Thursday, July 4, 2013

Serious Play

“I’ll have grounds more relative than this.

The play’s the thing, wherein I’ll catch the conscience of the king.”  Hamlet Act II, Scene ii

“Battle not with monsters, lest ye become a monster.

And if you gaze into the abyss, the abyss also gazes into you.”  Friedrich Wilhelm Nietzsche as quoted in Alan Moore’s The Watchmen

William Shakespeare (1564-1616)  At least as far as we can tell, we have few contemporary depictions of Hamlet's author.
While completing my post on the medieval period, I was contemplating the difference between the use of the religious devices designed for penance for their intended purposes, and for BDSM.  While the physiological capacity to enter altered states of consciousness is available for lustful and spiritual purposes, and it is only in St Augustine’s wake that we take for granted they must be mutually exclusive, there is no clear boundary between spirituality and carnality that we do not draw for ourselves.  The deadly seriousness of self-inflicted suffering in pursuit of a divine ideal is notably lacking in modern concepts of irony.  Does that make any difference in how we know psychopathological behavior when we see it?  I would be sorely tempted to diagnose religiously self-abusive behavior, despite the very considerable scaffolding of Western religious philosophy undergirding penance.  The guiltier it was, and the less realistic I thought the guilt to be, the more I’d be inclined to diagnose a mental health condition.  The doctrine of original sin just doesn’t persuade me that self-inflicted injury is a condign and effective response.  The more I thought self-punishment led to ecstatic states, the less I’d be inclined to diagnose it.  But that reflects a value judgment of mine that is not client-centered, which is another of my values. 

The matter of the relevance of irony reflects a clinical observation of long standing, that clients with good senses of humor are generally more amenable to treatment than those without.  And this observation makes sense to me clinically despite the countless examples in the consulting room when I have had to confront clients with interpretations that they were using humor defensively to distance themselves from the uncomfortable emotional significance of some clinical material.  But somewhere in the upcoming Renaissance, we are going to exchange the fabulous demonic representations of Grunewald and the folksy humor of Breughel and Bosch for the insightful irony of Shakespeare, and the modern sensibility is marked by that distinction.  In this way, Shakespeare is modern despite the archaic language and iambic pentameter.   Hamlet means to discover the ‘real’ truth about the apparition he met on Elsinore’s battlements with a ‘fake’ play that reflects the alleged circumstances of his father’s death.

The test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.  F Scott Fitzgerald

 Why humor is positively correlated with therapeutic outcome is, in part, a reflection of the clinical utility of being able to hold two feelings in mind at the same time and cross-ruff between them, creating a more nuanced appreciation of the problem under consideration. Apparently, it takes ambivalence to deconstruct ambivalence.  Absolutists do not take readily to the kind of insight-oriented work that is the foundation of modern psychotherapy.  I am inclined to view absolutism as a sign of intolerance of some feelings.  And therefore I may be ready to put those who cling too tightly to The Great Chain of Being on the couch, which may well be indistinguishable to them from the rack.  I wonder how many individual flagellants would have stopped following their cults if I interpreted their self-punishment as an attempt to control by displacement the frightening events in the chaotic world around them?  Did the Holy Inquisition narrowly miss a golden opportunity to invent psychoanalysis 400 years early?

The Pythons do the Inquisition.  Not wholy unexpected!

Lest one assume that modern notions of ambivalence and irony are a mere construction of Renaissance interest in internal human experience, it is worth looking at play.  We define play as activity done for its own sake; that is inherently not utilitarian.  A cat is playing with a ball of string, but we are inclined to think similar behavior with a mouse is predation, until the cat starts to show evidence of being more than single-mindedly devoted to killing it to eat.  Tom and Jerry are not practicing their species-specific survival behaviors, they are just friends playing with each other.  This example from the place where cartoon sadomasochism and ethology meet is intended to show that lots of behaviors are adaptive that do not immediately serve utilitarian functions.  Cat’s play not because they are friends with the mouse, but because such behaviors have evolved to simultaneously serve long term evolutionary functions, and to provide short-term satisfactions.   The adoption of a serious and non-ironic Medieval mindset was itself a social adaptation.  There are plenty of tribal cultures with ironic wit, and the Dark ages were not dark because humor went entirely out of them. 

Tom and Jerry playing

But the cat’s play, and the BDSM’s scene’s multi-layered use of the term ‘play’ have in common a kind of seriousness that goes beyond immediate gratification.  In BDSM play, real wounds get inflicted, disobedience has real consequences, real body fluids get exchanged, and real a trauma can result from failed scenes and misunderstandings. Altered states of consciousness are only sometimes evoked.  More often, people play in altered social states.  In that sense, even with its ‘as-if’ qualities, BDSM play can be every bit as capable of discharging unconscious guilt as cold-blooded self-administration of a cilice.  Play is serious, and seriousness may or may not be required for the enactment.  This explains the chronicity of complaints about ‘smart-ass masochists.’  Despite a strong prevailing ideology in kink that masochists should be submissive, many are persistently provocative.  They are playing with the seriousness of the scene and its ironic contexts, and tops struggle to decide how much control they surrender when they let masochists ‘top from the bottom’ by provoking them as a means of controlling their punishment it is the tops’ prerogative to mete out.    Flagellants experienced a lack of agency, and were punished by the Church for trying to get more by illicit means.  Smart-ass masochists are also blamed for trying to seize agency that is rightfully administered through intermediaries: tops!  So are these situations analogous or different?  What has changed so dramatically in 600 years is the language and voice we use to discuss and understand them.  The play was always the thing, whether we recognized its seriousness or not at the time.

Hamlet, Act III scene iii.  Hamlet (David Tennant) considers killing the kneeling Claudius (Patrick Stewart)

One final irony:  In Hamlet, the strategy of the play-within-a-play is effective.  Claudius freaks out and immediately rushes to his chapel to repent and pray.  But Hamlet, brilliant as he may be, is a tragic hero, and his faith in empiricism betrays him.  When he comes upon Claudius, seemingly in prayer, Hamlet’s direct observation misleads him.  He assumes that Claudius is confessing and in repentance for his sins.  But such is Hamlet’s hate that he will only be satisfied if Claudius is damned, and he dare not risk killing the vulnerable usurper if his soul might go to heaven, forgiven for his crimes.  If Hamlet was a smart as we think he is, he’d have recalled from his studies that there can be no absolution for Claudius while he still has all the benefits he committed his murder to obtain.  All would have ended in condign revenge if Hamlet had only trusted to his faith, not reason and direct observation, and killed Claudius while he had the chance!

"My Words fly up, my thoughts remain below,
Words without thoughts never, to Heaven, go."   Claudius

© Russell J Stambaugh, PhD, July 2013, Ann Arbor MI.  All rights reserved.

Wednesday, July 3, 2013

Under Construction

Generally, when the term 'construction' is used here, it means social construction.  But just this once, it means the construction of this blog itself, which will cease for the next three weeks while the writer vacations.  

Read closely!  It means what it says!
When works resumes, I'm planning essays on the multiple meanings of 'play', the work of Erving Goffman, and further history of sexual deviance setting the stage for the entries on Charles Darwin, Richard von Krafft-Ebing, and Sigmund Freud into the western discourse on sexual variation, and kink. 

Geochelone Elephantopus as Darwin might have seen him.  He's going fast for him!  Alas, the man from Hindoostan who tired to know this elephant would find him nearly extinct.

Later in the fall your intrepid reporter will make the ultimate sacrifice and travel to the Folsom Street Fair and CARAS and TASHRA meetings scheduled around it.  I guess if I am going to write about these things, it is necessary to attend them.  That kind of thinking, that you might know something better by direct observation, became all the rage during The Enlightenment, which will be an immediately forthcoming post, too!  And with any luck, the Art Department will get us a new title page and frontispiece.

Tuesday, July 2, 2013

Kenneth Zucker, PhD, and Michael First, MD’s DSM-5 plenary at AASECT

On the evening of June 6, 2013, Ken Zucker and Michael First opened AASECT’s 44th Annual Conference with a presentation discussing the Psychosexual and Gender Identity Disorders sections of the DSM-5.  Their presentation constituted a sort of DSM-5 road show; Dr  Zucker had presented on the DSM-5 Sexual and Gender Identity Disorders Work Group’s process, and the DSM-5 changes earlier this year at the SSTAR Conference, and I’m sure other appearances in support of the new addition’s release are planned.  Their goal was to discuss some of the key changes between DSM-IVTR and -5, present the thinking behind them, and to respond to those outside the American Psychiatric Association who have been critical of the volume.  The intent was to smooth adoption and implementation of the changes.  One of the goals of the DSM is to standardize diagnosis and this was an efficient way to do that.  The DSM-5 release had already been long delayed, and when the chair of the DSM-IVTR Working Group, Allen Frances, MD, started criticizing the DSM-5 process in 2010, charging that the revisions would ‘medicalize normality’, the psychiatry association had to respond.

Kenneth Zucker, PhD

In 2008, Dr. Zucker was appointed chair of the Gender Identity and Sexual Disorders Workgroup that recommended changes in those sections of the DSM-5 that deal with sexual behavior and gender identity issues.  His appointment was controversial with Gay, Lesbian and Transgender advocacy specialists.  Zucker was seen as supportive of reparative therapy for adult gays,  reparative therapy for children, especially males, with childhood gender identity dysphoria (GID), and has published a peer-reviewed study suggesting that many childhood cases of GID do not grow up to full transgenderism, and more frequently manifest in late adolescence and adulthood as homosexuality.  Dr Zucker is nonetheless, highly experienced in the field of gender dysphoria.  He has been the editor of the Archives of Sexual Behavior since 2001. He maintains academic and clinical appointments at the Toronto Faculty of Medicine, and Center for Addiction and Mental Health.  Formerly known as the Clarke Institute for Psychiatry, the Center has been home to other prominent researchers on gender identity and paraphilias, including the late Kurt Freund, and Ray Blanchard, who was also in the work group.

Ray Blanchard, PhD.  I believe Dr Blanchard first proposed the two-step paraphilia diagnostic process.
Dr. Zucker was clear that the DSM-5 process had become highly politicized.  His working group had received the third largest amount of input from outside of American Psychiatric Association of the 13 DSM-5 work groups.  Most of this was from advocacy groups and attorneys who were concerned about the effects of language changes on the rights of sexually variant defendants.  Dr Zucker defended the DSM-5 process as the most transparent DSM process yet.  Certainly the Internet provided extensive opportunity for outsiders to express interest and make commentary.  What is not at all transparent is the effect, if any, that this had on the work groups.

The areas under review by Dr Zucker’s work group resulted in three sections of the DSM-5:  Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders.  Each sub-committee assembled a literature review and these were published in the Archives of Sexual Behavior.  In a special effort to get Hypersexuality included in the volume, Martin Kafka, another work group member, did a special paper which called for its inclusion in 2010. 

Martin P Kafka, MD

It is difficult not to be critical of this evidence-based approach to the study of variant sexuality.  The funding process for most empirical research comes from governments and large institutions fearful of the negative effects of variant behavior.  Far too much of this work has been conducted on criminal populations, while potentially healthy kinky people are now guarded about research participation unless it clears them of charges they are psychopathological.  So the illusion of neutral data gathering is particularly frayed here, and not a great deal is known about modern non-criminal sexual variation. Just last month, a Dutch study suggested BDSM community members were mentally healthier than a non-affiliated Dutch comparison group!  Unshared epistemology is the order of the day.  And this leaves Dr. Zucker in an awkward position when advocates challenge his assertion that the work group went ‘about as far as they could go’ in attempting to allow for non-pathological sexual variations within the traditional paraphilia categories.

I have previously described the single greatest advance in paraphilia diagnoses between volumes, and Dr. Zucker summarized this:  the creation of a two-step process in defining sexually variant behavior as a mental health condition.  First the behavior needs to be recognized as variant behavior; that is a termed a ‘paraphilia,’ next it needs to be recognized as having negative effects on social adjustment, or be inherently non-consensual or harmful; that is termed a ‘paraphilic disorder’ worthy of clinical intervention.   This structure sidesteps the risk to psychiatrists of deferring to deviant-identified individuals the choice about whether their adjustment is a problem, while allowing clinicians to acknowledge non-pathological sexual variations. 

The second crucial differentiation made in DSM-5 that differs from DSM-IVTR is that behavior needs to be shown to be proof of some sort of identification in order to prove sexual variance.  This holds out the possibility that an actor or sex worker who performs acts with which s/he is not identified might not be regarded as having a paraphilia at all.  A pro-domme might whip people without, herself, being a sexual sadist.  Previously, the behavior alone sufficient for diagnosis.

Notorious 1950's bondage model Betty Page:  Paraphile, Paraphilia disorder, or just a normal working stiff?
Hypersexuality was a bit of an orphan, in that it is neither a sex dysfunction, nor is much of it paraphilic, but despite what appears to have been the paraphilia sub-committee’s solid backing, it did not make it into the published version of DSM-5 even as an experimental diagnosis in need of further study.  All the previously included paraphilias were retained, and Frotteuristic Disorder was added.  I suggested in my previous DSM-5 essay that Hyoersexuality might be difficult to get inter-rater agreement on, but the plenary presentation was not articulate about the reasons for it's exclusion.

Allen J Frances, MD, former DSM-IVTR Chair and current DSM-5 critic.

The rejection of Hypersexuality and the careful reasoning about variance constitute a pretty strong defense against the shotgun allegations of Dr. Frances regarding psychiatric power grabbing, at least in the sexuality sections of DSM-5.  At times, the committees were shockingly lax.   With respect to vaginal pain,  the sexual dysfunctions group though it should be a pain or anxiety disorder, and the anxiety disorder work group didn’t want it, so it was dropped altogether!  I guess all those poor ladies are all better now!  But despite the impression conveyed that the sexual and gender identity disorders covered by Dr Zucker’s committee were psychiatry’s poor step-children, it is clear that the committees were wary of over-diagnosis, and took some thoughtful steps to prevent it.

Michael First, MD
Michael First, MD, PhD is Professor of Clinical Psychiatry at Columbia University.  He rode shotgun for the American Psychiatric Association, with Frances Allen, MD, on the DSM-IV Text Revision process.  His specialty is diagnostic research methodology, and he helped set the stage for the current revision back in 2002 when he coauthored 'A Research Agenda for DSM-5' with David A Kupfer, MD, who was the DSM-5 Task Force Chair. 

Dr First’s presentation emphasized the evidence based methodology behind DSM-5.  Although he evaluated the volume from the position of an outsider, he was an editorial consultant to the DSM-5 effort.  He had praise and criticism for the final volume.  Special praise was given to the two-step process for paraphilias.  This had already led to a court case where the language change was credited by the defense team as having saved their client a negative outcome.  He reserved special complaints for the loss of Tanner Stage specifiers for pedohebephilia diagnoses.  I agree with the Work Group that it is hard to see how these relatively easily made determinations might not lead to increased specificity in diagnosis, and be valuable in research.  They, too, were casualties of the final APA approval process.

Tanner stages in the developing male

Dr. First gave special attention was to an extremely rare but potentially troublesome diagnosis: apotemnophilia.  This sounds like a John Money neologism, and he was indeed the first to identify and name it.  It is the desire for self-amputation for sexual purposes.  The belief that one is disabled, or should be amputated so that physical body and identity become congruent is termed Body Integrity Identity Disorder by Dr First.  It is easy to understand the medical profession’s interest in identifying these conditions as mental disorders.  With the improved social acceptance of Gender Identity Dysphoria and the provision of sex hormones and sex reassignment surgery, doctors are worried that they might have to give in to patient demands for medically unnecessary amputations.  Diagnosis of this mental disorder provides a bulwark against misplaced consumerism.

Erotica for apotemnophiles.  Requests for surgery are another matter.

This was an extremely useful and important presentation, and did give good insight into the DSM-5 process.  It addressed few of the objections I made in my earlier post, but also came well short of the goal of full transparency.  This was a consequence of both speakers operating under an American Psychiatric Association gag order regarding the association’s final decisions on the work groups’ recommendations.  Clearly these were sometimes rejected; sometimes on methodological grounds, others times for reasons seemingly political.  But if the grounds were purely methodological, there would have been no need for contracts requiring confidentiality about the final approval process. 

Sexual Paraphilia, Paraphilic Disorder, or Political Perversion?
I approached Dr. Zucker after the presentation, suggesting that the paraphilia sub-committee could easily have gone further to protect healthy kinksters.  If living in a society where one’s sexuality was widely regarded as deviant was bound to cause some psychological conflict, wasn’t it important for the psychiatric community to differentiate between adjustment problems attributable to discrimination, rather than those intrinsic to the kink?  His reply was both savvy and cagey.  “Stay tuned for the ICD-12.” 

Thanks to Drs. Zucker and First for a thought-provoking presentation and excellent conference opener.

The opinions expressed in this post reflect strictly those of the author.  They do not reflect the official position of AASECT or any other organization, although endorsements are welcome!


The DSM-5 work group's research reports that were published in Archives of Sexual Behavior, Volume 39, Issue 2 as part of the DSM-5 process constitute genuine transparency in the process. The references sections of these papers are an extremely valuable tool in studying the epistemology of professional mental health's understanding sexual variation.

The Archives of Sexual Behavior, Volume 39, Issue 2

© Russell J Stambaugh, PhD, July 2013, Ann Arbor MI.  All rights reserved.