To The Editors:
Dr. Spitzer's “Point of View” column concerning DSM III appraises the psychoanalytic community of his “current thinking” and the “general principles” underlying nosological changes as regards the sexual deviations. His invitation to the American Psychoanalytic Association to set up a liason committee to critically review DSM III is a welcome step in the right direction. Theoretical and clinical advances in our understanding of the sexual deviations have come about through new conceptualizations derived from our understanding of childhood development and ego psychology. Clinical research offers hope for profound structural change in these patients as a result of psychoanalytic treatment and psychodynamic psychotherapy.
Dr. Spitzer's “general principles” which are his guidelines for declaring the sexual deviations “disorders” are: 1) subjective distress; 2) impairment in social functioning; and 3) intrinsic disadvantage. These principles, when examined closely as to their use and meaning, represent beliefs and concepts which are largely in direct opposition to psychoanalytic theory and our growing clinical understanding of these conditions. If generally accepted, they could have far reaching negative effects, not only on psychoanalytic research, the training of psychiatric residents, but even on third party payments for the treatment and alleviation of these serious sexual disorders.
A major consequence of this position is that homosexuality has already been deleted as a psychiatric disorder from DSM II. Spitzer states: “Homosexuality is not included unless accompanied by subjective distress, and the condition is then termed sexual orientation disorder”. In substituting this term he is asserting that the only homosexual who is “disordered” is one who does not accept or like being homosexual and that the obligatory homosexual suffers from none of the multiple intrapsychic anxieties described in
the clinical research of many psychoanalysts for many years as causative of this condition. Certainly the concept that the only homosexual who is “sick” is one who seeks to ameleorate his condition through psychoanalytic treatment is erroneous in that often these individuals are far less masochistic and self destructive than their partners or associates who may not even attempt any realistic effort to relieve their disturbance.
Dr. Spitzer comments in his column that it was “a foolish provisional approach” to insist that a sexual disorder could only be termed a disorder if it “coexisted with distress” e.g. a fetishist must experience distress to be considered as having a disorder. (Despite this correction, no alteration is suggested as to the status of homosexuality.) We should be mindful that this change was made only after strenuous objections were raised by various psychoanalytic societies that this “requirement” be dropped in that it completely denied the concept of ego-syntonicity of symptom formation in the sexual deviations.
Dr. Spitzer further asserts that “all of the traditional sexual deviations are included in DSM III”. A perusal of his latest publication entitled “DSM III: A Classification System in Development” by Robert L. Spitzer, M.D. and Michael L. Sheehy, M.D. (Psychiatric Annals, vol. 6, no. 9, Sept. 1976, pp. 446-451) discloses that the phrase “sexual deviation” is nowhere to be found in the new nomenclature proposed for DSM III. The conditions to which he refers such as exhibitionism, voyeurism, sexual sadism, etc. are listed under the heading of “sexual arousal disorders”, a phrase commonly used and understood to refer to those disturbances of performance in the standard male-female coital pattern. All sexual disorders are “sexual arousal disorders” in that there is a disturbance attendant to the achievement of orgasm, but the sexual deviations owe their special configuration to earlier preoedipal disturbances not usually found in simple sexual arousal disturbances commonly represented by premature ejaculation, retarded ejaculation etc. The former are usually due to object relations conflicts in contrast to the latter which are usually the result of structural conflicts.
Even more disconcerting, however, is Dr. Spitzer's reason for listing exhibitionism, voyeurism, fetishism etc. as disorders, namely, that they place the “individual at an intrinsic disadvantage since no society can generally tolerate such behavior”. Not only is the concept of “disadvantage” not a psychoanalytic one but Dr. Spitzer reveals that he considers disorders to be dependent upon social definition, giving little or no credence to the unconscious psychopathological determinants in the production of these serious sexual disorders.
Lastly, it is ironic that one of the main reasons put forth by those in favor of removing homosexuality from DSM II was that it should not be considered a disorder because of negative societal attitudes towards it and therefore should be removed from our nomenclature.
Charles W. Socarides
Nathaniel Ross
Vamik O. Volkan