Terminology, diagnosis and labeling

Authored by Henry Strick van Linschoten

Using words, labelling, classifying and diagnosing are essential human activities, as language and verbal expression are an important distinction for us as a species. Although diagnosis is sometimes criticised by psychotherapists from various perspectives, some form of it is needed for many activities, such as doing research, making health decisions, classifying people’s issues statistically to lead to staffing and budgeting decisions. Also, under different headings of “formulation” or “assessment”, in the early process before a person is settled down into seeing a counsellor, there is often an attempt to determine and verbalize what kind of problem a person has, or perceive themselves as having, how severe it is, and what they want to focus on in psychotherapy.

DSM and ICD

There are two dominant systems of classification, designated by their initials as DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (## International Statistical Classification of Diseases and Related Health Problems**). DSM is a product of the American Psychiatric Association. Their latest major revision (the first one was published in 1952), DSM-5, was published in 2013. ICD is a classification issued by the World Health Organization (WHO), starting in 1949. ICD has a primary emphasis on its use for coding causes of death, to aid in national and international mortality and morbidity statistics. As such it is a universal standard, also used in the USA – but this aspect of the ICD is less relevant to psychotherapists. The last official ICD edition was ICD-10, endorsed in 1990. A fairly final version of ICD-11 was published on the Internet in 2018. It will be passed for endorsement to the member states of the World Health Assembly in 2019, and is scheduled to go into effect in 2022. The references used here for DSM-5 will be DSM-5 (2013) or DSM-5, and for ICD – ICD-10 (1992), ICD-10 (2016) and ICD-11 (2019). The level of detail in the ICD reference documents is considerably lower than that in DSM – about one third of the length in the case of sexuality.

DSM and ICD are imperfect systems and are much criticised. The reason for their great influence lies in their role in national health systems, for statistics about health, illness and death, or research, and because there is no other existing system that remotely approaches them in terms of acceptance or credibility. Hence, this module will summarise the current categories, as they continue to be the “best we have”.

DSM-5 and ICD-11 deal with sexual issues relevant to this module under a few overall headings. They both refer to “paraphilic disorders”. They have a very similar category called “gender dysphoria” by DSM-5 and “gender incongruence” by ICD-11. A third group of issues is called “sexual dysfunctions” in DSM-5, and divided under two headings, “sexual dysfunctions” and “sexual pain disorders” in ICD-11. ICD-11, with its greater general medical emphasis than DSM, also describe “changes in female genital anatomy” and “changes in male genital anatomy”. This section will mostly follow the DSM terminology and headings, and only refer to ICD-11 when there are significant differences.

The major categories recognised by DSM-5 are sexual dysfunctions, gender dysphoria and paraphilic disorders.

Sexual dysfunctions

The sexual dysfunctions listed are:

  • Delayed ejaculation
  • Erectile disorder
  • Female orgasmic disorder [i.e. not enough; insufficiently intense]
  • Female sexual interest / arousal disorder [absent or reduced; combining the previously separate sexual arousal and sexual desire disorders]
  • Genito-pelvic pain / penetration disorder [This diagnosis merges the earlier diagnoses of vaginismus and dyspareunia, largely because they were difficult to distinguish clearly]
  • Male hypoactive sexual desire disorder
  • Premature (early) ejaculation
  • Substance/medication-induced sexual dysfunction

DSM is somewhat more organised into separate male and female categories than ICD-11. They have in common the continued “official” emphasis diagnostically on normative-ideal categories. Ejaculation can be premature or delayed. Female orgasms and erections can be “disordered”. Sexual interest, arousal and desire (ICD) can be too low (but it is noteworthy that there is no diagnosis for it being considered too high).

A particular point worthy of note is that the formulation for the broadly equivalent “female sexual interest / arousal disorder” and “male hypoactive sexual desire disorder” is markedly different. This is maintained in the detailed diagnostic criteria used for men and women (and note the binary character of this distinction here), which are more precisely normative for women, where the criteria require investigation of initiation of sexual activity, sexual excitement / pleasure, and genital or nongenital sensations during sexual activity…

Norms

This leaves open the question where these norms have their origin. Is it genuinely internal, based on what the persons concerned feel and experience themselves? Or are the norms responding to, or have they internalised, judgements coming from society, culture, religion, the media, family, parents, the community, as to what is “normal” and “satisfactory” functioning, and what is “abnormal”, “wrong”, “problematic”? Other sections will say more about this, but the general trend of the past decades among sex educators, sexologists and most sex therapists has been to abandon such normative views as much as possible. Judgements about what is wrong and abnormal were also behind the condemnation as “abnormal”, “pathological” and criminal of homosexuality, and of wishes for gender transition / affirmation, leading to attempts at “conversion therapy”, lending support to stigmatisation, elevated rates of suicide and being subject to attacks, assault and homicide (Kleinplatz, 2012).

A main line of defence against the questioning from the designers of the classification systems is that they only recognise statistical anomalies as disorders when the general condition is fulfilled that the symptoms must cause “clinically significant distress in the individual, or disability in social, occupational or other important activities”. In the introductory passage on the general distress criterion, DSM-5 states that “socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual [i.e. the distress or disability referred to above].” These distinctions and qualifications need to be kept permanently in mind, the more so for anyone who gets involved in debating, influencing or making decisions about the diagnostic categories used in DSM and ICD.

Further qualifications made in the text of DSM-5 are helpful in making sense of sexual problems and of what can be regarded as a form of mental disorder. DSM-5 stresses that most of the “sexual dysfunctions” listed can also be caused by “nonsexual mental disorders”, by severe relationship distress or other significant stressors, be the effect of substance use or medication, or be due to another medical condition. If any of these reasons obtain, it is incorrect to maintain the sexual dysfunction as a diagnosable disorder in itself. In the introduction to the whole chapter, it is explained that sexual difficulties can be the result of “inadequate stimulation”, possibly caused by “lack of knowledge”. And for most disorders it is specifically reiterated that assessment must take the “interpersonal context” into account.

Finally, users of the categories are urged to consider that sexual response is usually “experienced in an intrapersonal, interpersonal and cultural context”, with biological, sociocultural and psychological factors interacting. They specifically mention “severe relationship distress” and “partner violence” as factors that may lead to a decision not to make a diagnosis of sexual dysfunction.

Gender dysphoria

Another important sexuality-related category is that of gender dysphoria (DSM-5) or gender incongruence (ICD-11). As explained in the introduction, this module will only briefly deal with this. The new formulations in DSM-5 and ICD-11 are different but similar. They both make a distinction whether the condition concerns a child, or on the other hand an adolescent or adult. ICD-11 uses the formulation: “Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.” DSM-5 also has the word incongruence in this central position, but uses “assigned gender” instead of “assigned sex”.

Paraphilic disorders and paraphilias

ICD-11 has two different higher-level categories. Under “conditions related to sexual health” they classify “sexual dysfunctions”, “sexual pain disorders” and “gender incongruence”. Note that the keyword here is “conditions”, not “disorders”. “Paraphilic disorders” are classified under the heading of “conditions related to sexual health”, as well as the heading of “mental, behavioural or neurodevelopmental disorders”.

The DSM classified a particular group of sexual behaviours and activities as “sexual deviations” until 1979; DSM-III from 1980 onwards, and the later editions, use “paraphilias”. This replaces the time-honoured psychoanalytic term of “perversions”, used by Freud as well as Lacan – although it goes back to French psychiatrists at least in 1885 (Valentin Magnan) and probably earlier. The term “perversions”, from its earliest uses on in the 19th century, was not a neutral diagnosis, but a form of condemnation – it included a judgement. In contemporary sexological thinking, many sexual behaviours that used to be called perversions or paraphilias are now recognised as statistically much less “abnormal” than before, but also, as long as they are fully (affirmatively, enthusiastically) consensual, and do not do any lasting damage, are seen as a legitimate use of human freedom to live varied and differentiated lives, accept one’s identity, or choose one’s lifestyle. DSM-5, in what many regard as a significant change, has broken new ground by making a distinction between paraphilias and paraphilic disorders.

DSM-5 defines a paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.” It will be clear, and has been fully documented in the Kinsey reports (1948; 1953), that this covers a great deal of sexual activity – probably even masturbation on a natural reading of the wording. They add that the qualification “intense” can not always be maintained, and the definition would really extend to any “preferential” sexual interest.

Against this, the same activities covered by this wide definition of paraphilia, turn into a “paraphilic disorder” if its satisfaction entails personal harm or risk of harm to others, or if the “sexual urges or fantasies cause clinically significant distress or impairment in social, occupational or other important areas of functioning.” Harm is automatically assumed if the individual “has acted on the sexual urges with a non-consenting person” (or, in the case of pedophilia, has acted on their urges at all). DSM-5 adds that “a paraphilia by itself does not necessarily justify or require clinical intervention” – only a paraphilic disorder does.

DSM-5 divides the paraphilias into two main groups – based on anomalous activity preferences (e.g. voyeurism; inflicting pain), and based on anomalous target preferences (e.g. fetishes).

ICD-11 has decided on a somewhat different wording, where they add, after the general definition of paraphilic disorders, that “paraphilic disorders may include arousal patterns involving solitary behaviours or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death.”

Non-sexual sadism and masochism do not feature in these definitions, nor is there elsewhere a category for violence, or anything indicating that violence can be a disorder. It is clear that it is assumed in DSM-5 that there are substantial areas of human action, especially involving violence, which may be legally regarded as crimes, but which do not involve the conclusion that the acting person has a (diagnosable) mental disorder.

DSM-5 lists the following paraphilic disorders:

  • Voyeuristic disorder
  • Exhibitionistic disorder
  • Frotteuristic disorder [always with a nonconsenting person]
  • Sexual masochism disorder
  • Sexual sadism disorder
  • Pedophilic disorder
  • Fetishistic disorder
  • Transvestic disorder
  • Other and unspecified paraphilic disorders

For voyeurism, exhibitionism, frotteurism and sexual sadism, the text of the detailed criteria makes clear that acting on these tendencies with consenting persons, and without the acting person being significantly distressed or impaired, do not fulfil the criteria, and cannot be classified as paraphilic disorders – they are paraphilias, but not mental disorders, in the newly created terminology of DSM-5.

The definition of paedophilia concerns fantasies, sexual urges or behaviours involving sexual activity with a prepubescent child or children, and only when the person diagnosed, the person committing the acts, is at least 16 years old and is at least 5 years older. Many other definitions and variants are possible and were considered in the committees. Some of these other versions are closer to legal definitions of non-consensual sex, or any sex with minors. Another proposal that has been advocated is the distinction between ephebophilia – sexual interest by an adult in 15-19 year-old children, hebephilia – interest in pubescent children younger than 15, and paedophilia – sexual interest in prepubescent children. With a basic assumption that there would or might be significant differences between the people with these three diagnoses. None of these ideas were maintained in the final version of DSM-5.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadelphia, PA: W B Saunders.

Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human female. Philadelphia, PA: W B Saunders.

Kleinplatz, P. J. (2012). Is that all there is? A new critique of the goals of sex therapy. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives (pp. 101–118). New York: Routledge.

World Health Organization. (1992). ICD-10 : The ICD-10 classification of mental and behavioural disorders : Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

World Health Organization. (2016). ICD-10 online. Retrieved from https://icd.who.int/browse10/2016/en

World Health Organization. (2019). ICD-11 online. Retrieved from https://icd.who.int/browse11/l-m/en