June 3, 2011

Dr. Allen Frances and his arguments against modern psychiatric madness

Doctor Allen Frances has caused uproar with his attack on the new American manual for mental diseases. This is highly relevant for crossdressers and crossdreamers.

Those who have followed this blog for a while know that I am very concerned about the fact that both crossdressing and crossdreaming  (“autogynephilia” and “autoandrophilia”) are classified as mental diseases and are included in the American psychiatric manual (the DSM) as well as the WHO ICD counterpart.

I have argued that these phenomena might as well be the psychological expression of natural human diversity as regards gender and sexuality, and that it is the fact that it is society – including psychiatrists who insist on calling this a perversion or a “paraphilia” – that causes the real mental anguish of these people.

I have also argued that the idea that something is true just because it has been published in a peer reviewed research journal is dangerously naïve. Scientists are regular human beings like the rest of us, with their own personal baggage of prejudices and narrow-mindedness, and if their very world view is wrong it does not matter if they follow strict scientific procedures. The end result will be crap, regardless.

You might think that it is only weirdoes like me (and some obscure French post-modernist philiosophers, maybe) that think this way, but the fact is that these are problems that are discussed intensely among the psychiatrists themselves.

Recently there has been a very interesting discussion going on regarding the new version of the DSM (the DSM 5), instigated by the father of the current version of the psychiatric manual, the DSM IV: Dr. Allen Frances.

Frances argues that American psychiatrist have gone too far towards believing that their diagnoses are scientifically proven descriptions of real phenomena. They are not, he says.

Mental disorders do not exist in the real world

In the AAP&P Bulletin vol 17, No 2 of 2010, in an article called “DSM in Philosophyland: Curiouser and Curiouser” he writes that:

“Biological psychiatry has failed to produce quick, convincing explanations for any of the mental disorders. This is because it has been unable to circumvent the fundamental and inherent flaw in the biological, ‘realist’ approach - mental disorders don't really live ‘out there’ waiting to be explained. They are constructs we have made up - and often not very compelling ones at that. It has, for example, become clear that there is no one prototype ‘schizophrenia’ waiting to be explained with one incisive and sweeping biological model. There is no gene, or small subset of genes, for ‘schizophrenia.’ As Bleuler intuited, ‘schizophrenia’ is rather a group of disorders, or perhaps better a mob. There may eventually turn out to be twenty or fifty or two hundred kinds of ‘schizophrenia.’ As it stands now the definition and boundaries of ‘schizophrenia’ are necessarily arbitrary. There is no clear right way to diagnose this gang and not even much agreement on what the validators should be and how they should be applied. The first umpire was called out on strikes when the holy grail of finding the cause of ‘schizophrenia’ turned out to be a wild goose chase.”

The point is, if I understand him correctly, that mental illnesses are not like (many) somatic illnesses, where it may be possible to explain the disease by one cause only (“I suffer from a fracture to the head due to a collision in a car.” “My HIV is caused by the AIDS virus.”).

The reason for this is that there are too many variables that can affect a healthy mind. He explains this as a kind of Anna Karenina principle: All normal brain functioning is normal in more or less the same way, but any given type of pathological functioning can have many different causes.

This is true for all complex diseases. There are likely hundreds of paths to schizophrenia, not one or just a few and perhaps no final common pathway. “Where does that leave the descriptive system of psychiatry?” he asks, and answers: “Fairly high and dry.”

Mental disorders as pragmatic social constructs

He refers to the American psychiatrist Thomas Szasz who  presented the view that mental illness is a medical ‘myth:

“Mental disorders were no more than social constructs that in some cases served a useful purpose, but in many others could be misused to exert a noxious social control, reducing freedom and personal responsibility. The biological ‘realists’ [those who believe the mental illnesses are real, “out there”] reacted predictably to Szasz' ‘nominalist’ attack [nominalism: it is all in the mind]. They dismissed it. ‘If schizophrenia is a myth, they crowed, it is a myth that responds to medication and has a genetic pattern.’ But their triumphalism was premature and based on both weak philosophic and weak scientific grounds. It turned out that the neuroscience, genetics, and treatment response of ‘schizophrenia’ follow anything but a simple reductionist pattern [reducing a phenomenon to one cause only]. The more we learn about ‘schizophrenia’ the more it resembles a heuristic [an educated guess], the less it resembles a disease.”

The pragmatist

It turns out Frances’ himself is a pure pragmatist. In preparing the DSM IV, he had no “grand illusions of seeing reality straight” on or of reconstructing it whole clothe from “his own pet theories”:

“I just wanted to get the job done - i.e., produce a useful document that would make the fewest possible mistakes, and create the fewest problems for patients…Psychiatric classification is necessarily a sloppy business. The desirable goal of having a classification consisting of mutually exhaustive, non-overlapping mental disorders is simply impossible to meet.”

No agreement on what a mental disease is

Frances, who knows the DSM processes from the inside, admits openly that there is no scientific rigor behind the different diagnoses. Heck, there is not even a common understanding of what a mental disease is:

“Alas, I have read dozens of definitions of mental disorder (and helped to write one) and I can't say that any have the slightest value whatever. Historically, conditions have become mental disorders by accretion and practical necessity, not because they met some independent set of operationalized definitional criteria. Indeed, the concept of mental disorder is so amorphous, protean [extremely variable], and heterogeneous that it inherently defies definition. …  And the specific mental disorders certainly constitute a hodge podge. Some describe short term states, others lifelong personality. Some reflect inner misery, others bad behavior. Some represent problems rarely or never seen in normals, others are just slight accentuations of the everyday. Some reflect too little control, others too much. Some are quite intrinsic to the individual, others are defined against varying and changing cultural mores and stressors. Some begin in infancy, others in old age. Some affect primarily thought, others emotions, yet others behaviors, others interpersonal relations, and there are complex combinations of all of these. Some seem more biological, others more psychological or social. If there is a common theme it is distress and disability, but these are very imprecise and nonspecific markers on which to hang a definition.”

An endless production of new diseases

Indeed, the number of mental disorders is increasing with number of health clinicians. And, Frances points out, society loves new mental disorders:

“As a result, psychiatry is subject to recurring diagnostic fads. Were DSM-V to have its way we would have a wholesale medicalization of everyday incapacity (mild memory loss with aging); distress (grief, mixed anxiety depression); defects in self control (binge eating); eccentricity (psychotic risk); irresponsibility (hypersexuality); and even criminality (rape, statutory rape).”

As Frances points out, none of these newly proposes diagnoses pass the standard loose definition of ‘what clinician's treat.’ None of these ‘mental disorders’ has an established treatment with proven efficacy. Each is so early in development as to be no more than ‘what researchers research’ - a concoction of highly specialized research interests.

According to an interview he made with Wired, he believes that his manual inadvertently facilitated these epidemics  of autism, attention-deficit hyperactivity disorder and bipolar disorder. Frances also thinks that it fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.

Autogynephilia as a one man’s pet project

Frances’ analysis fits well with what we know about the inclusion of the diagnosis of “autogynephilia” (a man’s sexual love of himself as a woman).

As I have pointed out, “autogynephilia” is nothing but a theoretical hypothesis forwarded by Dr. Ray Blanchard. He himself calls it a hypothesis. And even if his observations have merit (crossdreamers exist), no one else have managed to prove his theory right either. In spite of this a theory that is of real interest to three researchers only (Blanchard, Bailey and Lawrence) has been included as a mental disease in the proposed DSM-5 manual!

But that is not all. The current version has also included “autoandrophilia” (for female to male crossdressers and crossdreamers), reducing them to perverts as well. This is really remarkable, as Blanchard himself seemingly does not believe female to male transvestites exist, and there is not one single research paper discussing what and who they are!

The inclusion of autoandrophilia is probably the result of some misled politically correct unease about gender equality.

What is even more baffling is the fact that the theory of “autogynephilia” presupposes that all “non-homosexual” (i.e. woman-loving and bisexual) male to female transwomen are “autogynephilic”. That means that they are suffering from a paraphilia and should be diagnosed as such. The alternative diagnosis, “Gender Dysphoria in Adolescents or Adults”, however, is not limited to androphilic transwomen or gynephilic transmen. It is clear that the subcommittee that wrote that classification does not believe that all gynephilic transwomen are perverts. Now, what is a practitioner to make out of this?

The DSM as a cultural and democratic problem

Frances looks at the DSM from a pragmatic point of view. He argues that they need some sort of classification to make help the patient and establish rules for reimbursements. Fair enough.

But the fact is that large portions of society do not look at it this way. Too many have fallen for the myth of science as the deliverer of objective truth. Many of the doctors using the manual have also been raised with this belief, at home and at the university. This means that they will believe that a mental disease included in the manual is “real”, in the objective sense, in the same way as a house is real. So will the lawyers and the journalists.

They do not know that this “disease” is a mirage built on nothing but the curiosity of a scientist who find men who dress up as women fascinating. They do not know that there is no proof or that the majority of experts studying crossdressing and crossdreaming disagree with Blanchard. All they see is that the American Psychiatrist Association says that all crossdressers are “sick perverts” (which is the common term for “paraphilia”).

And that is not all: Many crossdressers and crossdreamers are also raised to believe in science, and wrongfully conclude that they are perverts themselves. Because of this the diagnosis causes more suffering than it prevents. Given that there is no “cure” for “autogynephilia” this often makes their pain intolerable.

No appeal

Moreover, you cannot appeal their decision. Sure, you can make a comment on the DSM-5 web site, and hope and pray that they will listen to an anonymous crossdreamer without a psychiatric degree. But you cannot petition your congressman or your member of parliament. And even if you had the money, you cannot drag the American Psychiatric Association to court and sue them for the stigmatization of billions of men and women worldwide. They are scientists, remember, and therefore above the moral law the rest of us will have to follow.

This means that the pragmatic approach of Dr. Frances may help the health practitioners and the psychiatrists. It may also lead to a healthier and more common sense approach to mental suffering. But it would not stop people from using the manual to stigmatize people. For that to happen, the whole scientific narrative will have to be rewritten.

We are slowly getting there, and the rising educational levels all over the world have given birth to new generations of skeptics who no longer believe everything a doctor says, just because she has a degree and wears a white coat. That is a start. But from what I see in the transgender community, we have a lot of work to do before all of us have been empowered to defend our dignity and our humanity.

UPDATE (links to articles mentioned in the comments):
Sunsetting Psychiatric Diagnoses (Frances and Andrew Hinderliter)
The Glaring Weakness In A Conservative Approach To Diagnosis: It Grandfathers In Weak Links (Frances on Hinderliter)
How To Solve The Problem Of Questionable Diagnoses Grandfathered Into DSM (Frances and Charles Moser)


  1. Of everything that Dr. Frances says in the AAPP bulletin issue you link to, the only place where I think he's completely wrong is his interpretation of Szasz. As noted in the commentary by Kinghorn, Szasz is a realist (a first umpire) and he sees mental disorders as balls.

    That said, if you haven't seen them already, there is some follow-up to this issue of the AAPP bulletin specifically about the so-called paraphilias on Dr. Frances blog, with comments by yours truly and by Charles Moser.

    Framing the issue: http://www.psychologytoday.com/blog/dsm5-in-distress/201101/the-glaring-weakness-in-conservative-approach-diagnosis-it-grandfathers

    My response: http://www.psychologytoday.com/blog/dsm5-in-distress/201102/sunsetting-psychiatric-diagnoses

    Moser's response: http://www.psychologytoday.com/blog/dsm5-in-distress/201102/how-solve-the-problem-questionable-diagnoses-grandfathered-dsm

    A follow-up by James Phillips: http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1808509

  2. So, speaking completely naively, how much comfort is the "The person has clinically significant distress or impairment in important areas of functioning" part-B that gets included in so many DSM diagnostic criteria?

    It seems like for any odd (or even perfectly normal) behavior X, you could have a "disorder" that was:

    A. The person does X.
    B. The person has clinically significant distress or impairment in important areas of functioning.

    Does the fact that for certain values of X there's an entry like this in the DSM, whereas for other values of X ("eats cashew butter"), there isn't, mean that we're implicitly classifying X as an illness or a perversion or generally Something Bad, even when the person DOESN'T have clinically significant distress or impairment in important areas of functioning?

    And/or, just by listing some X in the DSM, are we making it significantly more likely that the person WILL HAVE clinically significant distress or impairment in important areas of functioning, since after all they do X?

  3. Hi Jack:

    The issue is intellectual honesty. The study of the human psyche is by definition an unscientific enterprise. Applying a scientific method does not make the results of such a study science. There are never repeatable results; On the fine dim line between psyche and soma all we have left is observation. It seems to me that Dr. Frances recognizes this. It is not an accident that Dr. Benjamin called his study "The Phenomenon of Transsexualism". The results of psychiatric study are always, only a diagnostic or therapeutic tool, not "the truth". Frances understands this clearly.

    I fear that those who say otherwise are motivated by self-justification.

  4. @ACH Thanks for some very interesting links. The fact is that I found the Dr. Frances article thanks to you!

    @Dale Innis.
    Exactly! The very inclusion in the DSM labels as behaviour as strange and unnatural.

    @Kathryn Martin.
    Or maybe all science is a never-ending adventure depending on cultural fashions, prejudices and the limits of human intelligence. That being said: It beats the alternative, namely pure conjecture.

  5. One of the things that you have pointed out and something that really bugs me is the constant introduction of new disorders. That's not to say that they don't really exist but, too me it seems as thou they are simply trying to take the fun out of life. For instance if you collect stamps you've got a disorder. Their are a lot of things that i think are just being human and not a disorder. And about the next generation of people in this field i hope to be one of them it might help some day to have present first hand experience with crossdreaming.

  6. The fact that the DSM is chaging non stop while people don't change indicates that the DSM shouldn't be taken too seriously.

    The questions that should be asked when we want to label someone ill should be = "is the person unhappy and does the person make people around him unhappy".

    If the replies are NO, then why should anyone be labeld as ill ?

    That's why I consider more and more that psychiatrists have just replaced priests in the control of people's sexuality and that they don't know much about human's brain.

    You could be deviant from the mainstream and not be ill.

    That's why beeing called deviant shouldn't be a problem but a pride = not following the great unwashed crowd is a sign of intelligence.

    And even refusing to be mentaly ill is agreeing with the system that tells that ill people are some kind of monsters.

    So sexual outlaws are not mostly not ill and even if they are, they have no reason to feel ashemed.


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