Psychobabble: Medicalising rape?

By Keir Liddle

It had been proposed that this revision of the DSM-5 (Roman numerals are clearly out of fashion!) includes Paraphilic Coercive Disorder as a diagnostic category the definition of which is given below.

Paraphilic Coercive Disorder

A.    Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion. [23]

B.     The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occasions. [24]

C.     The diagnosis of Paraphilic Coercive Disorder is not made if the patient meets criteria for a diagnosis of Sexual Sadism Disorder.[25]

The notes accompanying this can be found here.

A major bone of contention with the proposed diagnostic criteria arises from opposition to the idea that it will result in the medicalisation of rape as the disorder is most widely reported by rapists who are receiving treatment:

Coercive sexual fantasy is commonly reported by rapists while participating in treatment (McKibben, Proulx, & Lusignan, 1994), and under optimal conditions in laboratory tests, about 60% of rapists demonstrate preferential arousal to saliently-coercive rape stimuli as compared to 10% of unconvicted individuals (Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003). Among convicted rapists it is those who have more persistently engaged in rape and assault who are more likely to show preferential arousal to saliently-coercive rape in laboratory tests (Willmot & Hart, 1996). Among individuals with no official record of sexual offending, preferential arousal to saliently-coercive rape as indicated by laboratory tests is found to be substantially correlated with self-report of engaging in sexually coercive behavior in the great majority of studies (Bernat, Calhoun, & Adams, 1999; Lalumière & Quinsey, 1996; Lohr, Adams, & Davis, 1997; Malamuth, 1986).

The concern stems from the idea that lawyers will use the diagnosis of Paraphilic Coercive Disorder as a means of “excusing criminals” on the basis of diminished responsibility. An idea that seems worryingly plausible. Presumably the driving force behind the proposal to add these criteria to the DSM is that potential rapists are identified and treated before they commit any crime: although this appears to me to rely on a couple of assumptions –

One: That people who fantasize about rape go on to become rapists and

Two: That these fantasies are unwanted and cause  enough distress to seek treatment.

I doubt that there is much support for either of these assumptions and this adds to my growing feeling of unease that the diagnosis would become not much more than a post-hoc excuse employed by lawyers and defence teams as a means of excusing defendants behaviours and reducing sentences for rape. In short it would add yet more unnecessary complexity to an already controversial system which many would argue is already clearly biased towards the defendants.

I could probably summarise my views on the validity of the diagnostic criteria with the following: “Many people fantasize about killing their boss but if they actually kill them this would be further evidence of their guilt rather than any diminished responsibility.”

In 2009 Richard Knight explored the evidence for Paraphilic Coercive Disorder and in his paper “Is a Diagnostic Category for Paraphilic Coercive Disorder Defensible?”. He summarised that the main evidence for Paraphilic Coercive Disorder being included as a diagnostic category stemmed from phallometric studies however he contends that they don’t necessarily show that arousal results from exposure of coercive stimuli but simply that coercive stimuli does not impair arousal when sexual stimuli is also presented. In addition, sexual fantasies about forcing sex and about struggling victims are highly correlated with sadistic fantasies and have not been shown to identify a syndrome that can be discriminated from sadism.

Knight concludes that there is little empirical justification to back up the inclusion of Paraphilic Coercive Disorder as a separate category and to do so would merely be to add an arbitrary diagnostic criteria to the DSM-5. He also shares my concerns that the potential for the diagnosis outweights any spurious potential benefits from inclusion:

Not only does there seem to be little empirical justification for the creation of this new syndrome, the inclusion of this disorder among the paraphilias would have serious potential for misuse. It would imply endorsement of Paraphilia, NOS, nonconsent, which is currently inappropriately employed in civil commitment proceedings to justify commitment.

This diagnosis is potentially extremely worrying, as Ray Knight mentions in his article, it may cause people to go looking in the wrong places to understand the causes of rape. It promotes the idea (debunked by decades of research) that rape is a crime committed because some guys are really horny and just can’t control themselves.

While it is true that many rapists have sexual fantasies of sexual coercion, these are EXTREMELY common in the general population as well.

Also, the studies they cite discuss greater arousal to coercion (in the aggregate) among the convicted population. While relative arousal is used in these studies, IT IS NOT USED in the proposed diagnostic criteria. Finally, the really worrying legal implication of this has to do with “Sexually Violent/Dangerous Predator/Person” laws that many states have. These allow people to be locked up, possibly for the rest of their lives, AFTER completing their sentences. The rights of the accused and the constitutional safegaurds in criminal cases are bypassed, permitting locking people up on a much weaker standard (“risk” not anything they have ever done–further punishment for things they have done would be unconstitutional.) To do this, it is necessary to diagnose someone with a mental disorder. So this “disorder” is being invented to lock people up who have no real mental disorder. (Lots of people are already “civilly committed” with this, diagnosed as Paraphilia NOS, and adding this to the DSM would help justify this).

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