DSM5 in Distress

The DSM's impact on mental health practice and research

DSM 5 Rejects Coercive Paraphilia

Confirming yet again that rape is not a mental disorder


The proposal to include "coercive paraphilia" as an official diagnosis in the main body of DSM 5 has recently been rejected. This confirms the previous like decisions of DSM III, DSM IIIR, DSM IV. It is unanimous- being a rapist doesn't mean someone has a mental disorder and does not justify psychiatric commitment.

This sends an important message to everyone involved in approving psychiatric commitment under Sexually Violent Predator (SVP) statutes. The evaluators, prosecutors, public defenders, judges, and juries involved in SVP hearings must all recognize that the act of being a rapist is almost always an aspect of simple criminality and that rapists need to receive longer prison sentences, not psychiatric hospitalizations.

The current careless and widespread application of "Paraphilia NOS, Nonconsent" results in commitments that are psychiatrically incorrect and constitutionally quite questionable.
The DSM 5 rejection of rape as mental disorder will hopefully call attention to, and further undercut this abuse of psychiatric diagnosis.

This DSM 5 rejection has huge consequences both for forensic psychiatry and for the legal system. If "coercive paraphilia" had been included as a mental disorder in DSM 5, rapists would be routinely subject to involuntary psychiatric commitment once their prison sentence had been completed. While such continued psychiatric incarceration makes sense from a public safety standpoint, misusing psychiatric diagnosis has grave risks that greatly outweigh the gain.

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Mislabeling rape as mental disorder in SVP cases allows a form of double jeopardy, constitutes a civil rights violation, and is an unconstitutional deprivation of due process. Preventive psychiatric detention is a slippery slope with possibly disastrous future consequences for both psychiatry and the law. If we ignore the civil rights of rapists today, we risk someday following the lead of other countries in abusing psychiatric commitment to punish political dissent and suppress individual difference.

Not Otherwise Specified diagnoses are included in DSM only as residual wastebasket categories provided for clinical convenience. They do not lend themselves for use in consequential forensic proceedings because NOS diagnosis is inherently idiosyncratic, imprecise, and unreliable. These are the only categories in DSM that lack the defining diagnostic criteria sets that are necessary to produce adequate diagnostic agreement.

Which brings us to a continuing problem raised by the DSM 5 posting. The sexual disorders work group proposes placing "coercive paraphilia" in an appendix for disorders requiring further research- an appendix for DSM IV. It was meant as a placement for proposed new mental disorders that were clearly not suitable for inclusion in the official body of the manual, but might nonetheless be of some interest to clinicians and researchers.

In preparing DSM IV, we had very strict rules and high hurdles for adding any new diagnosis- only a few suggestions made the cut, while close to 100 were rejected. Because it was no more than an unofficial tag along, we had no similar qualms about the appendix and felt comfortable including numerous rejected diagnoses in what seemed like a benignly obscure way that could do no harm.

If "Coercive Paraphilia" were no more dangerous than the average rejected DSM suggestion, it would similarly make sense to park it in the appendix- as has been suggested by the DSM 5 sexual disorders work group. This might facilitate the work of researchers and also provide some guidance to clinicians in assessing the vanishingly rare "black swan" rapist who does have a paraphilic pattern of sexual arousal.

But "coercive paraphilia" is not the average rejected DSM diagnosis. It has been, and is continuing to be, badly misused to facilitate what amounts to an unconstitutional abuse of psychiatry. Whether naively or purposefully, many SVP evaluators continue to widely misapply the concept that rape signifies mental disorder and to inappropriately use NOS categories where they do not belong in forensic hearings.

Including "Coercive Paraphilia" in the DSM 5 appendix and suggesting it as a possible example of "Other" Paraphilia would confer an undeserved back-door legitimacy on a disavowed psychiatric construct. Little would be gained by such inclusion and the risks of promoting continued sloppy psychiatric diagnosis and questionable legal proceedings are simply not worth taking.

The rejection of rape as grounds for commitment must be unequivocal in order to eliminate any possible ambiguity and harmful confusion. We did not include any reference to "coercive paraphilia" in DSM IV and it should not find its way in any form, however humble and unofficial, into DSM 5. The inclusion of "coercive paraphilia" in the DSM 5 appendix is a bad idea because the appearance of this white elephant anywhere in DSM 5 could be used to justify the otherwise unjustifiable use of Paraphilia NOS as a diagnosis in SVP commitments.

 

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

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