Sexual Disorders: New and Expanded Proposals for the DSM-5—Do We Need Them?
Total Page:16
File Type:pdf, Size:1020Kb
ANALYSIS AND COMMENTARY: SPECIAL SECTION Sexual Disorders: New and Expanded Proposals for the DSM-5—Do We Need Them? Howard Zonana, MD The sexual disorders in the current and proposed DSM contain a potpourri of categories that increasingly intersect with the criminal justice system. Caveats saying the DSM is designed for clinical and not legal purposes notwithstanding, our classification system has difficulty distinguishing what we consider criminal behavior from culturally unacceptable behavior and mental disorder. Several current proposals continue this trend and seem more responsive to criminal justice concerns than mental illness considerations. They also lack sufficient specificity to warrant being called a disorder. J Am Acad Psychiatry Law 39:245–9, 2011 The Diagnostic and Statistical Manual, Fifth Edition tions by 20 state legislatures. Mental health profes- (DSM-5) work group preparing for the next edition sionals (psychiatrists, psychologists, social workers, is proposing several changes to the American Psychi- and nurses) are involved in preparing reports and atric Association (APA) Classification of Mental Dis- testifying at the hearings at the end of an inmate’s orders in the Sexual and Gender Identity Disorders sentence to see if he meets the criteria for judicial category. The proposals have been the subject of two consideration of his status as a SVP. well-attended presentations at the American Acad- The second trend relates to the federal and state emy of Psychiatry and the Law at each of the annual law enforcement that targets pedophiles and those meetings in 2009 and 2010. The sentiment of the who download child pornography from the Internet. forensic psychiatrists who attended was decidedly Targeting is based on the idea that people who down- negative for many of the proposals discussed in this load these images have already, or soon will, become commentary. child abusers. Accompanying the arrest and prosecu- Forensic psychiatrists have become increasingly tion of these offenders, longer prison sentences have involved with the group of sexual disorders over the been added to the federal sentencing guidelines and past 20 years because of at least two trends. The first state statutes (e.g., the Arizona Supreme Court up- is related to the sexually violent predator (SVP) laws held a sentence of 200 years for the possession of 20 permitting civil commitment of convicted sex of- photographs of children deemed to be child pornog- fenders at the end of their prison sentences, if they raphy, 10 years for each picture, with the sentences to meet very low thresholds for having some mental be served consecutively). Again, mental health pro- condition that may make them a future risk for sex- fessionals become involved either at the plea negoti- ually violent and aggressive behavior. These statutes ating or presentencing phases of the criminal process. have been deemed constitutional by the U.S. Su- preme Court and have been passed with small varia- Conceptual Difficulties Dr. Zonana is Professor of Psychiatry, Yale University School of Med- icine, and Adjunct Clinical Professor of Law, Yale Law School, New Before we get into the details of the proposals, a Haven, CT. Address correspondence to: Howard Zonana, MD, Yale short detour into some of the underlying conceptu- Department of Psychiatry, Connecticut Mental Health, Center, 34 alizations of mental disorders is useful in understand- Park Street, New Haven, CT 06519. E-mail: howard.zonana@ yale.edu. The author acknowledges fiscal support from Connecticut’s ing the present conflicts. For the past 150 years, our Department of Mental Health and Addiction Services. society has developed institutions for those who have Disclosures of financial or other potential conflicts of interest: None. been classified as deviant: we have had asylums for Volume 39, Number 2, 2011 245 New Proposals for Sexual Disorder in DSM-5 the mentally ill and intellectually disabled, prisons below represent possible disorders. We do that with for those who have broken our laws, and juvenile IQ and call two standard deviations below the mean courts for younger people who misbehave. The indicative of a disability. On the other hand, we do boundaries are frequently overlapping so that the dis- not call those above by the same amount disordered; tinction between the mad and the bad remains a blur we value them as having special abilities. Such nor- for many individuals and many are treated or con- mative choices have an intuitive appeal, but may be- fined in multiple institutions. come contaminated by cultural values or arbitrary The DSM has not directly addressed the relation- norms. Normative scales are also more likely to gen- ship between criminality, deviant behavior, and erate false-positive cases. mental illness in the manual. This problem is exem- There are differences, however, between a norma- plified by some disorders’ being indistinguishable tive measure of intelligence and a normative measure from the crime (e.g., pedophilic disorder), whereas of sexuality. The norm for IQ was based on an un- some disorders like schizophrenia hardly mention limited sample of the population, not one defined as any specific illegal or bad behavior, even though in- impaired, distressed, or deviant. The psychiatric dividuals with schizophrenia may be charged with measure of sexual arousal or behavior is one derived crimes when they become too disruptive or violent. from a measure of patients or (as in the Kinsey re- Aside from the sexual disorders, the few other cate- port) of those willing to answer questions about their gories that identify specific criminal or bad behaviors sexuality, truthfully or not. Therefore, hyposexuality are conduct disorder, oppositional defiant disorder, or hypersexuality in the absence of distress or deviant kleptomania, intermittent explosive disorder, patho- behavior is less meaningful. A second relevant differ- logical gambling, and antisocial personality disorder. ence between norming intelligence and norms of sex- The question then is, why are some criminal be- ual practice is the predictive value of each. Levels of haviors classified as mental disorders and others not? intelligence correlate with the ability to learn, success What is the conceptual difference? We do not define in academics, and educational needs. Will sexual serial murder or stalking as a distinct disorder. The norms in the absence of behaviors or emotional cor- sexual disorders carry much additional moral and relates have the same connection to outcomes? religious baggage (e.g., fornication and adultery are still codified as crimes in one third to one half of the states). Hypersexual Disorder The DSM also remains unclear about the princi- The new proposal is to add a hypersexual disor- ple that distinguishes between symptoms, syn- 1 dromes, and disorders. For example, what are the der. The criteria are compelling data that transform hypersexuality as a symptom of many possible disorders into a proposed A. Over a period of at least six months, recurrent specific disorder? The DSM-5 Sexual and Gender and intense sexual fantasies, sexual urges, and Identity Disorders Work Group is proposing to ad- sexual behavior in association with four or more dress the problem by making a distinction between a of the1. following five criteria: paraphilia and a paraphilic disorder. The distinction 1. Excessive time is consumed by sexual fantasies is based on the presence of distress or impairment. and urges, and by planning for and engaging This effort is worthwhile, but the boundaries remain in sexual behavior. fuzzy. Impairment can be defined by an arrest in the 2. Repetitively engaging in these sexual fantasies, absence of subjective distress. urges, and behavior in response to dysphoric The three disorders that were debated at the meet- mood states (e.g. anxiety, depression, bore- ings were hypersexual disorder, paraphilic coercive dom, irritability). disorder, and pedohebephilic disorder. Without bi- 3. Repetitively engaging in sexual fantasies, ological markers for most psychiatric disorders, nor- urges, and behavior in response to stressful life mative distributions can be established. The distri- events. bution of most behaviors follows a bell curve. It is 4. Repetitive but unsuccessful efforts to control possible to select a line, for example, two standard or significantly reduce these sexual fantasies, deviations from the mean and say that those above or urges, and behavior. 246 The Journal of the American Academy of Psychiatry and the Law Zonana 5. Repetitively engaging in sexual behavior while 1. Recurrent and intense sexual arousal from prepu- disregarding the risk for physical or emotional bescent or pubescent children. harm to self or others. 2. Equal or greater arousal from such children than B. There is clinically significant personal distress or from physically mature individuals. impairment in social, occupational or other im- Specify type: portant areas of functioning associated with the frequency and intensity of these sexual fantasies, Pedophilic Type—Sexually Attracted to Prepu- urges, and behavior. bescent Children (Generally Younger than 11) C. These sexual fantasies, urges, and behavior are Hebephilic Type—Sexually Attracted to Pubes- not due to direct physiological effects of exoge- cent Children (Generally Age 11 through 14) nous substances (e.g., drugs of abuse or medica- Pedohebephilic Type—Sexually Attracted to tions) or to Manic Episodes. Both In Criterion B, a third sign or symptom has been D. The person is at least 18 years of age. 3 Specify if: added : Masturbation 3. Repeated use of, and greater arousal from, por- Pornography nography depicting prepubescent or pubescent Sexual Behavior With Consenting Adults children than from pornography depicting phys- Cybersex ically mature persons, for a period of six months Telephone Sex or longer. Strip Clubs The justification offered by the work group is that Hyposexuality was designated as a disorder in it will make it easier to diagnose or catch more pedo- DSM-IV, but hypersexuality had been regarded as a philes, since many individuals lie about their inter- symptom, not as a separate disorder.