of presuppositions or cognitive frameworks that scientists bring to the table 1. I want to

Transcription

1 Discussion of bias in the sciences often focuses on phenomena involving the relation between the selection of topics of study or the gathering of evidence and the sorts of presuppositions or cognitive frameworks that scientists bring to the table 1. I want to focus instead on a form of bias unique to the social sciences, a form of bias where negative social portrayals of particular groups comes to be reinforced by the study and classification of the group in question. This involves getting at the ways in which social scientific ways of classifying people interact with the objects of those social scientific classifications. I ll call this form of bias feedback bias. The idea behind feedback bias is that the ways in which social scientists classify people enacts or puts into motion the marginalization or trivializing of members of the classified populations. Feedback bias works through a variety of means. A classification may cause members of the classified population to consciously self-ascribe unhealthy social norms. It may serve to reinforce or provide institutional support for unhealthy social norms. It might modify previous classifications in a negative or unhealthy way. I will look at a case study of this sort of bias in the social sciences, namely the classification of paraphilia in the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association (APA). In the first section, I will present and evaluate the changes in the diagnostic criteria for paraphilia from the publication of the DSM-IV in 1994 through the current drafts for the DSM-V, scheduled for publication in In Section III, I will compare the treatment of two specific paraphilias, sexual sadism and sexual masochism, to the psychiatric classification of homosexuality as a 1 This is the basis of studies of phenomena such as confirmation bias, and much of the work of feminist science studies. See Lloyd 2005 for a recent example. 1

2 disorder, arguing that in the study of all these apparent disorders bias is manifested through the taking of certain practices as disordered where a more effective diagnostic practice would involve attending to the ways in which apparent disorders are practiced. Feedback bias is most fruitfully studied not as the application of a set of inappropriate presuppositions or cognitive frameworks, but rather as a result of the interacting practices of a group of social scientists and the populations they classify. What is at issue, then, is not biased beliefs held explicitly or implicitly by either social scientists or members of society, though such beliefs may be present. What is at issue, rather, is how we encounter certain practices in our everyday experience. Feedback bias involves social scientific classifications that change how we encounter our own practices and the practices of others in a negative or unhealthy way. Interaction and Diagnostic Criteria Many cases of social scientific bias can be profitably examined by considering the bias in terms of the interaction between objects of social scientific classification and the ways or means through which social scientists classify their objects of study 2. As I have argued elsewhere, these interactions take three forms 3. First, there are interactions between ways of classifying and the human objects of these classifications who selfascribe them. A social scientist might classify a person as a member of a particular social 2 See, for example, Hacking 1999a [1986], where Hacking uses this suggestion in the context of drawing a criterion to distinguish the natural sciences from the social sciences. See also Hacking 1999b for a further development of the suggestion that 'social kinds', or the kinds of things studied by social scientists, differ from natural kinds. See Cooper 2004a for a criticism of the idea that 'social kinds' cannot be natural kinds. See also Tsou 2007, p. 335, and Martinez 2009, pp Tsou points out that Hacking occasionally conflates 'classification' and 'object' in his own analysis and Martinez points out that the Hacking demarcation criterion slides into previously proposed criteria upon further critique. 3 Note: Self-citation removed to preserve blind review. 2

3 group, such as unwed mothers or unemployed people, and the person can respond by consciously self-ascribing the classification and accepting or rejecting its associated norms. Second, there are interactions between ways of classifying and broader cultural or social practices. The introduction of a new classification by the social scientist may introduce changes in a social group through habituation or imitation. Third, there are interactions between ways of classifying and other ways of classifying 4. The introduction of a new classification may serve the role of displacing or modifying an existing classification. The three forms of interaction outlined above capture some of the problematic ways that social scientists and their classificatory schemes interact with the people who are being classified. One such case is the classification of paraphilia in the DSM manual published by the APA. The diagnostic criteria for the paraphilias, since the publication of the DSM-III, have included two parts, criterion A and criterion B. I am taking criteria A and B to be individually necessary and jointly sufficient conditions for a proper diagnosis of a particular paraphilia 5. In the DSM-IV, criterion A includes recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one s partner, or 3) children or other 4 Taking the social scientist to be engaged in classificatory practices involves a number of introductory assumptions and is not itself an uncontroversial move. See Phillips 2004 for a background discussion of understanding and explanation in psychiatry. See Thornton 2004 for a discussion of the benefits and weaknesses of reductionist accounts of psychiatric disorders. See also Haslam 2002 for an account of psychiatric categories as taking multiple forms, from natural kinds to practical kinds and non-kinds. 5 This is not an uncontroversial move. Some have claimed that it is not the goal of the DSM to set out necessary and sufficient conditions for the diagnosis of a mental disorder. See Culver and Gert 2004 for one example of this claim. Culver and Gert point out correctly that there is not a sharp line between mental and physical illness and that the DSM incorporates clinical significance into the diagnostic criteria, a notion that depends on the clinician. See also Cooper 2004 who argues that while mental illnesses may constitute a natural kind, the DSM does not effectively study or classify these natural kinds. 3

4 nonconsenting persons, that occur over a period of at least 6 months 6. Criterion B specifies that the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 7. In the DSM-IV-TR, criterion A is unchanged. However, for certain paraphilias including Sexual Sadism, certain types of enactment of sexual behavior are added to criterion B. These diagnostic criteria are a general set of criteria used as a framework for the specific paraphilias. Since my focus here will be on the specific paraphilias of sexual sadism and sexual masochism, the diagnostic criteria for these are laid out in Appendix A. In the transition from the DSM-IV to the DSM-IV-TR, two major changes stand out. In the DSM-IV, there are two necessary conditions for diagnosis. The first is either recurring fantasies aimed at an unusual object or behaviors associated with such fantasizing. The second is distress caused by at least one of the disjuncts in criterion A. The DSM-IV-TR takes one of the disjuncts in criterion A, namely a certain type of sexual behavior, and adds it as a disjunct to criterion B. The change is subtle, but important. The result is that engaging in certain sorts of sexual behavior is a sufficient condition for diagnosis, as it is one of the disjuncts in both criteria in the DSM-IV-TR. In the case of sexual sadism, there is one additional change that stands out. This change is the addition of the word nonconsenting to the behavioral aspect of the diagnostic criteria. One positive aspect of this change is that it shifts the focus away from sexual behavior to the nonconsensual nature of that behavior. But one negative aspect is its effects on the BDSM 8 community, a community that takes itself to be marginalized by 6 DSM-IV, pp DSM-IV, p Bondage-Discipline; Domination-Submission; Sadism-Masochism. 4

5 these definitions. The BDSM community uses the terms sadism and masochism in a positive and affirmative way, a way that takes consent to be a core part of sadomasochistic practice. The DSM-IV-TR defines sadism in terms of nonconsent 9. The result of the redefinition of the paraphilias in the DSM-IV-TR, not necessarily an intended result, is a form of bias expressed through the second and third forms of interaction outlined above. By redefining sadism, a term with an established use where consent plays a critical role, the DSM marginalizes the BDSM community. Calling certain practices sadism, a move made decades earlier, already carried the potential to reinforce social norms marginalizing BDSM practitioners, but the attribution of nonconsenting practices to sadists takes this one step further. The BDSM community s response has been understandably less than enthusiastic. Issues with feedback bias enter into all three sets of diagnostic criteria. I ll look at two key issues with the DSM-IV and DSM-IV-TR before moving on to consider the draft material for the DSM-V. First, recurring fantasies and urges directed toward unusual objects or involving unusual sexual behaviors constitutes a necessary condition for diagnosis in the DSM-IV and one of two possible necessary conditions for diagnosis in the DSM-IV-TR. But the word unusual is ambiguous, and ambiguous in more than one way. There are both empirical and normative senses in which fantasies or behaviors might be unusual 10. Something might be unusual merely in the sense that not many people think about it or do it. But, prima facie, this is not problematic and provides no reason whatsoever for diagnosis. Alan Soble effectively captures this point when he 9 Not only does this run afoul of an established use of the term sadism, it also raises the key issue of how sadism is to be distinguished from rape or sexual assault. 10 Moser and Kleinplatz 2006 make a similar point, pointing to the importance of the object of desire in the definition. Their thought is that the mention of children and nonconsent adds a normative dimension that holds regardless of empirical results. 5

6 writes that DSM-IV asserts that being unusual (deviant) is necessary for sexual fantasies, urges, or behaviors to be paraphilic but that DSM-IV cannot get far with unusual, anyway. Consider a two-hour marathon of heterosexual fellatio 11. The objection Soble raises is that such an event would be unusual in the empirical sense that not many people do it, but the behavior is not indicative of a problem. I think Soble is right, but we ought to conclude that the DSM is using the word unusual in not the empirical sense but in a normative sense. The DSM-IV is asserting that one necessary condition for diagnosis is the violation of the community s sense of appropriate or typical sexual fantasies, urges, or behaviors. There is a second ambiguity, one that is manifested in the normative sense of the word unusual, and one that is closely related to some of the problems with criterion B. Many activities that are unusual in the sense that they violate the broader community s standards for appropriate sexual practice are used by the BDSM community in a postitive, affirmative way. While the diagnostic criteria for sexual sadism and sexual masochism use terms like suffering and humiliation, terms used in a negative sense to denote activities that surely none of us would want, these terms are actually used in a variety of ways. They pick out activities that are harmful and damaging, such as rape and sexual assault, but also pick out activities that are consensual and enjoyable in the context of sado-masochistic practice. By failing to distinguish between the positive and negative ways in which these activities are practiced, the DSM-IV s criterion A is reduced to the norms or standards of the community with no regard for the consent and enjoyment of the people who are being diagnosed. Expressed in this way, much of the language in the 11 Soble 2004, p

7 DSM-IV and the DSM-IV-TR suffers from the same problems as those arising from the use of the word nonconsenting examined earlier. This problem can be captured as feedback bias by noting that social scientists, like any of us, are influenced by the habitual application of community or social norms to specific practices. Once a practice is taken as unusual, in the normative sense, it is but a short move to label the practice itself as inherently problematic or disordered. A second issue with feedback bias occurs with the use of the term distress in criterion B. The DSM is clear that psychiatrists ought to offer a diagnosis only when the patient s distress is endogenous, or motivated by the patient s own attitudes toward her condition. The DSM excludes exogenous distress, or distress that originates in the patient s community or social norms. The reason for this is to make sure there is something about the patient herself or himself that is problematic. A patient suffering from exogenous distress alone is not suffering from a disorder, but rather is a victim of social persecution. This is a particularly critical issue because, as we saw above, criterion A in no way provides this protection from the influence of social norms. But the distinction between endogenous and exogenous distress is difficult to maintain, particularly in light of our discussion of feedback bias. It is entirely possible that a patient experiences so-called endogenous distress because she has internalized the community s norms through enacting them, by altering her own experience so that she encounters her own practices as disordered. A patient may internalize or self-ascribe psychiatric classifications, entering into a feedback loop with the psychiatric community and its own diagnostic and classificatory practices. These considerations render endogenous and exogenous forms of distress difficult to distinguish in actual cases. What 7

8 would appear to be endogenous distress for the purposes of a clinical diagnosis might actually be exogenous distress enacted through what I identified above as the second form of interaction, a process though which the ways in which the community encounters certain practices are transferred to the patient, obscuring their ultimate social origins. Draft material for the DSM-V incorporates two major changes, changes that have both positive and negative aspects. The first is the elimination of behavior alone as a sufficient condition for diagnosis, a move widely supported and largely a reversion to the criteria in the DSM-IV. This is widely regarded 12 as correcting a mistake in the DSM- IV-TR. This is fortunate, given that once we established that only the unusual nature of the behavior is at issue, we were left with a diagnostic criterion based solely around doing something a community finds inappropriate. The reversion to the DSM-IV is still problematic, as shown above in the discussion of the term unusual and the distinction between endogenous and exogenous distress, but it does remove the even more problematic behavioristic aspect. The second change, one that appears to be a clear step in the right direction, is the attempt in the DSM-V to distinguish between paraphilias and paraphilic disorders. On this distinction the paraphilias are identified with criterion A, while paraphilic disorders require both criterion A and criterion B. The intuitive idea behind this distinction is that the fantasy component alone, which is described in A, is not itself problematic. It only becomes problematic when accompanied by distress, impairment, or nonconsensual behavior. We begin with an apparent disorder, but one that can be enacted in either problematic or unproblematic ways. While a positive step forward, this move is not 12 See First and Frances

9 without is own problems. It is particularly reminiscient of the classification of egodysodic homosexuality in DSM-III many years earlier, an issue to which we will return in the next section 13. The DSM, Homosexuality, and Paraphilia The distinction between paraphilias and paraphilic disorders is a helpful first step. It represents a continued development of a trend begun in the early 1970s with the declassification of homosexuality as a disorder. This is a trend of moving from the classification of certain practices as disordered to an attention to the ways in which potential or apparent disorders are practiced. Homosexuality was removed from the DSM s list of mental illnesses by the APA in 1973, a move that was implemented in the re-issued DSM in But homosexuality reappeared in the DSM in new ways. In the 1980 publication of the DSM-III, it appeared as ego-dysodic homosexuality, a classification that problematized homosexuality that leads to endogenous distress in the patient over his or her sexual orientation. The 1987 publication of the DSM-III-R relegated the new illness to the more obscure category Sexual Disorders Not Otherwise Specified and dropped its exclusivity to homosexuals, expanding the illness to cover anyone persistently and markedly distressed by his or her sexual orientation. These changes exhibit feedback bias, particularly through the second and third forms of interaction identified above. The gay community had self-ascribed many of the earlier classifications and had responded negatively, engaging in various forms of activism aimed at changing these classifications. Both activists and psychiatrists changed 13 See NCSF 2010 and Wright 2010 for the largely positive responses from the BDSM community and its defenders. 9

10 the ways in which people experienced homosexual affection in public among strangers and in private discussions with one s family members. The changes in psychiatric classification spawned debates producing changes in other classifications, as well as changes in the diagnostic practices of psychiatrists. The entire debate brought to the forefront issues over the ways in which psychiatrists interact with the broader community, particularly as gay activists protested APA meetings in the early 1970s and met with the leading figures involved in drafting the DSM 14. Charles Silverstein, one activist who met with APA leaders during these debates, points out that one of the key goals of the activist community was to advance the social dignity and civil rights of the gay community. He writes: Because the psychiatric community was one of the gate-keepers of society s attitudes, we believed that this change would have profound effects on the lives of gay people; it would hasten the elimination of sodomy laws and moral turpitude clauses in state regulations that prohibited the licensing of otherwise qualified professions (e.g., physicians and lawyers). We also expected it to help establish civil rights protection for gay people, including non-discrimination in housing and employment 15. This shows in a particularly clear way the two-way nature of these interactions. Many of the objections to the DSM accuse its authors of uncritically transcribing social norms into psychiatric classification, but one can also see the psychiatric community s classification as a driving force behind social norms. The declassification of homosexuality as a 14 The debates over the classification of homosexuality occurred as a part of a broader movement within the psychiatric community from theory-based approaches, particularly psychoanalytic approaches emphasizing the symbolic meaning of symptoms, to a descriptive, medical approach attending closely to the symptoms themselves. The former approach admits of a continuity between healthy and unhealthy individuals while the latter approach is a more categorical one that attempts to demarcate the various illnesses from one another and the healthy patient from the unhealthy patient. 15 Silverstein 2009, p

11 mental illness was one step toward gaining respect for homosexuals and battling the exogenous distress associated with it. One key parallel is that the classification of sadism and masochism as mental illnesses reinforces the tendency to experience sado-masochism as social deviance, experiences that in turn drive the entrenchment of these classifications. This interactive process prevents consensual and affirmative forms of sado-masochism from being recognized as a positive force in people s lives. Eliminating or relabeling these classifications may help secure forms of civil or legal rights that sado-masochists currently lack, such as rights involving fair treatment in criminal and child custody cases, as well as employment non-discrimination cases 16. Conclusion We have seen that feedback bias enters the DSM in a number of ways. The specific terminology used in the classification of the paraphilias, particularly sexual sadism and sexual masochism, reinforces social norms that marginalize people. Furthermore, this marginalization creates exogenous distress, distress that often becomes internalized and difficult to distinguish from genuine endogenous distress in a clinical setting. But there has been incremental, positive movement away from these biases due to a good-faith effort on the part of professional psychiatrists. The key to further positive moment is to follow the trend developed in the gradual declassification of homosexuality as a mental illness. This trend is one of setting aside social norms in favor of close attention to how people engage in certain practices, whether this engagement is one of 16 See Wright 2010 for a description of one child-custody case. Despite the positive steps that have been made, courts still routinely conflate problematic and unproblematic forms of sado-masochism. 11

12 mutual consent and enjoyment on the one hand or coercion and nonconsent on the other. This sets the stage for a patient-centered diagnostic practices, which ought to be the goal. 12

13 Appendix A Definitions of Sexual Sadism and Sexual Masochism Sexual Sadism DSM-IV 17 A: Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person. B: The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-IV-TR 18 A: Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person. B: The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. DSM-V (Proposed Revision) 19 A: Over a period of at lease six months, recurring and intense sexual fantasies, sexual urges, or sexual behaviors involving the physical or psychological suffering or another person. B: The person is stressed or impaired by these attractions or has sought sexual stimulation from behaviors involving the physical or psychological suffering of two or more nonconsenting persons on separate occasions. Sexual Masochism 20 DSM-IV A: Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. B: The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 17 DSM-IV, p DSM-IV-TR, DSM-IV, p

14 DSM-IV-TR 21 A: Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. B: The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-V (Proposed Revision) 22 A: Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer. B: The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 21 DSM-IV-TR,

15 References American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association American Psychiatric Association Proposed Draft Revisions to DSM Disorders and Criteria. Cooper, Rachel. 2004a. Why Hacking is Wrong about Human Kinds, in British Journal for the Philosophy of Science, Vol. 55, No. 1, pp Cooper, Rachel. 2004b. What is Wrong with the DSM?, in History of Psychiatry, Vol. 15, No. 5, pp Culver, Charles M. and Bernard Gert Defining Mental Disorder, in Jennifer Raddon (ed.), The Philosophy of Psychiatry: A Companion. Oxford: Oxford University Press, pp First, Michael B. and Allen Frances Issues for DSM-V: Unintended Consequences of Small Changes: The Case of Paraphilias, in American Journal of Psychiatry, Vol. 165, No. 10, pp Hacking, Ian. 1999a [1986]. Making Up People, in Mario Biagioli (ed.), The Science Studies Reader. New York: Routledge, pp Hacking, Ian. 1999b. The Social Construction of What? Cambridge: Harvard University Press. Haslam, Nick Kinds of Kinds: A Conceptual Taxonomy of Psychiatric Categories, in Philosophy, Psychiatry, and Psychology, Vol. 9, No. 3, pp Lloyd, Elisabeth The Case of the Female Orgasm: Bias in the Science of Evolution. Cambridge: Harvard University Press. Martinez, Maria Laura Ian Hacking s Proposal for a Distinction Between Natural and Social Sciences. Philosophy of the Social Sciences, Vol. 39, No. 2, pp Moser, Charles and Peggy J. Kleinplatz DSM-IV-TR and the Paraphilias, in Journal of Psychology & Human Sexuality, Vol. 17, No. 3, pp

16 National Coalition for Sexual Freedom The APA Paraphilias Subworkgroup Agrees: Kinky is NOT a Diagnosis. Phillips, James Understanding/Explanation, in Jennifer Raddon (ed.) The Philosophy of Psychiatry: A Companion. Oxford: Oxford University Press, pp Silverstein, Charles The Implications of Removing Homosexuality from the DSM as a Mental Disorder, in Archives of Sexual Behavior, Vol. 38, pp Soble, Alan G Desire: Paraphilia and Distress in DSM-IV, in Jennifer Raddon (ed.)., The Philosophy of Psychiatry: A Companion. Oxford: Oxford University Press, pp Thornton, Tim Reductionism/Antireductionism, in Jennifer Raddon (ed.) The Philosophy of Psychiatry: A Companion. Oxford: Oxford University Press, pp Tsou, Jonathan Hacking on the Looping Effects of Psychiatric Classifications: What is an Interactive and Indifferent Kind? in International Studies in the Philosophy of Science, Vol. 21, No. 3, pp Wright, Susan Depathologizing Consensual Sexual Sadism, Sexual Masochism, Tranvestic Fetishism, and Fetishism, in Archives of Sexual Behavior, Vol. 39, pp