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.

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