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American Psychiatric Association launches draft guidelines for DSM5 – consultation open til April, have your say

February 11th, 2010

Dr Petra

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system created by the American Psychiatric Association to enable those working in healthcare to research, diagnose and treat mental health problems. It is not without controversy with critics arguing over each iteration of the manual more and more behaviours are medicalised and the DSM is tainted by the influence of drug companies with a vested interest in creating disorders in order to provide treatments. Supporters argue having a system of managing our understanding of mental disorders improves our approaches to research and care for those experiencing mental distress.

Today sees the launch of the draft version of the latest incarnation of the manual – the DSM5. It’s been worked on over the last decade and you can now see how mental disorders are being conceptualised (including what disorders have been amended, removed or added to). The whole draft is available here although I am most interested in how sexual functioning, gender identity and paraphilias are being approached.

In particular hypersexuality appears to be moving towards supporting diagnostics around sexually addictive/compulsive behaviours, which requires close attention as we already know this is one area full of very poor science, political and faith based ideology and a whole slew of homespun (but largely unevaluated) therapies.

If this is to be included in the DSM5 there needs to be a strong evidence base underpinning anything we want to label as ‘hypersexuality’ and robust reflections on how we classify problematic behaviour to ensure we don’t pathologise certain forms of sexuality (ie adultery, masturbation or alternative relationships) that particular faith based and neo conservative groups/professionals disapprove of.

The classifications around gender identity have proved controversial with critics questioning whether such guidance should be developed – particularly given a weak evidence base in this area. You can see how it is being approached in children here (approaches for adults also outlined in this part of the DSM5 draft). Mainly the debates around the classification in children have focused less on the issue of identifying problems and more about evidence based evaluations of treatment interventions for young people.

Sexual interest/arousal disorder in women is also an issue requiring close attention as we know this is an area where there’s been an ongoing issue about medicalising female sexual behaviour, suggesting women who don’t want sex for practical, relationship or health based reasons require hormonal or SSRI-type interventions.

You can expect to see discussions of this particular classification on sex blogs in the coming weeks, although it’s worth also looking at the additional classification aimed at men, and compare how these are new classifications as distinct from existing categories of orgasmic disorder aimed in women and men.

The existing DSM classifies difficulties in experiencing orgasm as a dysfunction, while the proposed new version would add to this lacking in desire for sex. Some people will welcome this seeing the lack of desire as the barrier to orgasm, others may conclude that there are many reasons women and men don’t feel desire or experience orgasm and classifying them as a mental disorder may be overmedicalising a range of normal human sexual responses.

If you’re interested in how we understand sexuality and human sexual behaviour I’d recommend reading through the entire list but focus your attention particularly on what’s being proposed as now needing classification, what’s being subsumed into existing categories and what established diagnostics look set to remain.

From this you should consider the evidence (shown by each category) and see whether you feel this is fair, balanced and whether it comes with any conflict of interest (you may need to track down the cited papers to do this). You could also reflect on what categories are being added, who is suggesting them and who might benefit or face discrimination from them should they be classed as a mental disorder. You may also want to think about what happens if any categories are added to or removed from the DSM – in terms of how we’ll be approaching research, therapy, drug treatments or surgery for sexual dysfunctions, and gender identity disorders and how those plus legal sanctions may be applied to the classification of paraphilias.

I’m not arguing here that all the items listed in the ‘sexual and gender identity disorders’ aspect of the DSM should be overlooked (for example nobody’s going to dispute paedophilia is a problem, although we need to be sure the way we classify this means those anxious about being potential abusers can get help and treatment). Yet we do need to cast a critical eye over some of the definitions activities that might come under the umbrella of fetish and kink, and also problematise those who apparently have too much or too little sex (or interest in sex).

No doubt colleagues far better versed in understanding mental health classification will be discussing the ramifications of the DSM5 draft in the coming weeks and I’ll add their reports to this blog.

In the meantime you have until 20 April 2010 to respond to this or any other aspect of the DSM5 draft. I would recommend we all do this as individuals or collective groups of practitioners or activists as this process will be used to inform how we define, research and treat mental disorders. If you feel there are particular areas which should be included or excluded from the DSM now is the time to have your say.

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