Arch Sex Behav DOI 10.1007/s10508-013-0246-2
COMMENTARY ON DSM-5
Politics of Diagnostic Criteria: Specifiers of Pedophilic Disorder in DSM-5 Richard Balon
Springer Science+Business Media New York 2014
The debate preceding the publication of the DSM-5 (American Psychiatric Association, 2013) was probably more passionate than the debate which we are starting after the publication of this manual. We were dealing with the unknown and assumed, with numerous opinion experts and the public. The debate following the publication of this manual may not be as heated, but is going to last longer and be more pointed—we know the enemy, and he is not us (this time), and we have information, opportunity, and time to make more rational arguments. Revising anything usually means reconsidering, changing, and modifying it based on new knowledge and/or data. We all expected various, hopefully rational, changes of diagnostic criteria in the revised version of the DSM manual. The DSM-5 brought many changes, some sensible, some less sensible. For instance, I personally believe that the change in naming Paraphilias—naming them Paraphilic Disorders—was not a bad one, a step in the right direction. Paraphilias, now Paraphilic Disorders, have been frequently the center of controversy and thus exposed to politics and political decisions. Nevertheless, some of us (surprisingly, including me, as I should know the organizational politics better) expected rational changes of diagnostic criteria not necessarily based on full proof facts, but based at least on the expert opinions. Through a complicated process, the American Psychiatric Association selected Work Groups of experts in each area, including the area of paraphilias. Thus, those of us with some remnants of rationality expected that the experts in those areas would be heard and respected. Alas, it seems that we have been naı¨ve! As Zucker
R. Balon (&) Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology, Wayne State University School of Medicine, Tolan Park Building, 3rd Floor, 3901 Chrysler Service Dr., Detroit, MI 48201, USA e-mail: [email protected]
(2013) writes, the Board of Trustees (BOT) of the American Psychiatric Association did not approve the Sexual and Gender Identity Disorders Workgroup proposal of three new diagnoses in the area of Conditions for Further Study (Section III of DSM5). The BOT also did not approve the proposed change to Criterion A for Pedophilic Disorder and the inclusion of specifiers pertaining to Tanner stages. Thus, as Zucker (2013) points out, the diagnostic criteria for pedophilic disorder remain unchanged from DSM-IV-TR. He and Blanchard (2013) disagree with this decision and most of us would probably join them. However, I would like to point out that in the debate about disallowed changes, one serious and maybe tragic non-change happened. By the assumed (by me) order of the BOT not to change anything in the diagnostic criteria of Pedophilic Disorder, all its specifiers remain unchanged. In all other Paraphilic disorders (except for Other Specified Paraphilic Disorder and Unspecified Paraphilic Disorder), including Sexual Sadism Disorder, the clinician is asked to specify if‘‘in controlled environment’’ and if ‘‘in full remission.’’ These specifiers are not included in the diagnostic criteria of pedophilic disorder. For those unfamiliar with the DSM-5 specific language: In controlled environment This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in… (description of specific paraphilic behavior) behaviors are restricted. In full remission The individual has not acted on the urges with a nonconsenting person and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years in an uncontrolled environment. In some paraphilic disorders, the statement about acting on urges with a nonconsenting person is not included. The lack of uniformity in specifiers and the lack of inclusion of these two specifiers in the diagnostic criteria of Pedophilic
Arch Sex Behav
Disorder is puzzling and incomprehensible. As I pointed out (Balon, 2013), the plan to include the ‘‘in controlled environment’’ specifier was interesting ‘‘because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges’’ (DSM-5 website, June 2012). The issue of possible remission of paraphilic disorders is a complicated one, as we do not know enough about their course and long term treatment response. However, that is beside the point. If we assume the possibility of remission of paraphilic disorders and their possible occurrence in a controlled environment, we must assume these specifications for all of these disorders and we cannot single out one specific paraphilic disorder, for whatever reason. Unless there is a scientific evidence to support this decision—and there is none. I believe that the lack of inclusion of these two specifiers has far reaching consequences. The lack of‘‘in full remission’’specifier means that an individual suffering from Pedophilic Disorder can never reach remission. Do we have any evidence to support this? What if an individual does not act on his/her urges for 10 years and has not been in distress? Is he/she in remission or not? Well, we may think he/she is, but the lawyers will tell us that remission of Pedophilic Disorder does not exist, as the DSM-5 does not include it.
The decision of the BOT in the case of these specifiers was (in my opinion) unfounded, capricious, unqualified, political, unwise, and deliberate. Why deliberate? Well, the DSM-5 had two Text Editors. I am sure they would note and correct any inconsistencies (and the lack of these two specifiers is, among many other things, an inconsistency) unless directed otherwise (I admit that this is my personal assumption). This unexplained, yet presumably deliberate action of the APA BOT, only underscores the unacceptable politics involved in the process of defining the diagnostic criteria. Hopefully, this‘‘omission’’of change could be repaired in the future. Or am I still naı¨ve?
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Balon,R.(2013).Controversies in the diagnosis and treatment of paraphilias. Journal of Sex and Marital Therapy, 39, 7–20. Blanchard, R. (2013). A dissenting opinion on DSM-5 pedophilic disorder [Letter to the Editor]. Archives of Sexual Behavior, 42, 675–678. Zucker, K. J. (2013). DSM-5: Call for commentaries on gender dysphoria, sexual dysfunctions, and paraphilic disorder [Editorial]. Archives of Sexual Behavior, 42, 669–674.