Hypersexuality: DSM 5, Are You Kidding?

                                                                                                                    

   As stated in this link, http://wellness.blogs.time.com/2010/02/10/dsm-5-hoarding-binge-eating-and-hypersexuality/, “hypersexual disorder would be added to the new version of the DSM as a diagnosis for people who, for a period of six months or longer, meet at least four of five criteria, including engaging in sexual fantasies and behavior as a response to depression and anxiety, or repeatedly indulging sexual desires without regard for the emotional repercussions-for themselves or others.”

   My goodness. How bad do psychiatrists have to get with diagnoses until the field is buried?

    The DSM, or diagnostic and statistic manual,  published by the American Psychiatric Association, for a profit, is used around the world by clinicians, researchers, psychiatric drug regulators, health insurance companies, pharmaceutical companies and policy makers. The manual evolved from a system which collected a census of psychiatric hospital patients, developed by the US Army, but then it was dramatically revised in 1980 to be more symptom oriented. ICD-10, the international classification of diseases, version 10, produced by the World Health Organization has a chapter on mental and behavioral disorders. The two books are not revised synchronously, so there are different codes for the same disorder.

      Given that DSM is essentially the reference book to define a mental disorder, the diagnosis of hypersexuality disorder means, to put it crudely,  that if the patient has more sex than the doctor thinks is appropriate, then the patient could be labelled mentally ill. Surely, I am joking, my critic says. Yes and no, I respond. Behavior is subjective. How can we begin to draw a line in the sand about sexuality? The critic returns. He says, well what about alcohol use? How do we decide who is an alcoholic? I see the point, however we do have objective markers; the DUI, the elevated liver function tests, the alcoholic blackout. What are the objective markers with sexuality? Pregnancy and sexually transmitted diseases  are not the same thing.

   Does Bill Clinton have hypersexuality? Does that explain Monica Lewinsky? If so, do we really want a president with a mental disorder? Forget that he lied, should his “mental disorder” be grounds for impeachment? What about John Edwards? He had sex with a woman, fathered a child, told his aid to lie on his behalf , ran for the President of the United States, all while his wife, the mother of his three living children, and one deceased child, had metastatic breast cancer. What if we say that John Edwards has hypersexuality disorder? What if he gets “treatment”? Is he now cleared to run for President again?

      What about the treatment for hypersexuality disorder? Is the goal to ensure the patient have sexuality, but not hypersexuality? Do we, as the psychiatrists, tell our patients how many times  a day, a week, a month, with one, two or three partners? If so, do we then become religious leaders in the community? What is the difference between a mental disorder and unethical behavior? If the patient has guilt, then is it a mental disorder, but if he has no guilt, then is it unethical? Does the presence of guilt imply a mental disease, or is this, in fact, a positive sign for the presence of a conscious? I am confused.

     I have seen a number of patients who have a lot of sex with a lot of partners, but I am not concerned about their sexuality, I am concerned about their relationships. I am concerned about their ego strengths, their sense of themselves, and their management of their anxiety. Sexuality is an end-result of many complicated psychological mechanisms. We psychiatrists, need to look at the underpinnings of  behavior. That is our job. To only look at the last stop on the train is to short change the wonders of the human mind. I hope we do not do that.

    Finally, I fear that hypersexuality disorder is a back door into reconstituting homosexuality as a  mental disorder. Until 1974, gays were considered mentally ill. In 1974, DSM II was amended, and homosexuality was removed from the DSM. One bemused observer of the American Psychiatric Association’s annual meeting  labeled it ”the single greatest cure in the history of psychiatry.”‘http://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html?scp=1&sq=homosexuality 

   Hypersexuality disorder is not just a step backwards, it brings psychiatry into the world of judgment, religious principles, and potential persecution. Where did the love of the brain, married to the love of the mind go? Where did the deep respect for the doctor patient relationship go? Where did protecting the vulnerable go? I fear I will no longer be able to recognize my field; the profession which seemed to me to be so personal and so respectful of individual choices. We have lost our way. I hope DSM 6 can find it again. I really hope that.