To the Editors:
In the July issue of the Newsletter Drs. Socarides, Ross and Volkan express their discontent with the way that sexual disorders are to be handled in DSM III. They state that Dr. Spitzer's “general principles,” which he uses as guidelines for designating sexual deviations as diagnosable disorders, “represent beliefs and concepts which are largely in direct opposition to psychoanalytic theory and our growing clinical understanding of these conditions.” I wish to express a more sanguine view.
Psychoanalysts, Dr. Socarides prominent among them, have certainly furthered our understanding of the sexual deviations from a psychoanalytic point of view. But it is not clear why this understanding is held to be subverted by Dr. Spitzer's position. Dr. Spitzer's “principles” do not challenge the analytic findings nor the concept of ego-syntonic disorders. In effect he is enlisting an adaptational point of view in his attempt to make distinctions which are meaningful for clinical psychiatry. Societal values have always been relevant to the psychiatric designations of normal and abnormal, and have provided fluctuating guidelines for distinguishing activities variously as socially valuable, socially acceptable, criminal, immoral, valid expressions of religious belief, and mentally deranged, among others. It is essential to realize that Dr. Spitzer is working on a psychiatric nomenclature and not a psychoanalytic one, and that his position must of necessity differ from that of psychoanalysis.
The psychoanalytic view that neurotic phenomena are ubiquitous and that human beings vary from one another along a complex, multi-dimensional continuum renders our formulations of limited relevance to Dr. Spitzer's task where ego-syntonic conditions are concerned. Many conditions have been illuminated by psychoanalytic inquiry which are not in themselves diagnosable in either DSM I or DSM II. In fact some of these conditions may express ego-syntonic, and in many instances obligatory, behavioral defenses against anxiety deriving from repressed intrapsychic conflicts. The mere finding of ego-syntonic defenses against such anxiety, whether manifest in behavior or not, cannot in itself sustain a diagnosis of clinical disorder. We need not be surprised if the nosological status of ego-syntonic sexual orientations and behavior is influenced more by cultural considerations than by psychoanalytic findings.
Dr. Socarides offers no alternative guidelines for making the distinction which Dr. Spitzer needs; i.e., the distinction between a neurotic condition and a diagnosable neurotic disorder. He alludes to the presence of pre-oedipal disturbances and obligatory quality in some sexual deviations as evidence of their severity, but quite properly does not explicitly identify these features as essential or sufficient for the diagnosis of a pathological state.
Dr. Socarides notes that homosexuals who seek help are often “far less masochistic and self-destructive than their partners or associates (who do not).” This is true, but it is also true that Dr. Spitzer's “general principles” encompass both groups and in both warrant a clinical diagnosis. Dr. Spitzer has not suggested that the presence of a disorder per se is contingent upon the desire for treatment,—rather that accurate diagnosis can be attained only through clinical evaluation. This position is generally accepted by analysts.
The anticipation of “far reaching negative effects” of DSM III on psychoanalytic research and third party payment for treatment is difficult to understand in the light of our reliance in psychoanalysis upon the patient's distress to sustain a therapeutic alliance directed to the alleviation of that distress. By what means are we to treat or investigate directly those individuals who are content with their lot and want nothing from us?
The deletion of a valid diagnostic category from the psychiatric nomenclature merely because its inclusion might cause personal hardship to individuals so diagnosed is clearly untenable. But in the case of the proposed omission of homosexuality it is the validity of the diagnosis which is being questioned. The issues of egosyntonicity and satisfactory adaptation to the culture are the pertinent considerations, and have to be taken seriously. Such matters are a legitimate concern of clinical psychiatry, and attention to them seems to me in no way to depreciate or impede the work of psychoanalysis.
George L. Alexander, M.D.
Pittsburgh