DSM5 in Distress

The DSM's impact on mental health practice and research

The Rejection of Paraphilic Rape In DSM III: A First Hand Historical Narrative

Rape is a crime, not a mental disorder.

There have been four ringing rejections of the concept of paraphilic rape- in DSM III, in DSM IIIR, in DSM IV, and in a 1999 APA Task Force report. The circumstances surrounding the latter three decisions are fairly well known, the first less so. Dr Abraham Halpern, one of the fathers of forensic psychiatry, played a crucial role in the DSM III deliberations and gives us his vivid recollection of the events:

"In the first draft of DSM-III in March, 1976, it was proposed that  rapists be officially recognized as a patients suffering from a mental disorder. The following diagnostic criteria for "Sexual assault disorder" were listed:
A. The fantasy of sexual assault is erotically exciting.
B. There is significant motivation to translate the exciting fantasy into action. The individual has committed an act of sexual assault, or inevitably will in the near future. If the act has been committed in the past, there is significant motivation to repeat it.

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A DSM-III Task Force conference in June 1976 in St Louis  reviewed and rejected this proposal. The American Academy of Psychiatry and the Law (AAPL) pointed out that"Sexual Assault Disorder" might foster the decriminalization of rape with the effect of minimizing the wrongfulness of the perpetrator's conduct, opening the door to a widespread misuse of psychiatry. Prosecutors would seek to hospitalize offenders when there was insufficient evidence to convict, and defense attorneys would seek to hospitalize offenders when there was overwhelming evidence making conviction otherwise inevitable. Sexual assault is not a disorder-it is a crime; DSM-III is a classification of mental disorders, not a classification of criminal conduct.

The AAPL recommendation that "302.850 Sexual assault disorder" be excluded from DSM-III was endorsed by women's groups throughout the country. Subsequent drafts of DSM-III (April 15, 1977, and January 15, 1978) did not include "Sexual assault disorder" and  it did not appear in the 1980 edition of DSM-III.

We should have gone further. DSM-III should have clarified that its diagnostic categories are not meant to justify or be confused with criminal conduct. The continuing misuse of  DSM in legal settings shows that the DSM III cautionary statement is not  worded clearly enough.

Including "Paraphilic Coercive Disorder" as a diagnostic category in DSM-5 would be bad for psychologists, psychiatrists, psychiatric hospitals, and for society.  Moreover, it would be an invitation to the anti-psychiatry movement to scorn and ridicule the American Psychiatric Association."

My response. Many thanks to Dr Halpern for his description of past events and wise cautions to avoid future dangers.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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