Monday, March 8, 2010

Homosexuality and the distress criterion

Time for a bit of history.  The DSM is the Diagnostic Statistical Manual of Mental Disorders.  It's published by the American Psychiatric Association, and is known as the "psychiatrist's Bible".  Currently, the fifth edition, DSM-V, is being prepared for publication in 2013.

Homosexuality was originally classified as a disorder by the DSM, but it was removed in 1974 thanks to gay activists and new research.  However, that's not the end of that story.  The DSM replaced homosexuality with a category called "sexual orientation disturbance", later renamed to "ego-dystonic homosexuality".  It was only really removed in 1987, though it is still mentioned in the category of "sexual disorder otherwise not specified".

Here is ego-dystonic homosexuality, distilled to its most essential components:
ego-dystonic homosexuality = homosexuality + marked distress

(Aside: This topic interests me partly because asexuality is currently in the same position that homosexuality was in 1974-1987.  That is, if I am asexual, and experience marked distress, I will probably fit under the diagnosis of Hypoactive Sexual Desire Disorder (HSDD).  I've heard that HSDD is not taken very seriously by psychiatrists, but the existence of the diagnosis still does not sit well with me.)

Intuitively, the diagnosis of ego-dystonic homosexuality seems wrong to me.  In my own experience, questioning my sexuality was very distressful.  Most gay people did not even have my advantage of starting from a queer-friendly perspective.  And of course, gay people can be unhappy for all sorts of reasons.  Being in a sexual minority makes it easy to blame any unhappiness on one's sexual orientation. Do gays need to force a smile just so they can be considered healthy?

However, I do not wish to assume my intuition is shared by everyone.  So I followed one of the references on Wikipedia to this article: "The diagnostic status of homosexuality in the DSM-III: a reformulation of the issues".  It was written in 1981 by Robert Spitzer, who was a major player in DSM-III.  I do not necessarily agree with Spitzer, but he had lots of great insights.

What is the purpose of classifying something as a disorder?
To call something a disorder is to encourage a set of actions by society, caretakers, and people with the condition.  Society and caretakers provide a way to treat the condition or a way to live with it.  The people with the condition are called to take the role of patients.

What qualifies as a disorder?
According to DSM-III, a condition is a disorder if it causes distress or if it causes impairment in an important function.  He recognizes that the latter is subjective, since you have to judge which functions are important and which are not.  For most disorders, nearly everyone agrees on the judgment, but this is not the case for homosexuality.

Spitzer mentions that if we consider sexuality to be an important area of functioning, then lack of sexual desire could be considered a disorder, regardless of whether distress is present.

Spitzer believes the cause of the disorder is irrelevant.  So is the existence of a treatment.

Why do people think ego-dystonic homosexuality should be removed from the DSM?
Some opponents claim that heterosexuals are also frequently distressed by their sexual impulses.  Should they be diagnosed with ego-dystonic heterosexuality?  Doesn't it show prejudice to have one category and not the other?  On the other hand, is the distress experienced by both groups really the same?

Opponents also say that there are already categories for the people who would fit under ego-dystonic homosexuality.  If the person is depressed, there is the diagnosis of depression.  If the person is compulsive about their sexual impulses, there is the diagnosis of obsessive compulsive disorder.

Spitzer replies that ego-dystonic homosexuality is fundamentally different from those other diagnoses.
By including this category, DSM-III acknowledges that at least in some cases, an appropriate therapeutic activity is to help the individual develop a normative sexual arousal pattern and not merely to become more comfortable with his or her homosexuality.
Let me put that in simpler terms:
ego-dystonic homosexuality = homosexuality + marked distress
solution = treat distress OR treat homosexuality

This strikes me as a compelling reason to remove the diagnosis of ego-dystonic homosexuality.

1 comment:

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