense sexual urges AND sexual fantasies involving…” In DSM-IV, this was changed (mistakenly) to “recurrent intense sexual urges, sexually arousing fantasies OR behaviors.” (It should have said “sexual urges, sexually arousing fantasies and possibly sexual behaviors…”)

    In the proposed criteria, they get rid of “behaviors,” but keep the OR–making this potentially apply to a larger group of people than the version rejected in the 80’s. In addition, this would mean that someone who has sexual fantasies about rape (which are extremely common in the general population) and has committed rape for similar reasons to other people who have committed rape (i.e. essentially unrelated to those fantasies), this would fit the diagnostic criteria. (Note, again, the word “or.”)

    Even more problematic is the issue of absolute vs. relative sexual interest. In DSM-II and DSM-III all of the sexual deviations/paraphilias were defined in terms of relative/prefered sexual interest (except exhibitionism and transvestism). In DSM-III-R to the present, they have been defined in terms of absolute sexual interest. Most of the research that supposedly justifies PCD as a mental disorder defines it in terms of RELATIVE sexual interest (e.g. PPG studies), yet the diagnosis they are proposing defines it in terms of ABSOLUTE sexual interest. The proposed diagnostic criteria doesn’t even attempt to match the research supposedly justifying including it in DSM-V. Likewise, the case studies in Thornton seem to be examples of “relative sexual interest.” Given how the diagnosis Paraphilia NOS: nonconsent has been used in SVP cases, there is every reason to believe that one of the main functions of this diagnosis would be the involuntary civil commitment of people who have no real mental disorder. A huge issue you didn’t mention in your post is the problem of discriminant validity. As I understand it, this diagnosis is really lousy at distinguishing between “paraphilic rape” and “non-paraphilic rape.” Frances concerns about the SVP laws are a major concern–lots of people are pretty sure that people like those in Thornton’s case studies would be the exception, not the rule, for those diagnosed. The science involved in very questionable, which I one reason I think that Frances concerns need to be taken very seriously.

    • Stuart Ritchie
      April 8, 2010 at 6:48 pm

      Thanks for the comments!

      ACH, not sure your first point is a major issue, bearing in mind that there’s going to be a split between ‘paraphilia’ and ‘paraphilic disorder’. The latter is the one that’ll get the psychiatrist’s focus.

      …this diagnosis is really lousy at distinguishing between “paraphilic rape” and “non-paraphilic rape.”

      Wait, wait. The criteria says: ‘Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion.’ This is the distinguishing factor between an individual who’s raped someone, and an individual who has a mental disorder which probably caused them to rape someone. If those ‘recurrent, intense’ fantasies aren’t there, then they wouldn’t be diagnosed, and wouldn’t be eligible for involuntary civil commitment.

      The relative/absolute distinction is interesting. I’m not sure what you mean, though – do you mean that the PCD diagnosis only applies if the person is ONLY interested in coercive sex? I don’t think that’s the case (but I bet I’ve got you wrong).

      You are certainly right to say that the science is questionable, but the only way to sort that is to do more of it. Until then, maybe it’s a bad idea to include the CPD diagnosis in DSM5 (maybe the APA could do a Text Revision, like they did for for DSM-IV, once new research comes in).

  3. ACH
    April 9, 2010 at 4:15 pm

    My first point seems fairly irrelevant, but my point is that if they don’t seem to even understand the difference between “and” and “or” I think we really need to wonder just how “scientific” this is. About the absolute vs. relative issue, a large number of men in PPG studies show arousal to most stimuli shown. Thus, many of the “normal” men will be aroused to both coercive stimuli and non-coercive stimuli. To deal with this, researchers often subtract one from the other, so that someone might be considered to have PCD if they show more arousal to the coercive stimuli. Sexually coercive fantasies are very common in community samples (but people seem to be able to understand the difference between fantasy and reality just fine), and the way that this is dealt with is to consider PCD to be “preferential rape.” That is, someone is more aroused by rape than my consensual sex. And this seems to be how it is operationalized in the PPG studies. But it is not how it is operationalized in the diagnostic criteria.

    If those ‘recurrent, intense’ fantasies aren’t there, then they wouldn’t be diagnosed, and wouldn’t be eligible for involuntary civil commitment.

    Do you honestly think that sex offenders are going to be open and honest about their sexual fantasies and urges if they know that doing so means that they could be locked up for the rest of their life (in a way that completely bipasses numerous constitutional rights)? It has long been known that sex-offenders tend not to be open about these things, so that a lot of inference is needed.

    Here’s what Allen Frances says in “Opening Pandora’s box: The 19 Worst Suggestions For DSM5” I think that this is one of the most concise and devestating critiques of this diagnosis I’ve seen so far:

    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. Paraphilic Coercive Disorder was initially considered for inclusion in DSM-III-R (under the name Paraphilic Rapism) but was rejected because it was impossible to reliably and validly differentiate those rapists whose actions are the result of a paraphilia from the large majority of rapists who are motivated by other factors (such as power). Given the facts (acknowledged in the rationale section) 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.

    Regarding the issue of a need for more science, I’m inclined to agree with Ray Knight in his paper: we don’t need more science here. Time, energy, and money spent on researching this is time, energy, and money not spent researching other topics. He thinks that studying this is a matter of looking in the wrong places for understanding the causes of sexual violence, and more research would divert us from where research is really needed.

  4. ACH
    April 18, 2010 at 5:50 pm

    I couldn’t find any contact information to email you, but I’ve made a post on my blog I think you may be interested in.


    I give information about the context in which this “disorder” is being proposed, and I am hoping to raise awareness about these issues. Most people who see the proposal don’t know about these issues, but they are essential for understanding this proposed diagnosis as well as the criticisms of it.

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