Tuesday, June 27, 2017

Kink’s Evelyn Hooker Moment

Cabaret

“Start by admitting from cradle to tomb
It isn’t that long a stay.
Life is a cabaret, old chum
Only a cabaret, old chum
And I love a cabaret”
Fred Ebb and John Kandler

From its modern inception, psychiatry regarded homosexuality as a sexual perversion and as psychopathology. You heard the beginning of this story on Elephant in the post on Richard von Krafft-Ebing, here: .Richard von Krafft-Ebing  In the early 1950’s, flush with huge administrative responsibilities for 16 million service personnel and veterans of World War II and the Korean War, the US army demanded an official classification system for all of the mental disorders. At that point, hundreds of different local nosologies were in use.  After all, the armedforces needed a systematic way to determine who was crazy, who was malingering, and a reasonable basis for knowing how to allocate their medical resources.  As a minor after thought, sexual perversions were included in the resultant volume:  Diagnostic and Statistical Manual of the Mental Disorders I constructed after much debate, by the American Psychiatric Association.  Sexual deviations were mentioned, but not described, in the initial 50-page mimeographed publication, which sold for the entirely manageable price of 50 cents, when a Coca-Cola sold for a nickel and a Saturday matinee cost 25 cents.  The so-called ‘Kinsey Report’ cost more!

The second half of the Kinsey Report (1953) was a close contemporary of the DSM - 1

And there the matter might well have rested but for the twist of fate that found a psychologist at UCLA living next door to an expatriate British writer.  Both had spent time in Germany during the rollicking period of sexual license that comprised the waning years of the Weimar Republic.  She was well acquainted with the gay life, and generally accepting of homosexuality.  Both were deeply affected by the rise of Nazism, and the holocaust that became World War II.   She had barged her way into the nascent psychology profession in the 1930’s when it was less than friendly to women, mainly through her reputation as a brilliant researcher.  He was working on a screenplay that would eventually become a brilliant little send up of the funeral industry.  Your blog author saw that film, The Loved One at age 14 at the recently reopened Heights Art Theater in Cleveland Heights, Ohio in the company of his parents.  It played not long after the foreshortened run of a more famous film, Louis Malle’s The Lovers (1958), which had played there just a few years earlier and had been shut down as obscene, leading to the Supreme Court Case Jacobellis v Ohio, in which Justice Potter Stewart entered the famous opinion the he couldn’t define pornography, but “I know it when I see it.” in the process of overturning the theater owner’s conviction.

Evelyn Hooker

Christopher Isherwood

The writer was Christopher Isherwood, who you are far more likely to know for his Berlin stories which included the tales of American expatriate Sally Bowles, and became the basis for the famous Broadway musical Cabaret.  The psychologist was Evelyn Hooker, an ardent early advocate for de-pathologizing homosexuality.  Isherwood challenged Hooker to use her skills to conduct what became  one of the most famous studies in diagnostic history.
 
As the professional discourse arose about whether homosexuality might not be a disease began to heat up, advocates for retaining the diagnosis claimed that they could use psychological testing to prove it was a mental disorder.  They could diagnose it using psychological testing protocols derived from projective testing.  Hooker arranged to test exactly that assertion, by taking three of the best projective tests, and challenging their star practitioners to blindly sort the protocols of homosexuals from those of heterosexual men.

She chose a leading authority on each test to evaluate the subjects’ protocols, into homosexual and heterosexual piles, and to evaluate the extent of each subject’s signs of psychopathology on the tests. She also collected their sexual preferences and gave each an IQ test.  Bruno Klopfer was a top expert in the Rorschach test which was widely regarded as the best projective test for assessing psychopathology.  His book was so famous that I read it in my first projective testing course in graduate school 25 years later in 1981.  Edwin Schniedman, the inventor of the Make a Picture Test, interpreted the protocols from his test, and Mortimer Mayer interpreted the Thematic Apperception Test protocols.  Hooker gathered the data in her home, typed up the testing transcripts, counterbalanced them for IQ, and then farmed them out to the experts for interpretation.  The ratings were blind because the test evaluators never actually saw the test subjects, only these protocols, as a protection against the possibility that some sort of information irrelevant to the hypothesis might account for the experts ratings of the tests.  When the results came in, the three experts all agreed that they could not sort the protocols effectively through test interpretation.  Contrary to the opinions of the clinical profession, their best experts could neither detect psychopathology differences in these two samples, nor could the correctly sort the heterosexuals from the homosexuals.  In 1961, Evelyn Hooker got a lifetime achievement award from the American Psychological Association for this work and became an ardent professional advocate of removing homosexuality from the DSM.  In the mid 70’s, it was replaced by the diagnosis ‘Ego-Dystonic Homosexuality’ in later versions of DSM – II, and taken out altogether in DSM -III in 1978.  Hooker’s study was the fatal blow to the idea that homosexuals were all suffering from psychopathology that prevented them from being healthy heterosexuals.



Christian Joyal is a thoroughly French sounding Quebecois sex researcher with a crew cut, winning smile, and wry sense of humor.  In his SSTAR presentation on his 2014 Journal of Sexual Medicine article,  Joyal asked the awkward question, “Diagnostic and Statistical Manual?  Where are the statistics?” which left me imagining the Monty Python skit about the cheese shop with zero kinds of cheese.  The DSMs have not included these data since 1978!  In his day job, Joyal investigates subjects convicted of pedophilic crimes in a lab with fabulous virtual reality facilities.  There he can arrange all manner of stimuli and see how these effect patient's brain function using fMRIs.  He was utterly innocent of any interest in undermining the Paraphilia Section of DSM - 5 until he found himself wondering about the relationship of his subjects’ sexual fantasies and their illegal behaviors.  Joyal found many of his subjects had clear deficits in that portion of their brains related to executive function, which is implicated in processes of planning and impulse regulation.  But before he could draw conclusions about the relationship between pedophiles’ fantasies and their behavior, he would first like to have a baseline about the general population’s fantasies and behavior.  Having read the best books on fantasy and seen no studies worth reviewing, he concluded that his efforts to examine this connection required that he gather the data about ordinary peoples’ fantasies for himself.

Variant, perhaps, but far from statistically unusual!

He was aware that the diagnoses of the paraphilias, of which pedophilia was an example, depended on the recognition that paraphiles have ‘anomalous’ fantasies or behaviors.  So he made sure to include questions in his survey of fantasies examples that included all the major paraphilia categories from DSM – 5.  These are essentially eight classes of these fantasies and behaviors.  Voyeurism (looking at someone non-consensually for the purposes of sexual arousal) Exhibitionism: (exposing oneself to someone non-consensually for sexual arousal) Frotteurism: rubbing up against someone’s body without their consent for the purposes of sexual arousal) and pedophilia.  These acts were unethical, and in most cases heavily criminally sanctioned in Quebec.  He also looked at the consensual paraphilias:  Sadism, Masochism, Transvestism, and Fetishism.  These, of course, are the core interests of BDSM.  These are also the specific fantasies and behaviors that constitute the ‘anomalous’ content of the vast majority of paraphilias, even though countless other variations exist.

With the exception of pedophilia, none of these thoughts are criminal.  In some jurisdictions in the United states, any visual material of children under the age of consent (which itself varies depending on what state you are in) can be a serious criminal matter.  In Quebec, Christian can do fMRI scans of any image he wishes to construct on his fancy VR equipment as long as no real life child was used to make it.  In many places in the United States, it would be illegal to construct images of any sort that were intended to provoke pedophilic desires, even in a controlled research environment, and no IRB could approve such a research design that involved a researcher in criminal conduct.   So Dr Joyal is in a position where exploring the relationship between fantasies and behavior is important, and such research is possible to conduct, which might determine just when some fantasies might be genuinely dangerous, and when they are actually helpful to people who are trying to control behaviors that might be criminal or damaging.

The results of Joyal’s study, as summarized in his 2014 Journal of Sexual Medicine article, completely exploded the idea that sexual fantasies involving paraphilia content were ‘anomalous’.  Far from it.  A great many fantasies involving multiple partners, power exchange, sadism, masochism, and bondage, casual sexual encounters, and encounters with multiple partners were reported by more than half of Joyal’s samples of Quebecois. Individuals who reported none of these fantasies were in the extreme minority.  Only three of the 55 things he asked about were so uncommon that less than two standard deviations (a little under 2%) of his respondents reported ever having them.  Thus, hardly any fantasy was anomalous, and fantasies seemed to have no respect whatever for conventional sexual practices.  It is true that intimate relations with romantic partners, and romantic encounters on the beach were very popular, enjoyed by a large majority of respondents (85-90%).  But far more fantasies that the psychiatry manual referred to as ‘anomalous’ were extremely widespread, even among a nearly representative sample of Quebecois.

None of this should be surprising to professional sexologists, who have known since Alfred Kinsey’s landmark studies in 1948 and 1953, that sexual behavior is more varied than conventional wisdom endorses.   Later works by Friday (1973), Playboy (1974), and Janus and Janus (1993), Laumann, Gagnon, Michael and Michaels (1994), have reminded us that of that variability, although the latter study elided direct assessment of kinky behavior.  Recent studies suggest an uptick in interest and behavior, but most, with the exceptions of Richter et al, of Australia and Langstrom et al of Sweden, lacked representative national samples.

For over thirty percent, some variant behavior was acted upon one or more times in their lifetimes.  Here, Black Leatheramn cavort in front of the camera at the Folsom Street Fair in San Francisco.  The Folsom Street Fair is exceptional among kink events in its widely publicized open photography policies.  Cameras and smart phones are often banned at most kink events.

In immediate follow up to the JSM study, Joyal and Carpentier drew a representative provincial sample of Quebec, compared telephone and on-line admirations, and followed up their inquiries about fantasies with questions about abuse history, fantasy satisfaction, and behaviors.  They replicated a considerable body of research that has failed to demonstrate any statistical evidence for the widely held mythology that interest in kink is linked to early abuse.  This nearly representative sample established that 34 percent of Quebecois had acted on one or more of their variant fantasies within the DSM – 5 consensual paraphilia spectrum at least once in their lifetimes.   In yet a later article, they would demonstrate that 3 in 10 subjects had engaged in a knky behavior one or more times lifetime, up considerably from the 1.4-2.1% rate for behaviors in the past year Julia Richters et al had found in data from 2001 in Australia.  Joyal also found that subjects who admitted to masochistic fantasies had significantly more intense and satisfying fantasies than those who did not enjoy masochistic fantasy. 

Overall, this series of papers by Joyal and Carpentier fail to answer the larger question that interests him concerning the relationship between fantasy and behavior.  Are fantasies a compensatory safety valve we use to salve our frustration for experiences which we prefer not to undertake the full risks of living out in reality?  Or are they precursors to plans and actual behavior?  The answer is not simple.  It is clear that many people in Joyal’s studies day dreamed of behaviors they did not actually carry out:  The fantasy endorsements were far higher than the behavior rates in all categories.  But some people actually do things in the kinky categories they also dream about.  The study design could establish base rates, but could not establish causality.  Furthermore, pedophilic fantasies were so infrequent in these studies that few inferences could be generalized from such tiny numbers.  So clearly Joyal has much more work to do in that fabulous lab.



ICD -11:


But on another level, Joyal’s research comes at just the right moment.  The revision of The Diagnostic and Statistical Manual of the Mental Disorders – 5 is not the end of the process of struggling to define the proper diagnosis and treatment of problems in variant sexuality.  In 2017 and 2018, the further revision of medical diagnoses continues with the revision of the IDC – 11, the International Classification of Diseases - 11, a system of categorizing all diagnoses and conditions that affect medical health.  The current recommended revisions of this document can be found on the NIH website, and is conducted under the auspices of the World Health Organization, part of the United Nations.  WHO offical site for the ICD -11 revision  This is extremely important, as this system of classification underlies the DSM -5, and serves as the basis for diagnosis and treatment for every billable medical code and procedure everywhere in the world.  Struggles over some of these codes have huge implications for epidemiology, insurance reimbursement, and public health in all western countries, and the behavior of NGO’s in the developing world.

The current beta draft of this document drops the consensual paraphilias; transvestism, fetishism, consensual sexual sadism, and consensual sexual masochism, from the classification system altogether.  Where ICD – 11 is adopted as recommended, these will no longer be paraphilias at all, as Kinsey had suggested 65 years ago and as Joyal has demonstrated again in his recent research.  These standards are recommended by WHO, but they are adopted on a country by country basis.  Indeed, the four Scandinavian countries, Norway, Sweden, Denmark, and Finland have already dropped consensual paraphilias from their national coding systems derived from ICD -10.  It is unlikely that places dominated by traditional thinking and religious conservatism will adopt the ICD – 11 as recommended.  In Uganda, homosexuality is still regarded as a both criminal and psychopathological, even though it was already dropped before ICD -10 in most other countries.  But the ICD – 11 is likely to have a major impact in the Europe, the West, and in parts of Asia such as Korea, Japan, and China.

Evelyn Hooker did not end psychiatric discrimination against homosexuality with a single study.  It took the work of Frank Kameny, Barbara Gittings and the Gay Liberation Front, and the inside work of gay psychiatrists, and disruption of APA’s annual conference by activists to force consideration of this data.  Compared to that difficult struggle, National Coalition for Sexual Freedom’s negotiations with the DSM – 5 Paraphilia Committee and Norwegian activists editing of the ICD – 10 have proceeded with little conflict.  But just as the data would never have provoked change without the hard work of activists, Evelyn Hooker and Christian Joyal and Julie Carpentier’s data armed activists with the scientific power they needed to complete the political work required to change diagnoses.

Those of you who read my summary of Michael First and Ken Zucker’s presentation at AASECT 4 years ago may recall that Zucker’s last words in that piece were a response to my concern about the DSM-5’s two-tiered diagnostic system because psychiatrists might fail to attribute distress of a paraphilia to social stigma, rather than anything intrinsic to sexual variation.  He had said to wait until ICD -11.  Ken Zucker and Michael First's DSM - 5 plenary at AASECT
’ 
That moment has arrived.  Much of the credit for the ICD – 11 change rests with this research.

© Russell J Stambaugh, June 2017, Ann Arbor MI, All rights reserved



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