What's wrong with sex?

Several psychiatrists and psychologists have recently made important criticisms of specific diagnostic innovations proposed by the DSM-5’s Sexual and Gender Identity Disorders Work Group (DeClue, 2009; Frances, 2010; Green, 2010; O’Donohue, 2010). As a historian and philosopher of science, my goal here is more general: I want to show that what this Work Group is trying to accomplish undermines the definitions of ‘‘paraphilia’’ and ‘‘mental disorder’’ that have been operative since the DSM-III. If the revisions proposed by the Work Group are implemented, the DSM-5 will be closer to the DSM-I and DSM-II than to their successors. In order to understand why this is so, we need first to take a short historical detour and to look at how ‘‘mental disorder’’ and ‘‘paraphilias’’have traditionally been defined. Only then will we be in a position to grasp the magnitude of what the DSM-5 is trying to accomplish. As is well known, the DSM-I (American Psychiatric Association, 1952) and DSM-II (American Psychiatric Association, 1968) did not define ‘‘mental disorder.’’ In the DSM-II, the paraphilias (called ‘‘sexual deviations’’) were simply described as sexual interests directed‘‘primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstance’’ (American Psychiatric Association, 1968, p. 44). Needless to say, it is rather bizarre to use‘‘bizarre’’as a nosological criterion, and probably not the best way to make psychiatry look like a serious science. In 1973, however, psychiatrists voted to remove homosexuality from the DSM, and at that point the need arose to spell out what a mental disorder is. According to the DSM-III (American Psychiatric Association, 1980), a mental disorder must meet two criteria: (1) it must cause harm, either to oneself (in the form of distress or disability) or to others; (2) it must be a dysfunction. The fact that both criteria have to be met is a guarantee that doctors cannot transform every problem into a disease. Childbirth, for instance, is not a disease even when it causes harm, because it is not dysfunctional. Nor is homosexuality a disease since, even if it were dysfunctional (as some have claimed), it is not harmful. Theweaknessofthisunderstandingofmentaldisorderhinges mostlyontheideaofdysfunction,which,aslongasit isnotbetter defined, can easily be interpreted in sociocultural terms. The following example clearly illustrates how this can have troublesome consequences. In 1851, Dr. Samuel A. Cartwright described a condition that he called ‘‘drapetomania,’’ a disease that made slaves try to flee captivity (Cartwright, 1851). Is ‘‘drapetomania’’a real disease? If we apply the DSM-III definition of mental disorder and use a sociocultural understanding of function,theanswermustbe‘‘yes’’:slaveswhotrytoescapefrom theirmastersindeeddonot‘‘function’’inaracistsociety(andthey harm their masters by depriving them of their property). ‘‘Function’’ must therefore be clearly distinguished from sociocultural values, lest psychiatry be exactly what antipsychiatrists have for decades accused it of being: a mere instrument of social control. This is why some of the psychiatrists who in the past have been in charge of the DSM, such as Robert L. Spitzer and Michael B. First, have recently pushed for a narrower understanding of ‘‘function’’ (Spitzer, 1999; Wakefield&First, 2003).Theywant tomakepsychiatry intoascience whose job would not be to mirror and to fuel social prejudices, but to cure genuine diseases. They have usually relied on the influential work of Wakefield (1992). According to Wakefield, a function should be understood as an internal mechanism selected by evolution. The theory of P. Singy (&) The Bioethics Program, Union Graduate College, 80 Nott Terrace, Schenectady, NY 12308, USA e-mail: pbsingy@gmail.com