You cannot do it in the dark. You cannot do it in a park. You cannot do it on a train. You should probably do it if you have something weird with your brain, though, and/ or if you have been entangled with the psychiatric system from the age of nine like I have— you should read the Diagnostic and Statistical Manual of Mental Disorders. You don’t have to read it from start to finish (unless, of course, you do, but my OCD is in remission). Instead, you should read all the introductory and how-to bits (Section I), since this is where the sad little soul of the DSM is hidden.
I expected to unreservedly loathe the DSM-5 (the latest edition) based on my interactions with so many dozens of its owners and also this terrifically amusing review in the The New Inquiry that assess the tome as “a new dystopian novel” with obvious Borgesian influences. The DSM-5 explicitly cautions against the New Inquiry reading—which also happens to be the reading of a good number of psychiatric professionals— “that every person’s illness is somehow their own fault, that it comes from nowhere but themselves: their genes, their addictions, and their inherent human insufficiency.” The shocking plot twist of the DSM-5 is not that “its originator can’t even tell that they’ve subsumed themselves within its matrix” as an obsessive-compulsive cataloguer with poor insight (the TNI review again); it’s that the originator has perfect insight into its own limitations but knows its reader will refuse to heed these same limitations. As such, it’s more compelling than repelling.
It is even occasionally likeable. Consider, for a moment, it’s necessity. Something like the DSM-5 would have to exist even in a perfect world, because it allows for “guiding treatment recommendations, identifying prevalence rates for mental health service planning, identifying patient groups for clinical and basic research, and documenting important public health information such as morbidity and mortality rates” (5). In other words, we need to have some sort of taxonomy of mental dysfunction in order to so much as discuss it. The problem is (wait for it, wait for it, wait for it) how such taxonomy must function under capitalism and within an adversarial mental healthcare system that pits patient against doctor against insurer.
The DSM-5 sucks primarily because it is the bible for a mental healthcare system in which care has been commoditized and therefore rationed and therefore must be explicitly justified through pathologization. Pathologization in turn creates its own problems, including overly rigid diagnostic criteria and diagnostic boundaries that exclude and obscure more problems than they delineate. (“We recognize that mental disorders do not always fit completely within the boundaries of a single disorder,” the author writes pitifully in the Preface.) This tragedy is captured in the prosody of the index listings: “312.34 (F63.81) Intermittent Explosive Disorder (466)/ __.__ (__.__) Conduct Disorder (469) /Specify whether:/ 312.81 (F91.1)”… and so on and so forth, lists of numbers and letters that have significance only in the bureaucratic bowels of the insurance industry.
The competence and foresight of the DSM-5 render it compelling, but the ultimate fact is that the DSM-5 knows what evil ends it will be used for. Don’t mourn the scribes at the American Psychiatric Association; they aren’t the victims of this tragedy. Their ranks are swarming with the villains, and those who aren’t directly guilty are the complicit sad saps who whine to the victim-cum-hero when she returns for revenge wielding an orbitoclast, “Well what did you expect me to do?” I expected you to do better, my dudes, but you didn’t, and so now I have to fuck you up.
Where the DSM goes, all other psychiatric texts follow, and so I bring my metaphorical orbitoclast to bear down on Principles and Practices of Sex Therapyand New Directions in Sex Therapy as well. Most of my ire is reserved for the former, which is preternaturally invested in preserving the abusive power of the psychiatric establishment, especially as it affects transgender people (ugly details below). New Directions seems to be written directly in response to its brutality, the liberal wing of the sex therapist profession responding to the violence of men like Dr. Kenneth Zucker with suggestions of alternative treatments that are more aptly described as ‘toothless’ than ‘compassionate.’
Both books repeatedly demonstrate the absurdity of pathologizing dysfunction and professionalizing therapeutic approaches to sex. The editors seem acutely aware that the informal psychiatric specialization of ‘sex therapy’ describes nothing more than a mixture of regular psychiatric therapy, sex work, and sex education, though of course they don’t describe it as such. Instead, they moan about sex therapy being ill defined and wring their hands over whether it is becoming outmoded. Ultimately, like a petition for a multinational corporation to feature more same-gender couples in their advertisements, these textbooks aren’t offering up critiques so much as spinning their wheels within the system.
THE PROFOUNDLY QUESTIONABLE PARTS
- “ ‘Dependence’ has been easily confused with the term ‘addiction’ when, in fact, the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction” (xlii). Check out this spectacular little “well ACTUALLY” that downplays the hellacious effects of SSRI withdrawal.
- “DSM-5 is designed to better fill the need of clinicians, patients, families, and researchers” (5); “Finally, patients, families, lawyers, consumer organizations, and advocacy groups have all participated in revising DSM-5 […]” (6). I guarantee that at no point in this text are ‘patients’ consulted independently of ‘families’. The wonderful irony here is that the DSM-5 goes to great lengths to catalogue the evidence of heritability of many mental illnesses at the same time it positions ‘families’ as the rational, healthy, normative advocates of the irrational, ill, and abnormal black sheep in their midst. This echoes the cultural trope of the crazy person as loner and outsider, a bizarre contrivance when you think about how we are forced to interact with one another not only in families but also in institutional settings— and also when you consider our sheer number.
- “Mental disorders are defined in relation to cultural, social, and familial norms and values” (14) is a fun way of acknowledging that, though mental dysfunction and suffering are objective facts, craziness is a social construct dictated by those with political power.
- “One’s perceived gender” (15) One has no other gender.
- In this latest edition of the DSM, paraphilias are distinguished from paraphilic disorders. A paraphilic disorder is defined as “a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others” (816). So, whether you’re a pedophile with a long history of offenses or someone who consensually spanks their adult partner, you’re of the same diagnostic category. I would eat my own foot (not one of my kinks) before I identified BDSM practitioners as an oppressed group, but I’d like to note that these anti-kink criteria are used against queer people and sex workers to paint us as harmful to children and society at large.
Principles and Practice
- “[…] Sex therapy can be adapted to be more inclusive” (xi). This is the exact wrong approach to diversity. The concerns of various marginalized groups must be foundational to any practice, organization, or philosophy if diversity is to be achieved.
- “They suggest the tantalizing idea that many men diagnosed with low desire actually have desire, but not for their partners” (3). If that’s what qualifies as tantalizing, then this is going to blow some minds: women also sometimes don’t want to have sex with their partners but would have sex with other people.
- “Graham (Chapter 4) points out that ‘directed masturbation’ continues to be the mainstay treatment for [female orgasmic disorder] because it has shown to be highly effective” (4). So, sex work. Credentialed professionals are gentrifying sex work.
- This book, like the DSM-5, groups pedophilia and consensual BDSM together but at least acknowledges the differences between the ‘coercive’ and ‘noncoercive’ paraphilias (6).
- “It is possible that, even without outcome data, sex therapy will survive as long as people continue to seek help in figuring out their sexual problems and dilemmas; as long as people find it gratifying and useful to consult with smart, caring people about issues they cannot share with anyone else” (548). Replace ‘therapy’ with ‘work’ and see if the meaning changes. (It does, because sex work is primarily driven by a surplus gendered labor force and not by demand. This hints at the practical differences between ‘sex work’ and ‘sex therapy’ and the kinds of labor they entail.)
- “How likely is it that an individual requesting treatment for what he or she considers a problem, regardless of its sociopolitical framing, will be interested in or helped by these [political] debates? (552)” Really fucking likely, since those debates determine what kind of help the person receives and how she receives it!
- “If the feminist literature has been helpful in focusing attention on the social construction of female sexuality, the new psychology of men has applied this perspective to the understanding of male sexuality in all its complexity” (2). This ‘new psychology of men’ comes from feminism, similar to how masculinity studies owes its existence to women’s studies.
THE BLATANT LIES
- The subsection of the Introduction titled “Gender Differences” attempts to distinguish between ‘gender’ and ‘sex’ and fails immediately and spectacularly, claiming that premenstrual dysphoric disorder is an example of a disorder exclusively determined by gender. D’oh!
- In order to be diagnosed with anorexia, you need to be “at a significantly low body weight for [your] developmental stage” (813). This isn’t a lie, but it really quite obviously should be.
Principles and Practice
- “Brown and Zucker [yes, THE Kenneth Zucker] point out that autogynephilia— that is, sexual arousal to the idea of oneself being a woman— may be a crucial mechanism in male-to-female gender dysphoria and that this ‘erotic location error’ is considered by some as a sexual orientation” (5). This is utter crap. No one who is not an established bigot believes that autogynephilia is a thing anymore. If “sexual arousal to the idea of oneself being a woman” exists apart from all women’s sexual desires, it’s as a cross-dressing fetish, which has zero to do with being transgender. This is a pernicious transmisogynistic lie used to justify all kinds of violence, including denial of access to necessary healthcare.
- “This theory [Zucker’s autogynephilia crap] has aroused bitter controversy, as evidenced by the recent brouhaha between J. Michael Bailey of Northwestern University and some militant gender activists […]” (5) OH MY GOD DELETE YOUR ACCOUNT, DELETE YOUR EXISTENCE!
- “The LGB community has expanded and welcomed transgender, questioning, and queer individuals, so the moniker now frequently reads LGBTQ” (7). This claim is ahistorical and contradicted by all available evidence. All of these groups have been enmeshed in queer communities since there have been queer communities. Next you’re going to tell us that Stonewall was a peaceful protest started by white cis gay men to demonstrate their appreciation for the police.“
- Both sexual difficulties and associated distress may be culturally defined and influenced” (542). They are.
- None! Yet.
THE ACTUALLY USEFUL BITS
- The ‘Highlights of Changes from DSM-IV to DSM-5′ section is overly exhaustive for the casual reader but the summary in the Preface is extraordinarily helpful. The major changes include “representation of developmental issues related to diagnosis” (in other words, the chapter organization is arranged chronologically, starting with disorders more likely to emerge in early childhood); “integration of scientific findings from the latest research in genetics and neuroimaging”; “consolidation of autistic disorder, Asperger’s disorder, and pervasive developmental disorder into autism spectrum disorder”; “streamlined classification of bipolar and depressive disorders” (which are apparently the most common diagnoses– good to know that I’m not special); “restructuring of substance use disorders for consistency and clarity”; “enhanced specificity for major and mild neurocognitive disorders” (i.e. disentangling what were previously “the dementias”); “transition in conceptualizing personality disorders” (proposing an alternative model that assesses interpersonal functioning and personality traits separately); “Section III: new disorders and features” (a section on disorders that require further study before they’ll be officially included); and “online enhancements” (whatever) (xlii- xliii).
- These revisions were evaluated on the basis of rationale, scope of change, expected impact, strength of evidence, overall clarity, and clinical utility (7).
- This version of the DSM was designed for “harmonization [cute!] with the ICD-11,” which is the international classification system of mental disorders used by the World Health Organization (11).
- DSM-5 has a “dimensional approach to diagnosis,” which mostly means that diagnostic categories (e.g. ‘feeding and eating disorders) are designed to highlight the overlap between certain disorders and dissolve some of the rigid boundaries between related diagnoses (e.g. anorexia and bulimia). The need for this revision became clear when (get this!) “not otherwise specified diagnoses” became the majority of diagnoses for eating disorders, personality disorders, and autism spectrum disorder. Disorders are also “clustered” into ones with internalizing symptoms (e.g. mood disorders) and externalizing symptoms (e.g. conduct disorders) (12- 13).
- Halfway through the shitshow that is the ‘Gender Differences’ subsection of the Introduction, we learn something useful: that professionals should be aware that there are differences in presentation of certain disorders in men and women (ugh, binary, I know).
- The DSM now has an explicitly “nonaxial documentation of diagnosis, with separate notations for important psychosocial and contextual factors” (16). This means that insurance companies don’t care why your patient is depressed, so you shouldn’t bother including “psychosocial and contextual factors” or “disabilities” in your diagnosis, even though these things should still factor into your treatment.
- Mental disorder is defined as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (20).
- A diagnosis should have ‘clinical utility’ but “is not equivalent to a need for treatment” (20).
- You can be disordered without being disabled but not vice versa (21)
- A principal diagnosis “is the condition established after study to be chiefly responsible for occasioning the admission of the individual” (22), i.e. what you bill insurance for.
- I was shocked to find, under ‘Highlights of Changes from DSM-IV to DSM-5′, that Gender Dysphoria was re-conceptualized in several progressive (though hardly radical) ways. One, it “[emphasizes] the phenomenon of ‘gender incongruence’ rather than cross-gender identification per se” (814). Two, it “replaces the previous ‘repeatedly stated desire to be… the other sex’” under ‘child criteria’ with “strong desire to be of the other gender” because not all trans kids live in environments where they feel safe verbalizing their desires (814). Finally, “subtyping on the basis of sexual orientation is removed because the distinction is no longer considered clinically useful” (814). The fact that these changes appear in the DSM doesn’t mean that they’ve seeped into clinical spaces, though.
Principles and Practice
- “Since the first edition was published in 1980, Principles and Practice of Sex Therapy has been the major text in its field” (x). WOOF. But, I mean, good to know.
- The editors describe the differences between ‘sexual medicine’ and ‘sex therapy’ as the former aiding function and the latter “[providing] the opportunity and context to be sexual” (xi).
- Most of the introduction of Principles and Practices is devoted to explaining how this new edition reflects the changes in the latest edition of the DSM. “For better or worse, sexual dysfunction has been defined, at least in North America, as those dysfunctions listed in the [DSM-5]” (2). These include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/ arousal disorder (previously two distinct disorders whose combination has been heavily contested), genito-pelvic pain/ penetration disorder (previously vaginismus and dyspareunia, which were collapsed into one disorder because of the significant overlap of symptoms), male hypoactive sexual desire disorder, premature (early) ejaculation, and substance/ medication-induced sexual dysfunction (as well as other specified and unspecified dysfunctions). Sexual aversion disorder was nixed from the latest edition of the DSM since it was so rarely diagnosed (2- 3).
- “The relationship between sexual dysfunction and the other sexual disorders might be best characterized as a DSM-arranged marriage. Paraphilia and gender dysphoria clinicians and researchers [gender dysphoria—not even primarily a sexual issue!] have usually not been sex therapists” (5).
- “The difficulty in classifying problems as sexual or not is also exemplified by the discussion of persistent genital arousal disorder in Chapter 12[…] the presence of persistent physical genital symptoms of arousal is not sufficient to define a problem as sexual” (5).
- The DSM-5 has no definition of sexual dysfunction. Cool, super helpful (10).
- Factors that are “driving or complicating the current transition” in sex therapy (you know, it’s personal crisis about its relevance and usefulness) include: “questions about construct utility” (like the problematic binaries of function and dysfunction, physical arousal and sexual desire); “encompassing multidimensionality and diversity” (you guys could start by not being transphobic???); “the rise of sexual medicine and interdisciplinarity” (e.g. the need to work with physicians who prescribe Viagra); “reconceptualizing treatment outcome”; “lack of sex therapy outcome research; “inability of sex therapy to articulate its unique contribution” (lmao); “defensiveness and fragmentation” (roflmao); “polemical/ political/ disciplinary debates” (e.g. those dastardly feminists); “public demand for easy solutions”; and “access to and cost of interdisciplinary treatment,” which has the shortest subsection even though it is quite obviously the biggest problem (pp. 542- 553).
- “The DSM-5 sub-work group on sexual dysfunction did not really address the question of construct validity in the concept of sexual dysfunction” (543). Looool womp-womp.
- Sex therapy includes “cognitive reframing, emotional interventions, stimulus control techniques, and relationship skill building” (548).
- Sexual problems “happen to be more prevalent than depression or anxiety” (549). I remind you that the DSM-5 states that depressive disorders are the most commonly diagnosed disorders. I don’t know what measures thePrinciples and Practices authors are referring to when they say ‘sexual problems’, but this is certainly something to note.
- “We do not certify individuals as being depression or anxiety specialists, as the treatment of these disorders is expected of the general mental health practitioner. Considering that most sexual dysfunctions are more prevalent than depression or anxiety disorders [this is decidedly not what the DSM-5says, but let’s go with it for a second], it is hard to rationalize special certification for the treatment of sexual difficulties” (551). This whole “Defensiveness and Fragmentation” subsection in the Conclusion is worth reading just for the brutal self-owns.
- Most of Kleinplatz’s book is helpful rather than ‘profoundly questionable,’ and the ways in which it is questionable correlate neatly to many of the problems in Principles and Practice (other than P&P’s aggressive transphobia.) Because time is finite to us mere mortals, I’ve chosen to exclude most of the useful bits in New Directions that will come up later in the book (such as the summaries of forthcoming chapters).
- Kleinplatz comments on the collapsing of Female Sexual Interest/ Arousal Disorder into one diagnosis (which was, at the time of her writing, still only proposed and not yet confirmed), that “the rationale […] includes the beliefs that women cannot distinguish between their own [physical] arousal and [psychological] desire and that women’s sexual desire may be more fundamentally responsive than men’s” (xxiii). She also comments that we would never consider collapsing erectile dysfunction and low desire in men into one disorder, which rings pretty true.
- Although her proposed solutions are notably more progressive, Kleinplatz identifies many of the same problems with the field of sex therapy as the Principles and Practices editors do. Among the causes for the “[isolation] of sex therapy from the broader worlds of psychotherapy in particular and healthcare in general” she includes: “the current conceptualization of sexuality itself” (compare this with P&P’s concerns about ‘construct utility’); “the narrowing of the field and splintering of our professional bodies” (this is echoed in P&P); “the reduction in training” in sexual issues (contrast this with P&P’s comments about certification for sexual issues); and “the estrangement of sex therapy from developments in psychotherapy research” (essentially the same as P&P’s concern over ‘lack of sex therapy outcome research’) (xxiv).
- “[I object] to the implication that sexual problems are to be understood primarily as technical difficulties, subject to treatment and cure devoid of psychological, relational, and social contexts in which they come to be perceived as problematic” (xxv). Woot! Kleinplatz gives two relevant examples: prescribing lubricant to a (cis) woman with dyspareunia (this was before the DSM-5 changes took effect and collapsed dyspareunia and vaginismus into genito-pelvic pain/ penetration disorder) instead of finding out what it is about her sexual encounters that may be problematic, and treating a (cis) man for erectile dysfunction without considering that there are plenty of circumstances in which a perfectly functioning and psychologically healthy man should be unable to get aroused.
- The class of drugs that Viagra belongs to is mentioned throughout the sex therapy textbooks as PDE-5, and Kleinplatz spells out the full name here: phosphodiesterase type-5 inhibitors.
- Current research shows that the patient-therapist relationship is a better indicator of patient outcome than any other variable (xxcii).
- There’s a long lists of professional organizations for sex therapists even though the numbers of registered sex therapists in these organizations continue to decline to embarrassingly low numbers. The number of sex therapists in The American Association of Sex Educators, Counselors, and Therapists (AASECT) dropped from 928 in 1987 to 442 in the early 2010’s (xxvii). Haha YIKES. Wonder if it has anything to do with AASECT’s costly and time-consuming certification criteria? (A topic for another time.)
- This second edition of New Directions includes “the kinds of issues left behind in the training of sex therapists. For example, we learn little about how to promote sexual intimacy— as opposed to the frequency of functional, sexual contact […]” (xxx). This is so GRIM!
- Kleinplatz has a critique of the limits of sex therapy and “how little [it] seeks to achieve” (4). These limits include excessive focus on solving problems rather than creating foundational change; a focus on individual treatment to the exclusion of of social advocacy; and a reluctance to “embrace sexual diversity” (4).
- “Historically, it has been assumed that one of the markers of an appropriate candidate for sex reassignment was the client’s willingness to end current intimate relationships and begin anew. In fact, divorcing one’s spouse has typically been a legal requirement to receive approval for surgery” (125). This is terribly depressing and not a well-known factoid, so it’s wise of Kleinplatz to use it in her brief argument for a new approach to treating transgender clients. If only she’d acknowledged the harm that her colleague Zucker is doing, but perhaps that will come in the chapter on working with trans patients.
WHAT TO READ INSTEAD
I was saving these recommendations for the weeks devoted to disability and gender, but if you need a chaser after reading these excerpts of uncritical psychiatry and obvious transmisogyny, check out Margaret Price’s “Defining Mental Disability” and Bradley Lewis’s “A Mad Fight: Psychiatry and Disability Activism” in The Disability Studies Reader, and b. binaohan’s e-book Decolonizing Trans/Gender 101, which is as much a response to Julia Serano’s white transfeminism as it is to the white supremacist transmisogyny of the medical industrial complex. (FTR, I linked to Serano twice in this post mostly because her blog is so well maintained, and not because I consider her the ultimate authority on transgender issues). If you have any other recommendations for radical readings on these topics, let me know in the comments.