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 armed forces 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 afterthought, 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, to sort them into homosexual and heterosexual piles, and to evaluate the extent of each subject’s signs of psychopathology on the tests. She also collected her subjects' 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. He scored the Rorschach protocols. 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 they 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.
She chose a leading authority on each test to evaluate the subjects’ protocols, to sort them into homosexual and heterosexual piles, and to evaluate the extent of each subject’s signs of psychopathology on the tests. She also collected her subjects' 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. He scored the Rorschach protocols. 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 they 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 fantasies are
criminal. Obviously, private fantasies would not be known to authorities. However, inn 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) intended to provoke sexual feelings 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 sample of Quebecois. Individuals who reported none of these
fantasies were in the extreme minority. Only
three of the 55 things Joyl and Carpentier asked about were so uncommon that less than two
standard deviations (a little under 2%) of their respondents reported ever having
them. Thus, hardly any fantasy was anomalous,
and the diversity of these fantasies seemed to have no respect whatever for the boundaries of conventional sexual
practices implied by the DSM. 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 of that variability, although the latter study elided direct
assessment of kinky behaviors. Recent
studies suggest an uptick in interest and behavior in kink, but most, with the
exceptions of Richter et al, of Australia and Langstrom et al of Sweden, the studies lacked
representative national samples.
In immediate follow up to the JSM study, Joyal and
Carpentier drew a representative provincial sample of Quebec, compared
telephone and on-line administrations, and followed up their inquiries about
fantasies with questions about abuse history, fantasy satisfaction, and
behaviors. In si doing 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 physical or sexual abuse. These nearly representative samples 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, and this underscores another of Joya's observations that how these sexual behavior questions are asked makes a substantial difference in how frequently people endorse them.. 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 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 specific 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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