Sunday, May 26, 2013

Out of the Shadows

Romulans?  What are they doing in here?

A good example of the problems in DSM's use which Foucault's insight explains is the massive electronic database that a consortium of the country's major insurance companies uses to keep track of all medical diagnoses and procedures.  If your insurer ever paid a claim for your care for a hang nail, drug overdose or suicide attempt, the medical procedures used needed to justified as appropriate to your diagnoses, and these diagnosis, cost and procedure data are kept so that the companies can estimate the economic risks associated with your health, and that of all other insured patients.  This central database is presumably a more valid indicator of the actuarial risks insurance companies face than the data from any single company would be since individual company data might be distorted by regional business models, or variations in their clientele. Some regions of the country have different health risks than others, as do different occupations. By associating diagnostic codes with demographic information, insurance companies save money and manage their own risk.  But they also are allowed to use this data to determine if you have a preexisting condition, and increase the costs of your policy.  The Affordable Healthcare Act, aka 'Obama Care', when fully implemented, will prevent limiting coverage for preexisting conditions.  But it will not prevent a diagnostic code from following you for life within the insurance industry, even if you change jobs, jurisdictions or insurers.  Of course, the government has access to the information too and their 'big data' projects could associate it with other information they keep on you.  All of this sounds like bedtime stories for conspiracy theorists.  It has been going on for 20 years, so whether there is any immediate cause for alarm depends on your personal diagnoses and comfort level with them.

Because individual clinicians; medical doctors and allied healthcare professionals alike, have professional ethical commitments to their individual clients, the insurance and government data requirements create considerable professional conflict for those who treat socially controversial diagnoses.  This came up in HIV/AIDS reporting, and it applies to diagnoses of psychosexual disorders, personality disorders and paraphilic disorders too.  If a doctor interprets his responsibility to ‘first, do no harm.’ strictly, s/he will decline to diagnose conditions that create socially risky consequences for clients.  Many mental health professionals have been doing this with consensual paraphilas for years.  If any other diagnosis fits, paraphilias won’t be mentioned.  There is also considerable debate about what techniques can effectively treat paraphilias, so few patients have been exposed to dangers of not getting reimbursed if they do not get the diagnostic label.  Most insurers decline to cover paraphilias entirely.  

This is all well and good, but more or less defeats any epidemiological research that searches medical records for data on paraphilias.  It is quite likely these are dramatically under-reported in clinical settings, especially private practice, where variant consensual behaviors are most often encountered.  It is time to switch science fiction genres:  this is analogous to Star Trek’s Romulan Cloaking Device.

A Romulan Warbird decloaking
Which brings us to the problem of hypersexuality.  In the DSM-5, hypersexuality is in the glossary but it is not a diagnosis.  Hypersexuality is defined therein as ‘a stronger than usual urge to have sexual activity.’  The literal–minded will immediately find lots of objections to the ambiguous “I’ll know it when I see it” diagnostic approach, but those are precisely the basis for a very large and political debate about what hypersexuality might be and what to call it.  Hypersexuality enjoyed a considerable prospect of making the DSM-5 list of diagnoses earlier in the process before the objections of Dr. Francis and others described in the previous post.  Historically, it has been turned back at the gate of the last 4 DSM revisions all the way back to 1980.  In 1987, it managed a near miss, achieving mention in the Sexual Disorders, Not Otherwise Specified example descriptions of DSM-IIIR.  Martin Kafka, MD, who sat on the Sexual and Gender Identity Disorders Committee that revised DSM-5, forcefully made the case for inclusion in an article in the Archives of Sexual Behavior in 2009, but it was not included in the published edition.

Although this is the sex addiction movement's best seller, AA groups were treating 'sex addiction' for several years before Carnes published the first edition in 1983
All of which is a great disappointment to Patrick Carnes and his adherents, who, following Carnes publication of Out of the Shadows: Understanding Sexual Addiction in 1983, have been treating people who get into difficulties with those stronger than usual urges.  ‘Sex addiction’ ‘compulsive sexual behavior, 'hypersexuality', 'impulsive/compulsive sexual behavior,' and 'problem sexual behavior,' are all terms that have been applied to excessive sexual desire or behavior.  Leaving aside the fact that the neuroscience that sex addiction theorists use to justify their analogy to chemical addictions is very much a work in progress, different professional and consumer constituencies have varied epistemologies for understanding this concept of ‘excessive’ sexual urges.  This is another example where science isn’t strong enough to silence most critics.
In the meantime, hypersexuality is mostly diagnosed as an anxiety disorder.  This effects not only the avoidance of social stigma and makes treatment reimbursement possible, but it masks the prevalence of sex addiction as a separate category of disease, and does not classify the Alcoholics Anonymous treatment methodology of 12-Step programs run by lay group members as a treatment for excessive sexual urges.  The American Psychiatric Association retains professional jurisdiction for licensed mental health professionals in this instance by not legitimizing a diagnosis.  The science suggesting that hypersexuality is an anxiety disorder isn't conclusive either.
All of which leaves sex addiction very much still in the shadows.  With no diagnosis and no data, from a purely epidemiological point of view, it is as if it does not exist!

Cloaked, it looks just like the final frontier

 Out of the Shadows: Understanding Sex Addiction by Patrick Carnes. (Hazelden, 1983) ISBN 978-1-56838-621-8
Kafka, M. P. (2010). "Hypersexual Disorder: A proposed diagnosis for DSM-V" (PDF). Archives of Sexual Behavior 39: 377–400.

© Russell J Stambaugh, May 2013, Ann Arbor MI, All rights reserved

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