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 Continue reading