معیارهای تشخیصی برای انحرافات جنسی پیشنهادی DSM-5 : تنش میان تشخیصی و اعتبار ابزار پزشکی قانونی
|کد مقاله||سال انتشار||تعداد صفحات مقاله انگلیسی||ترجمه فارسی|
|35740||2011||15 صفحه PDF||سفارش دهید|
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Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : International Journal of Law and Psychiatry, Volume 34, Issue 3, May–June 2011, Pages 195–209
In order to prevent sexual crimes, “sexual predator” laws now allow indefinite preventive civil commitment of criminals who have completed their prison sentences but are judged to have a paraphilic mental disorder that makes them likely to commit another crime. Such proceedings can bypass the usual protections of criminal law as long as the basis for incarceration is the attribution of a mental disorder. Thus, the difficult conceptual distinction between deviant sexual desires that are mental disorders versus those that are normal variations in sexual preference (even if they are eccentric, repugnant, or illegal if acted upon) has attained critical forensic significance. Yet, the concept of paraphilic disorders – called “perversions” in earlier times – is inherently fuzzy and controversial and thus open to conceptual abuse for social control purposes. Consequently, the criteria used in diagnosing paraphilic disorders deserve careful scrutiny. The DSM-5 sexual disorders work group is proposing substantial revisions to the paraphilia diagnostic criteria in the DSM-5 nosology. It is claimed that the new criteria provide a reconceptualization that clarifies the distinction between normal variation and paraphilic disorder in a way relevant to forensic settings. In this article, after considering the logic of the concept of a paraphilic disorder, I examine each of the proposed changes to the DSM-5 paraphilia criteria and assess their conceptual validity. I argue that the DSM-5 proposals, while containing a kernel of an advance in distinguishing paraphilias from paraphilic disorders, nonetheless would yield criteria for paraphilic disorders that are conceptually invalid in ways open to serious forensic abuse. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000) – often called the “Bible of psychiatry” in virtue of its influence and authority – is undergoing a revision that will shortly lead to a fifth edition (DSM-5). Starting with the third edition in 1980 (DSM-III; American Psychiatric Association, 1980), the DSM has offered descriptive, symptom-based diagnostic criteria that define each of the mental disorders. The DSM's necessary-and-sufficient diagnostic criteria are used by virtually all mental health professions, as well as attorneys, to determine what is and is not a mental disorder in clinical, research, and forensic settings in the United States and increasingly throughout much of the world. On the DSM-5 website (American Psychiatric Association, 2010a), the Task Force working on the DSM-5 has posted many proposed changes to the diagnostic criteria for categories throughout the Manual, each of which could have a substantial impact on who is considered to be mentally disordered. In this paper, I evaluate the proposed changes to the section of disorders known as “sexual paraphilias,” that is, disorders of the objects of sexual impulses, desires, and arousal, as they currently appear on the website (as of November, 2010). These conditions used to be known as “sexual perversions” or “sexual deviations.” The DSM-III introduced the more neutral term paraphilia, noting that this term's Greek components correctly emphasize that there is a deviation (para) in that to which the person is attracted (philia). Currently, the specific DSM paraphilia categories prominently include pedophilia, exhibitionism, voyeurism, sadism, masochism, frotteurism (rubbing against strangers), fetishism, and transvestic1 fetishism. Many other paraphilias, from asphyxophilia to zoophilia, can be diagnosed within a “wastebasket” category of “paraphilia not otherwise specified” (paraphilia NOS) that encompasses any condition judged by the clinician to be a paraphilia that does not fall under any of the specific categories provided by the DSM. However, the categories specifically named in the DSM along with the new categories proposed for the DSM-5 between them encompass the paraphilias most relevant to forensic evaluation, so I focus on these categories. Because of strong feelings about what is normal versus disordered sexuality, as well as theoretical uncertainty about the nature of human sexuality, the definitions of the paraphilias remain among the most controversial in the DSM. Given the malleability of human sexuality and the creativity of human beings in pursuing and amplifying sexual pleasure, it remains a debated question as to what justifies the classification of a source of sexual pleasure or a type of sexual activity as a mental disorder. The malleability of normal sexuality and our current ignorance of the mechanisms underlying sexual desire are powerful reasons for being conservative in attributing paraphilic disorders. The justification for paraphilic diagnoses has become even more puzzling since homosexuality was eliminated as a diagnostic category from DSM-III (Bayer, 1981 and Spitzer, 1981), followed by the final elimination in the revised third edition (DSM-III-R; American Psychiatric Association, 1987) of a remaining more limited category of “ego-dystonic homosexuality” in which the patient is distressed about his or her homosexuality. During the nineteenth and early twentieth centuries, homosexuality was considered the prototypical sexual perversion. For quite powerful reasons, including changing social values regarding both homosexuality itself and the importance of the reproductive function of sexuality, and the fact that homosexuality is compatible with a full capacity for love and relationship happiness, homosexuality was reclassified as a non-disordered variant of human sexuality. One might have expected, based on parallel logic, that other supposed paraphilias would inevitably be depathologized as well as part of a broadened acceptance of human sexual pluralism. But that has not happened. This historical circumstance pointedly raises the question whether there is a defensible conceptual basis for the lines that are being drawn by the DSM between the normal and the disordered. There are four changes in the paraphilia criteria proposed for DSM-5 that I consider here. The first is a proposal to clarify terminology by distinguishing paraphilias – which are to be considered non-disordered sexual variations – from paraphilic disorders, which are to be distinguished from the paraphilias themselves by the harm they cause (currently, “paraphilia” is used for both the deviant desire and the disorder). A second proposal is for diagnosis to rely more on the objectively ascertainable data of the number of an individual's sexual victims, along with a continued emphasis on behavioral criteria as central to diagnosis. Two further proposed changes consist of new categories to be added to the paraphilic disorders. The first is hebephilia (sexual arousal to pubescent children), to be incorporated into an expanded category of pedophilia (arousal by prepubescent children) to be labeled pedohebephilia. The second proposed new category is paraphilic coercive disorder, which is basically arousal by the coerciveness of a sexual act, thus in effect a paraphilic rape disorder. After some introductory explanation of why the definition of the paraphilias has become of crucial importance to larger issues regarding the protection of civil liberties, I address the concept of disorder and its application to the paraphilias in some detail. I then offer a conceptual history of DSM criteria for the paraphilias, after which I consider each of the DSM-5 proposals in turn.
نتیجه گیری انگلیسی
I have wrestled in this paper with the conceptual underpinnings of diagnosis of paraphilic disorders, and examined the validity of the proposed changes to the paraphilic diagnostic criteria in DSM-5. The DSM-5 proposals are driven to an extent by challenges posed by the need for diagnosis in the forensic context of sexual predator civil commitment proceedings. The most valid indicators of true paraphilic disorder – such as exclusiveness, fixation, and compulsiveness – which are difficult to establish in a forensic context, are not adequately taken into account either in the paraphilia criteria of the past or the proposals for DSM-5. Weaker criteria are used that open the door to false positive diagnoses. The proposals offered by the DSM-5 Workgroup dealing with sexual and gender identity disorders incorporate an enormous effort of thought and scholarship. They have some potentially useful features, but also some troubling limitations. If combined with other requirements, it may be that a “multiple victims” requirement could be helpful in protecting against false positive diagnoses under some circumstances, even though a history of multiple victims is neither necessary nor sufficient for disorder by itself. Terminological clarification of the distinction between a paraphilia, which may be a harmless sexual inclination even if a dysfunction, versus paraphilic disorders that are sexual dysfunctions that cause substantial harm to oneself or others, is useful, although it is already implicit in the “Criterion A/Criterion B” structure of the diagnostic criteria sets. On the other hand, the proposals for the new categories of “hebephilia” (incorporated into an omnibus “pedohebephilia” category) and “paraphilic coercive disorder” fail to satisfy rigorous standards for diagnostic validity, and open up major new avenues for false positive diagnoses. The proposed new categories as well as the multiple-victims proposal are open to abuse by confusing the performance of criminal sexual acts with having a paraphilic disorder. The paraphilic disorders present a continuing challenge to our conceptualization of mental disorder. Oddly enough, with the passing of laws allowing civil commitment of sexual offenders whose behavior is the outcome of a mental disorder and the declaring of such laws as constitutional by the Supreme Court, the valid diagnosis of paraphilic disorders has also become tactically central to the future of civil liberties in our country. At this important juncture, one would hope that the DSM-5 Workgroup might focus on basics and build on the long intellectual tradition of grappling with the nature of paraphilic disorders independent of the issue of forensic facilitation, so as to clarify the kinds of evidence that distinguish genuine sexual paraphilias from deviant sexual behavior not due to a sexual paraphilia. Unfortunately, it appears instead that the Workgroup's deliberations may have overly emphasized the facilitation of forensic evaluations with noncooperative respondents in sexual predator proceedings, rather than the core issue of diagnostic validity. The importance of protecting the public means that one cannot blithely adopt anti-psychiatric attitudes in this arena. The Workgroup's attempt to be both practical and respecting of the public and victims as well as the rights of the offender is to be admired. However, the first task should be to “get it right” with respect to diagnostic validity, and then to explore the practical needs in the forensic context within the framework set by validity considerations. Otherwise, the forensic tail is wagging the validity dog, and we are likely to get criteria that possess a misdirected pseudo-validity that will not serve us in the long run and set a dangerous precedent for future tensions between civil liberties and civil commitment for mental disorder.