The American Psychiatric Association (APA) has concluded a first step in revising the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association by releasing proposed new classifications and criteria for the next revision of the DSM due to be released in 2013. At the same time, the World Health Organization (WHO) is undergoing its own process of revising its International Classifications of Diseases (ICD). The sexual and gender diagnoses are sure to spark intense debate. Sexual and gender disorders can be barriers to sexual health. Access to care for these disorders can lead to improvements in sexual health. At the same time, pathologizing normative sexual behavior and gender expressions can lead to stigma, discrimination, and poor sexual and other health outcomes. What is considered a disorder by these organizations has an enormous impact on all of us.
We know from history that psychiatrists once classified masturbation, oral sex, and homosexuality as perversions. With new knowledge regarding human sexuality, these were removed from the category of "sexual disorders." While the American Psychiatric Association declassified homosexuality in 1973, it was not until 2001 that the Chinese Psychiatric Association did so.
At present, there is quite a bit of concern and disagreement about the existing diagnostic categories and criteria for the sexual and gender diagnoses. Several national health boards have broken from the ICD and have declassified previously classified "disorders." For example, Denmark removed sadomasochism from their classification system in 1995, and as of January 1, 2009, Sweden declassified dual-role transvestism, gender identity disorder of childhood, fetishism, sadomasochism and multiple disorders of sexual preference. They retained transsexualism in order to preserve medical and psychological treatment for this condition (Pink News, 2008).
In February 2010, Norway followed suit and declassified these same "disorders" from their national health board. In February 2010, France became the first country in the world to remove transsexualism from its official list of mental disorders but has retained under a special category the ability for individuals with severe gender dysphoria to received appropriate treatment. The French Health Ministry has already agreed to push other countries in the European Union to drop transsexualism from their lists of mental disorders (Time, 2010). As noted in the article below, Cuba has recommended that transsexualism be removed from the ICD as well.
Last revised in 2000, there seems to be a general feeling that revision of ICD is necessary because of advances in knowledge, a deep concern about balancing the restriction of sexual freedoms and pathologizing normal variations in sexual and gender expressions, and the need to define pathological states for research purposes and access to care (and the right to the best possible care).
There is certainly intense concern regarding ridding the ICD of old and pejorative terms such as impotence, frigidity, premature ejaculation, nymphomania and satyriasis and excessive sexual drive.
A fundamental shift has been suggested in classification of sexual dysfunctions according to the traditional Kaplan/Masters and Johnson model of sexual response. This has mostly been driven by research on female sexual functioning and dysfunction that challenges the old assumption of parallelism of sexual response. Many argue that there is a fundamental difference in sexual response and dysfunctions in men and women are fundamentally different and therefore need different diagnostic criteria. Also, as we further understand the interplay between psychogenic and organic factors, many believe that there is a false dichotomy between organic and psychogenic factors in sexual dysfunction and perhaps in the other sexual and gender disorders. Sexual disorders may involve multiple psychological, interpersonal, and biologic/organic causes, and these influences are not always separate entities. They challenge the prevailing notion that organic sexual problems can be separated from psychogenic problems. There have been suggestions to creating a different category for sexual problems, eliminating the "dependence" of psychiatry and the stigma of a mental illness.
The debate over the paraphilias and whether to retain fetishism, transvestic fetishism, sadism and masochism will be contentious. The proposed new category of hypersexual disorder is clearly an attempt to recognize that some "normal" sexual activity can become excessive, driven, compulsive and in some ways "addictive." The potential misuse (and threat of over pathologization) of this category is enormous and there are also still fundamental questions regarding pathophysiology and nomenclature. And the debate over gender identity disorders will loom even larger. Clinicians, physicians, and researchers have made many important recommendations. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to satisfy anyone on either side of the debate. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to be received well by many on either side of the debate.
I am pleased that the faculty of the Program in Human Sexuality have been involved in this debate and that their research has been used to inform the revision process. Having just reviewed and made recommendations to the WHO regarding proposed revisions to the ICD sexual and gender diagnoses, I am very aware of how difficult this task will be. It will be very challenging for the APA and WHO to find the right balance in the revision of the sexual and gender diagnoses in the DSM-V and ICD-11. Both bodies have opened up the revision process to public discussion and debate (DSM and ICD).
In considering the revisions, sexual health and rights need to be taken into consideration. Based on work from the World Association for Sexual Health (WAS), I offer these guiding principles.
1. Recognition and treatment of sexual and gender disorders is a basic sexual and human right.
2. DSM and ICD should take into consideration the sexual rights of individuals as it considers pathologizing sexual behaviors or gender expressions and individuals' right to freedom to express their full sexual potential, as well as to freedom from sexual coercion, exploitation, and abuse. The individual has a right to individual decisions and behaviors as long as they do not intrude on the sexual rights of others.
3. Sexual and gender diagnoses should not be used in any way to support any forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability.
4. Sexual and gender diagnoses should not be used in any way to pathologize the derivement of sexual pleasure, including autoeroticism, as a source of physical, psychological, intellectual and spiritual well being.
5. Sexual and gender diagnose should not be used in any way to pathologize those who decide to marry or not, to divorce, and/or to establish other types of responsible sexual associations.
6. Sexual and gender diagnoses should not be used in any way to infringe on the individuals right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation.
7. The DSM and ICD sexual and gender diagnoses should support the right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders.
8. There has not been enough research into the understanding or treatment of female sexual dysfunctions and that a gender perspective is needed.
9. A lack of scientifically valid information concerning sexual function within the general population is pervasive and the negative impact of this ignorance is felt around the world.
10. Given the importance of adequate sexual functioning for general sexual health, overall health and well-being, and the health of interpersonal relationships, the updating of the DSM and ICD is welcomed to recognize the distinctions between normal range of sexual and gender expression, and the concerns, problems, and dysfunction and disorders that require intervention. Appropriate sexual health services must be made available throughout the world.
11. Given the concern about "Americanization of mental illness," as an international classification of diseases (Watters, 2010a, b), ICD will need to pay particular attention to the influence of culture and globalization in arriving at a classification system that will meet the needs of the world.
I welcome your comments and encourage you to express your opinions to the APA before April 10, 2010 and to the WHO.
Pink News. Sweden removes transvestism and other 'sexual behaviours' from list of diseases November 19, 2008 Accessed from the Internet on March 14, 2010, http://www.pinknews.co.uk/news/articles/2005-9616.html/
Time. In France, Transsexuals Celebrate a Small Victory. March 1, 2001. Accessed from the Internet on March 14, 2010 at http://www.time.com/time/world/article/0,8599,1968767,00.html?xid=rss-topstories
Watters, E. (2010a)The Americanization of Mental Illness. New York Times Magazine, January 8, 2010. Accessed from the Internet on March 14, 2010 at http://www.nytimes.com:80/2010/01/10/magazine/10psyche-t.html?scp=1&sq=ethan%20water&st=cse
Watters, E. (2010b). Crazy Like Us: The Globalization of the American Psyche. New York: Free Press.
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