Summer is here at last in England after a long, cold Spring so where better to enjoy the belated sunshine than in the, err, stifling atmosphere of a conference centre with no air conditioning?

Well, call me a masochist but I had a great time last week at Classifying Sex: Debating DSM-5, a two-day conference at Cambridge University. DSM, for the uninitiated, is the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, routinely dubbed the bible of psychiatry, a description often criticised but one which captures the intensity of the religious warfare its various versions and interpretations provoke worldwide, not just in the United States. A quasi-religious aspect is evident, too, not just in the ferocity of debate but also in its labyrinthine theology: grasping what is at stake in all the rhetorical cut and thrust demands close attention to decades of scriptural exegesis since the first edition in 1952 up until the fifth edition launched in May this year. Hence the conference: nothing less than days of lectures from experts will suffice to get one’s head around it.

Speaking of mental disorders, the sanest response might be, why bother? Don’t the shrinks give minor-attracted people a tough enough time as it is, without breaking our heads trying to unravel their precise modes of oppression? Possibly, but that would be to miss an important point: psychiatry is not monolithic; not every oppressive initiative succeeds. A clear example of this is the defeat of the DSM-5 Paraphilias Subworkgroup’s proposal to include hebephilia as a mental disorder, an outcome with potentially huge implications for the lives of sex offenders in the U.S. diagnosed with hebephilia[i]. It could mean the difference between being released at the end of a sentence on the one hand and being confined in a “civil commitment” gulag on the other, with little prospect of ever being freed. The latter fate has increasingly been the desperate lot of those offenders designated paedophiles in recent times: they are supposed to stay behind bars until treatment renders them “safe”, with the Catch 22 that no current treatment can guarantee they will not reoffend, so they cannot get out.

A separate diagnosis along similar lines for hebephiles i.e. those preferentially attracted to early adolescents, as opposed to paedophiles with a pre-pubertal preference, would have drawn in a substantial proportion of the adult population and would have had the strange effect in the case of man-girl and woman-boy love of calling it a mental disorder to be preferentially attracted to a reproductively viable (after menarche or semenarche) early adolescent partner of the opposite sex. It is one thing to criminalise behaviours deemed socially undesirable, but quite another to say a person whose sexual desires are consistent with nature’s imperative to go forth and multiply is mentally disordered. Surely only an idiot would make such a proposal?

Wrong! Try genius instead. Ray Blanchard, perhaps best known for his brilliant and well supported theory that male sexual orientation is affected by fraternal birth order, was described at the conference by another DSM big cheese as “the smartest guy I know”. And one of Blanchard’s smart answers is that it may be true that a high proportion of men (OK, let’s say nearly all of them) find freshly nubile girls a turn-on (and the remainder get hot for young boys!) but the preference, for most, is a more fully mature physique: the truly curvaceous adult female form, with big breasts and butts, is what really does it for them, or the filled-out, muscular frame of a grown man. By contrast, those men whose preference is for pubescent girls (typically aged 11-14) are unlikely to have much reproductive success compared to those whose preference includes women in their twenties and beyond. Therefore, so the reasoning goes, the hebophile’s preference for 11-14 year olds is not what nature intended and accordingly in biological terms it points to a mental disorder.

Coming from Blanchard, of all people, the audacity of this argument is staggering. He is gay! And he has the nerve to pass judgment on people’s mental health based not only on whether their sexual preferences are reproductively viable but whether they are reproductively maximal! On that basis homosexuality should never have ceased to be classified as a mental disorder, but I haven’t seen him campaigning to have gayness restored to the DSM as a psychiatric condition! Nor should this happen: with overpopulation a huge threat these days, not extinction, it makes little sense to define sexual health in crudely reproductive terms, as several speakers at Cambridge noted.

To many minor-attracted people it seems as though all of Blanchard’s research on minor-attraction is hell-bent on dehumanising  paedophiles and hebephiles, making us seem an inferior sub-species: according to his work we are less intelligent, shorter, and are more likely to have suffered head injuries than others.  His research could in theory be used to argue for social policies aimed at helping the minor-attracted overcome any such difficulties if they really exist. But as philosopher of science Patrick Singy eloquently argued in a presentation at Cambridge titled Danger and difference: the stakes of hebephilia, the strategy may be rather less worthy.

Not Blanchard’s personal strategy that is. His motives may be entirely benign as an individual. No, what Singy had discerned is, rather, an unconscious strategy adopted by modern society.  In the liberal democracies that have developed from the 19th century onwards, Singy points out, there is a tension between security and liberty: creating a safe society for the majority can only be achieved by restricting the rights and freedoms of those who present a threat. This cannot be done without a bad conscience by liberally-minded policy makers unless they can first dehumanize offenders, emphasizing their supposedly radical difference from normal people in every possible way: they must be called inferior, or monsters or predators (as in America’s “sexually violent predator” laws), which then enables them (us) to be treated like animals. It is a strategy which preserves as much liberty as possible for the majority by according a radically different, much lower, status, to just a few – with the language of mental disorder coming in very handy for the purpose.

[Added 19 July: The significance in a liberal democracy of claiming supposedly animalistic “predators” are mentally ill is that the individuals thus labelled can be oppressed in ways which superficially appear to be humane: in theory, they are held in civil confinement not as punishment but so they may be treated. The Nazis rhetorically dehumanized their victims before committing acts of genocide, but mass exterminations would obviously be inconsistent with liberal democracy. Such democracies pride themselves on being tolerant and respectful of diversity as far as possible; when there are exceptions, as with “predators” who supposedly must be caged like animals to protect society, the conscience and ethos of liberalism are salved thanks to the availability of medical rather than penal language.]      

Blanchard, bless him, may not be in love with hebephiles but he does appear to adore hebephilia as a theoretical construct and has done elegant work on the relationship (in terms of preferential and lesser levels of attraction) between paedophilia, hebephilia and teleiophilia (attraction to adults). Perhaps that is why, as chair of the Paraphilias Subworkgroup, he fought a long, bitter, and ultimately losing battle for hebephilia to take its place in DSM: victory would have given hebephilia a higher profile and provided DSM with a diagnosis underpinned by a significant element of scientific research.

Indeed, it is precisely the lack of good research behind most of the DSM’s diagnoses that has been a major and growing cause of embarrassment to the APA and the profession of psychiatry in recent years: the latest edition runs to around a thousand pages, but like earlier efforts it has been criticized as just a rag-bag of symptoms to which labels of often highly dubious medical validity have been attached, with too little attention paid to the underlying nature and causes of the conditions described. As several conference speakers pointed out, what gets labeled as sexually pathological is pretty much all down to politics of one sort or another: if it is not the moralists (who traditionally valorize reproductive sex and pathologize everything else) who are calling the tune, it is insurance companies who need diagnoses in support of legal claims, or big pharma, whose pill-peddling also needs a range of named, medically approved,  dysfunctions, diseases and disorders which they can claim their drugs address, thereby justifying an artificially generated market among  “the worried well”.

The radical psychiatrist Thomas Szasz, who died last year, looms large behind all this. His books The Myth of Mental Illness (1960) and The Manufacture of Madness (1970) argued that mental illnesses are not real in the sense that cancers are real: there are no objective methods for detecting the presence or absence of mental disease. That may change, as medicine becomes more sophisticated. A straw in the wind to this effect came in April, just before the launch of DSM-5, when the American National Institute of Mental Health (NIMH) announced that in future it would be re-orienting its research away from DSM categories. The institute’s director, Thomas Insel, issued a statement titled Transforming Diagnosis. NIMH, he said, “has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.”

Remarkably, unless I was nodding off in the sweltering heat and missed it, not a single word was said in Cambridge about this landmark development. Not that the switched-on, hi-tech new approach by NIMH will take the politics out of sexual psychiatry: it might even give our oppressors more opportunities to blind us with science; but this futuristic ambition to ground mental health diagnosis more deeply in biology (without, one hopes, harking back to reproductive fitness) should at least offer scope for the rational interrogation of any assertions that may be made.

Back to Singy. He contended in his platform speech that whether hebephilia is a mental disorder or not is completely irrelevant to society’s concern about it. What really matters is whether it is dangerous and, if so, how such danger can be assessed reliably. I think he is right, and the same applies to paedophilia. Several speakers from the floor, asking questions, appeared to conflate the harm/danger issue, which at least in theory could be measured objectively, with consent i.e. non-consensual sex is ipso facto harmful. Again, I agree, but the issue of harm is then prejudged by the legalistic fiction that those below a certain age cannot consent. After I pointed out this confusing conflation in a question of my own, Singy approached me in the lunch break for further discussion. I found it an interesting exchange, so I might come back to that and further Cambridge stuff in another post.

[i] It has been claimed that a diagnosis of hebephilia would not in practice necessarily have led to more sex offenders being snared in civil commitment, because it has long been possible to diagnose “Paraphilia NOS” (Not Otherwise Specified), a catch-all category, as an alternative. The NOS diagnosis, which also covers necrophilia and zoophilia, has been used to help label an offender as a “sexual violent predator” in the U.S., thereby providing the legal justification for civil commitment. However, this has only ever been applicable in certain cases, at least in theory, because “the essential features of a paraphilia are recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one’s partner, or children or other nonconsenting persons…” (Kafka, 2010). Absent any evidence that the paraphilic (or “perverted”, as would once have been said) offender had any desire to hurt or humiliate a young partner, such a diagnosis would appear to be unjustified. In other words the NOS diagnosis should not ensnare the hebephile who has sex with a willing young partner (statutory rape) but a diagnosis of hebephilia would. However (I warned you this stuff gets complicated!), a simple but bogus (i.e. purely legalistic) diagnosis of “paraphilia nonconsent” has been used frequently in the American courts in support of civil commitment (Frances, 2011).

Frances A, First MB, Paraphilia NOS, nonconsent: not ready for the courtroom, J Am Acad Psychiatry Law. 39(4):555-61 (2011)

Kafka MP, The DSM diagnostic criteria for paraphilia not otherwise specified, Arch Sex Behav. 39(2):373-6 (2010)