I suspect nothing will actually stop the NYT taking you out of context. You’ll probably just get something stupider about the Ns being a dog whistle: “Scott Alexander drops N bombs in article comparing pedophilia to homosexuality.”
Yes, this has always been a weird thing about "Born this Way" moral arguments. Each of us is born with certain tendencies we want very much to transcend, some of which would be immoral to indulge. You can't sidestep ethics with appeals to biology.
"the relevant difference between homosexuality and pedophilia is moral, not biological." (edited for clarity) <- I believe this is how you quote it out of context.
The inserted 'N's make parts of this virtually illegible. Honestly, at this point, does it really make a material difference to you if some media outlet takes something you said out of context, yet again?
Oh, but Scott, I do want the taxonomy that correctly identifies mental disorders the way your N'd statements above do. I want that very much. That would be psychology finally getting off its ass and doing something useful. You could have a dual-classification scheme: 1) is this maladaptive in the patient's current environs? and 2) is there reason to think it's biologically maladaptive in the EEA? In the case of your two listed sexual targeting errors, the answer is overall yes to 1 and 2 for both.
I think in the future you should use a marker other than "N". Having the word "a" surrounded by Ns looks like "N a N" which makes me think of NaN, the floating point number value. And "all N things N" makes me think of a mathematical theorem.
Maybe you can use the Hebrew letter aleph, or one of the weirder Greek letters like the one that's not Zeta?
Fully agreed. Trying to come up with fully biological explanations for human behavior seems to be mostly some kind of "Hard Sciences Fetish", a silly attempt to remove humanness from human behavior. In the end of the day pooping is completely biologically determined, but if you pooped your pants on a board meeting that biological explanation wouldn't go very far.
Since homosexuality pretty clearly is a mental disorder (in addition to the obvious evolutionary mismatch, there's a very high rate of comorbidity with other mental disorders), the problem here seems straightforward. Psychiatry is under the influence of politically motivated activists. As is the rest of the academy. As long as that continues to be the case, squaring the circle of empirical science and politics will be impossible. Indeed as you note, politics and science are intrinsically irreconcilable, so a better way of putting it is: so long as ideologically motivated actors insist on twisting science into pretzels to conform to their preferences about how the world should be, attempts to develop things like biological taxonomies of mental disorders are doomed from the outset.
The solution is quite obvious but a lot of people won't like it.
Isn't the main difference that pedophilia is a criminal act if the desire is acted upon?
I don't really understand why homosexuality wouldn't be classified as a paraphilia (aside from influential people who were into it successfully lobbying to have it reclassified). "Can consent and won't be harmed" does not seem to be a consistent delineation between paraphilia and "variants of normal sexuality." Case in point, coprophilia/coprophagia is still classified as a paraphilia in the DSM. "Men kissing men is okay but poop is icky" is hardly a consistent principle. Same case for zoophilia.
If you just optimize for truth and don't get irrationally angry at things you like sharing categories with things you don't like you are able to just wipe all of these downsides away like so much irrelevant screeching. Sure, homosexuality is a mental disorder, it has a clear downside if you would like to have biological children with your preferred partner. It shares a category with pedophilia as well as being unreasonably kind and self sacrificing. This is not a category on the moral dimension.
Optimizing for truth is nice, you spend far less time playing naval gazing word games terrified that the total nonsense you made up so that you could have your cake and eat it too comes back to bite you.
Journalist: "We can't edit quotes!" Editor: "We can selectively pick fonts for emphasis and readability! Use a transparent font for N and say that you blipped out the N-word."
The underlying issue is that having a mental disorder doesn't warrant stigma, while having an untreated mental disorder which poses a danger to oneself or others *does* warrant stigma proportional to the likelihood and magnitude of danger posed.
Please go ahead and label things mental disorders that you want to have treated by mental health professionals. Please don't stigmatize any of them any more than is necessary. I recognize that this is a hard problem that we don't and won't agree on the boundaries of. This does not absolve us from making our best efforts.
Have you read the HiTOP proposal? Unless I missed something, the HiTop is not proposing a strictly biologically based taxonomy of mental disorders at all nor is anyone serious.
The DSM and any future taxonomy can effectively distinguish between pedophilia and homosexuality and the other conditions you list with the harm criteria, which requires the presence of distress, impairment in functioning, or involvement of non-consenting victims.
I agree with the thrust of this post, as nicely summarized by Leah Libresco Sargeant in her comment.
That said, if you're concerned about a comparison between homosexuality and pedophilia being taken out of context, it seems prudent to at least to give that comparison a thorough examination. Much has been written on how
some rate of homosexuality may be evolutionarily adaptive, but to my knowledge there is no equivalent corpus for pedophilia. Of course, setting out to prove such a theory would be somewhat taboo, but so was the earlier research on homosexuality - to the extent that it lacked an implicit or explicit condemnation of homosexuals - and yet the work exists. I certainly don't see how sexual targeting of sexually immature individuals could be adaptive.
Not exactly addressing the point, but some thoughts:
If I could use gene editing to modify embryos of my future offspring, I think I would select against every mental disorder if possible.
I think that transgender people and pedophiles have more difficulty lives.
If given the decision between homosexual and heterosexual, I would choose for my offspring to be heterosexual. I think even many homosexuals would do the same, although I’m not certain of that.
If conversion therapy from homosexual to heterosexual were painless and possible, I would think insurance should subsidize it.
I don’t think homosexuality is immoral but I don’t think being anxious and depressed is immoral. It’s just I wouldn’t want to be those things and most people wouldn’t either. It seems to reduce quality of life.
Although this is kind of “word games” of a sort and there aren’t good exact definitions of ordinary language.
In before the hit piece gets written with "Scott Alexander wrote: "from a biological point of view, homosexuality and pedophilia are probably pretty similar. Both are “sexual targeting errors” [letters removed for clarity]."
On a more serious note, are we thinking about mental illness incorrectly? As far as I understand, physical illnesses are *diagnosed* by their symptoms - mental illness are *defined* by their symptoms. [This is because a mental illness is a malfunction of the mind, and the mind is not an organ, but a function.]
It is perfectly cogent to speak of a broken bone that is not causing symptoms, but it would be meaningless to speak of mental illness that is not causing symptoms.
If so, the criterion for "mental illness" should not be the underlying biological cause, but rather a superset of symptoms.
A reasonable candidate seems to be a way of thinking that causes a person harm. A broader definition might be a way of thinking that causes a person or others harm.
A corollary, is that all discrete mental illnesses would be thought of as clusters of symptoms all of which are gradational, rather than binary. Diagnostic criteria would thus be useful for convenience, rather than as observations in a Bayesian framework used to diagnose a physical condition. [e.g. if the "illness" is a broken bone, one could have a list of diagnostic criteria such that it is sufficiently unlikely that someone would have some number of symptoms without the underlying cause of a broken bone. But in the case of mental illness, there is no objective "state of being diseased;" rather, there are experiences / ways of thinking that can be counterproductive and treated.]
A corollary would be that a given behavior could be a mental illness or not, depending on conditions. Perhaps there could have been a time or place in human history where kleptomania would have been a useful trait [assuming the definition that mental illness = detrimental to the sufferer, rather than to others]. There could also be times and places where it is a maladaptive trait.
This would seemingly go against the whole conceptual underpinning of the DSM as I understand it. But it would also probably go against these DSM alternatives, as I understand them.
I don't think it is useful to conflate biology and misfunction for the same reason - it misses the point, which is the impact on the sufferer [and others.] The distinction between e.g. pedophilia, which from a biological perspective could be looked at as an aberration, since it does not facilitate reproduction, and a compulsion to engage in heterosexual rape - not an aberration since it can lead to reproduction seems rooted in the state of affairs under which humans evolved millions of years ago, which seems unhelpful if the goal is treatment. Today, even ignoring the harm to others, being a rapist probably does not make someone any likelier to pass on their genes (as emergency contraception, etc. are available). And let's say some study would find that actually being a rapist increases the probability of passing on genes by 5%, would that be a reason to not treat it as a problem? If one uses the criterion of hurting others, it surely hurts others, genes be damned. And even using the criterion of causing unwanted effects to the sufferer, being a rapist causes all sorts of negative ramifications to the rapist (e.g. increases the chances of him being stuck in prison).
The reader may question this model on the ground that certain "mental illnesses" correlate to genes. E.g. someone with gene X is much likelier to have mental illness X, or vice verse. This fits with the model of the mental illness being an underlying characteristic, and challenges the mental illnesses merely being conveniently clustered symptoms.
However, I think that neither objection is a problem. As far as the first, it may well be that underlying phenomena affect the frequency of certain symptoms. But I think it is still useful to conceptualize the symptoms as distinct from the cause.
More importantly, the existence of correlation between genes and named mental illnesses does not prove that superiority of the "discrete illness" model rather than the "arbitrary but useful symptom cluster model," since we would expect the same effect with an actual arbitrary but useful symptom cluster model!
E.g. if we were to divide the human population into two groups - the worst 2.2% of runners, and the other 97.8% of people, it seems extremely likely that we would find systemic genetic differences between the two populations. That doesn't mean that "WorstTwoPointTwoPercentofRunnersism" represents a meaningful Platonic "syndrome" rather than an arbitrary, if perhaps useful categorization.
[The same could be said for observed differences in fMRI. They can correlate with diagnoses, even shedding light on them, without legitimizing the model of equating mental illness with physical illness.]
Is my way of looking at mental illness a useful model, and have I correctly understood the existing frameworks?
“ If you call something a mental disorder, insurance has to cover treatment for it, which is good.
But if you call something a mental disorder, people will accuse you of trying to stigmatize them, which is bad.”
I kind of think we should just bite the bullet on the second part and say “stigma is bad mmmkay” and get on with it? The first part is much more important anyway, so it should dominate the “is it a disorder?” question. Lots of weird stuff in the brain - the stuff that creates problems for the sufferer or people around them are disorders.
Thus, homosexuality is not a mental disorder, because it requires no treatment - just go be gay. Pedophilia is a disorder because it often needs to be treated or controlled to prevent the afflicted from victimizing children. Gender dysphoria is a mental disorder, because it requires treatment (social and or physical gender transition). I get the urge to not call transgender people “mentally ill” but having already declared “stigma bad, mmkay”, it feels quite natural to say that a transgender person is “an individual who has undergone a successful intervention for gender dysphoria”.
If a thing in your brain will make you want to kill yourself if you don’t intervene, it seems very silly to not call it a “mental disorder”.
Re “This doesn’t seem especially destigmatizing to me - yes, you’re the wrong gender, but you’re crazy for being unhappy about it?”
Unless you’re willing to suggest that someone can be “in” the wrong body, Gregor Samsa style, how can anyone’s gender be wrong _except_ that the person be unhappy about it?
People’s bodies just...are what they are. If you’re a supermodel, you’re probably much more satisfied with your body than the ugliest person on the planet. Maybe the ugliest personal is even dysphoric about his appearance. But is either one of those people “in” the wrong body?
One is hard pressed even to find evidence that “Trans brains are different though.” Not really.
What could “being trans” be, other than a mental state characterized by emotional distress about one’s body? If one were cool with one’s body, one wouldn’t be trans. One would be gender nonconforming, which is arguably emotionally healthier than being “dysphoric” about the body one has.
In any case, emotional distress that disrupts one’s life is squarely in the domain of the mental health professions. So “being trans” (gender dysphoric) makes sense as part of the DSM.
Similarly, the reason homosexuality is not in the the DSM and pedophilia is, is because homosexuality rarely causes anyone any problems in the 21st century. You’re just gay or lesbian, you go along with your life, no mental health assistance needed.
(There probably is the rare gay or lesbian out there who is dysphoric about their sexual preference and who wishes they were straight. That would be something to explore with a mental health professional too, even if there were no specific DSM diagnosis for it.
But if you’re a pedophile, your desires are against the law, and if you’re a decent human, you realize they’re morally wrong too. No decent person wants relations with a partner who can’t consent, so if that’s what they’re wired to want sexually, I suppose this conflict would cause a lot of emotional distress -- again, the domain of mental health.
Maybe I’m missing something, but the distinctions don’t seem very challenging to make?
Is the person experiencing emotional distress that disrupts their life?
But I Do Want A Purely Biological, Apolitical Taxonomy Of Mental Disorders, now I'm pretty unusual in this respect but that's fine with me. I haven't actually read Thomas Szasz but this seems to get at a similar point (he made lots of points) he was making (and maybe Caplan), that is in the public conscious the term mental disorder has been too medicalized that is it carries the same sort of weight/sense as medical disorders as opposed to being explicitly there for pragmatic purposes such as social control. Not sure if this is a correct interpretation of Szasz but I recall him saying something similar in a interview. Personally I think a lot of people conceive of mental disorders in a way similar to evil spirits in the mind (sort of abstract maybe physical like entities, similar in some respects to many Platonist or realist positions in philosophy). I think a lot of people would object to this characterisation but it's the general sense I've gotten looking at people, a good example in my personal life would be when my school counsellor told me that the WHO just classified gaming disorder as a thing (something she and others thought I had), her reaction seemed not to be consistent with the view that the WHO thinks gaming disorder is a new social problem that needs to be tackled or something similar rather her reaction seemed more consistent with the view that the WHO after doing extensive research discovered some part of (or thing in) the brain that proved gaming disorder was a real thing. For her I was not just a child with unusual and perhaps counterproductive habits/preferences rather I had this thing in my mind that had been suspected to exist and had recently been discovered to exist, that needed to be removed/fixed. I should also add that I don't think pedophilia in the contemporary ordinary language meaning of the term is a "targeting error" that is it seems to be not only consistent with but a fairly obvious prediction of evolution by natural selection. Of course with respects to the technical meaning of the term that is, a strong persistent or exclusive sexual attraction to prepubescent individuals, the view that this is a targeting error seems very likely but of course basically no one uses the word pedophile like this and the broadening of the term is only increasing over time.
The DSM doesn't actually categorize pedophilia itself as a mental illness. It instead has Pedophilic Disorder, defined as being pedophilia+they either did something illegal or are distressed about it.
I don't think the solution to the general problem of 'people who need treatment cannot get it paid for by the insurance companies unless what they are suffering from is classified as a mental illness contained in this book of mental illnesses' can be solved by playing Whack-a-Mole and rapidly patching the book to contain each new thing that people turn up in the doctor's office with. If somebody shows up in your office with a compulsion to steal Telsa automobiles and crash them into trees, the proper response isn't 'oops, not in the book', surely?
the "this is needed because else health insurance will not cover necessary interventions" is an horrifying kludge on multiple levels.
and proves too much: if a queer got deluded into believing social conservative memes, then treating their distress (with e.g. drugs known to delete libido) would be as justifiable as transgender treatments for dysphoria.
Completely agree with your take, Scott. There are many inconsistencies and absurdities in DSM. Some of the ones that I ruminate about a lot:
One intuitively plausible definition of illness is that it is something that causes the ill person to suffer, and many of the things labelled psychiatric disorders fit that criterion: Anxiety and depression, for instance certainly do. But then how do we think about disorders that do not cause suffering, or at least would not if the individual was allowed to act as he pleases, suffering neither interference nor censure? Homosexuality, pedophilia and in fact all of the paraphilias fall into this category. In fact, is there any reason to think that indulging one’s kink gives less pleasure than vanilla sex gives non-kinksters? Actually, my impression from talking with a lot of kinksters is that their sexual pleasure is unusually intense. It’s as though they’ve found the sexual motherlode. From that point of view, people with sexual kinks are exceptionally high functioning.
How about drug addiction? Seems like that some addictive drugs have quite a pleasant effect, and that people addicted to them would be content and able to function reasonably well if they were supplied with the gradually increasing doses they need to maintain the drug’s effect. Of course using the drug in ever-increasing doses will probably harm their health — but so do the surgeries and drugs required for changing one’s gender.
Should we think of gender dysphoria as a form of Body Dysmorphic Disorder? According to the DSM, surgery to change the defect that preoccupies people with BDD rarely decreases their distress.
Why aren’t the experiences small children have with doctors thought of as being similar to the experiences of sexually abused childen? I don't think I was any more horrified by doctor visits than the average preschooler, but I still have vivid memories of the horrors my pediatrician perpetrated upon me when I was a small child. I was often forced to be naked except for my underpants and felt vulnerable and embarrassed to be seen undressed. And even the underwear usually came off before the end. He stuck things into my ears and nose and throat that really hurt, and the things in my throat also made me gag and feel like I could not breath. He pushed down hard on sore injuries and poured stuff that burned into raw wounds. He jabbed me with spikes in the butt and pushed a glass rod up my butthole. He looked at my genitals. And all the while he acted friendly and plied me with candy and gave explanations for the humiliations and tortures he visited on me that somehow fooled my parents. I truly believe that I would have been less distressed by visits to the pediatrician if the doctor had, instead of doing medical exams and procedures, fondled my genitals and shown me his penis. Of course I do realise that child sexual abuse often includes other toxic elements besides fondling, etc. I am speaking here just about the effects of an adult imposing his will on a child’s body.
It seems that deciding that homosexuality shouldn't be considered a mental disorder to avoid stigma its just as much a political decision as deciding that it is a mental disorder because of stigma. I suspect that some people just assume that an unbiased, apolitical process will just end up confirming their own political commitments because they believe that their own political commitments are unbiased.
" It’s just the claims to be able to avoid political bias in what is vs. isn’t a disorder that I find compelling."
... compelling? Or problematic?
Also, maybe the problem is that 'disorder' has a non-technical meaning. If we just called gender dysphoria a 'potential subject of treatment' or used some clunky term that didn't have a popular meaning and was awkward enough to not seep immediately into the popular lexicon then maybe that would buy us some time.
>We may want to categorize being addicted to meth differently from being addicted to Twitter, even if the neurobiology behind both addictions turns out to be similar, just because meth addicts have the bad luck to be addicted to something that’s really bad for them and for society.
I'm not sure whether the phrasing of this was meant to be subtly darkly humorous or not, but I can't help reading it that way.
What if I want a purely biological, apolitical definition of mental disorders and I'm willing to bite the bullet of calling homosexuality a mental disorder?
Let's assume I don't really care if people are mad at me, I just want to have an accurate and consistent model of the world.
Seems like it is a lot easier just to bite the bullet and say that, yes, homosexuality is a mental disorder, that DSM declassified for political reason. I mean, it is what the history books tell us happened, and homosexuality has strong loadings on mental illness symptoms, so it is rather obvious once you put on the evolutionary psychiatry glasses.
Another curiosity here is that the opposite of pedophilia, gerontophilia, is not in the DSM, despite also being a targeting error. https://en.wikipedia.org/wiki/Gerontophilia In fact, it might be a bigger error when men are doing it, as old women are never fertile and cannot become so, while girls might be, and at least will be at some later point.
>>(a common claim is that the DSM says transgender itself is not a mental disorder, but the distress it produces is. This doesn’t seem especially destigmatizing to me<<
It seems straightforward to me, to understand this as saying that biased public reactions to trans people pruduces stress which is unhealthy.
Outside of psychiatry, there are things covered by medical insurance that do not constitute a disorder. Anything that has to do with birth control or childbirth comes to mind.
Perhaps there should be a way to decouple "should be covered by insurance" from "constitutes a mental disorder"?
(Oh, and nothing will ever prevent people who believe they get to tell everyone what to think from quoting you out of context. Anyone who is happy to lie to get their point across will also think it's OK to misquote.)
The explanation for homosexuality I’ve found most interesting is that the combination of genes and in utero hormone exposure that cause homosexuality at the extreme, lead to higher reproductive success at lower levels. For example, if your goal was to have as many surviving defendants as possible, would you trade a 3% chance of a child being gay if it came with a 6% increase in the rate of your children reaching adulthood - assuming the world that held for most of human history where child mortality was extremely high.
>If this is accurate, the N relevant N difference N between N homosexuality N and N pedophilia N is N moral N, not N biological. Both are sexual targeting errors, but one re-targets sexuality onto other people who can consent and won’t be harmed, so it’s fine. The other targets people who can’t consent and will be harmed, so it’s bad.
The fact that you said this shows that either you didn't even have serious doubts about it or you're just lying. Maybe you lied in order to make people think their way to the truth more efficiently than if you had told the truth, but I don't see how they would, besides by your inviting a tiny number of implausibly courageous souls to object to it.
I don't want to spend too much text telling you how viscerally bad it made me feel that you said this; the sheer hopelessness that overcomes me when I think that you of all people cannot discover, through curiosity or by simply attending to the neurotypically-unspeakable strangeness of the world, the totality of clues on this matter.
How many characters short should my paragraphs be? How many paragraphs per post can I give you that you won't reject them for being too long? Will you just round me off as crazy if I have a mountain of anecdotal clues that humanity is collectively delusional about this topic? If our epistemic institutions and socialization are riddled with incentives to be carelessly misleading, it does not make reality and its clues any less real!
>If I understand journalistic ethics correctly, they can’t edit the sentence to remove the Ns - and if they kept them, people would probably at least wonder what was up.
You don't understand journalism ethics correctly. And again, you're behaving like a quokka. When they quoted you out of context before, they were *intentionally misrepresenting* you. Anything that a layman would call ethics has already been violated. When they say that they didn't change the words, that's an *excuse*; they say that because a ton of people who like to make excuses for journalists will say "sure, they didn't change any words, so they're not lying". (See also, previous Scott article denying that the media lies).
It's conflict theory all the way down. Whether they would remove extra N's is not based on "journalistic ethics"--it's based on "if we removed the N's, and got caught doing so, would there be backlash that inconveniently calls us liars". There won't be such backlash, so the journalists will have no problem removing the Ns.
Should we consider transexuality a physical disorder rather than a mental one?
From my point of view, a transgender person's mind is fine. Their body just doesn't match. That sounds physical, not mental to me.
Perhaps the DSM is the wrong place to define it, and doing so elsewhere would avoid the need for the "this is bad and should be covered by insurance" and "this is not a mental disorder" inconsistency.
I don't think "gender dysphoria is a mental disorder but transgender isn't" is really a contradiction. The two are different conditions - if you successfully transition, you no longer have dysphoria but you're still trans.
Presuming a perfectly biological taxonomy is impossible, how much politics is ok and what are its limiting principles?
I mean, I get it, pure political neutrality is a myth, but on the spectrum between a purely biological taxonomy and a purely political taxonomy, where do we fall and what determines that as we change the taxonomy? Because the logically consistent thing seems to be a political knife fight to the bottom but that's not, yet at least, what I see and biological realities seem to be driving a lot of it. For example, while the exact dividing line on when someone goes from "weird" to "mentally ill" seems pretty socially constructed but people in the midst of a psychotic break are pretty unambiguously "wrong" or "off". At what point on that line, or similar lines, does the biological reality outweigh political considerations, if it does?
Since this post is a can-of-worms-a-thon anyway, shall we open another one? How about "some degree of stigmatization of mental disorders is beneficial for society"?
I see some indications that the pendulum has swung from "mental disorders are bad, having them is a disgrace, we should not talk about them" to "mental disorders are cool and interesting, and we need to announce we have them (even if maybe we actually don't)"... which leads to impressionable young people brainwashing themselves into displaying (and probably feeling) ADHD, PTSD, ASD, gender dysphoria etc - to their own and their families' detriment.
Of course it sucks for someone who genuinely has a mental disorder if society stigmatizes them or doesn't even know what the issue is, but from a utilitarian perspective, if the alternative is to multiply the number of sufferers, maybe it's the lesser of two evils (or we should at least think about finding the optimal middle ground)?
> We may want to categorize being addicted to meth differently from being addicted to Twitter, even if the neurobiology behind both addictions turns out to be similar, just because meth addicts have the bad luck to be addicted to something that’s really bad for them and for society.
Can definitely see why you had to put those Ns in! Hope the trick works out for you. On the note of honosexuality being weakly linked to genetics, I thought that was actually quite strong. I remember studying that they found sex-linked genes on the X chromosome that could significantly predict it, also I recall that identical twins have very high chances of being gay if the other is (something like 50%), is that not true?
I think there *is* and we should *strive* for a purely biological, apolitical taxonomy (I'll abbreviate with "pure") possible, but that we will never achieve it. Because humans.
Let's start with a definition of "behavioural disorder": "A disruptive behaviour, causing distress or harm for the patient or their surroundings". So a behavioural disorder is already defined in two different levels: the *individual level* and the *inter-personal level*.
On an _individual level_, we can and should have a pure taxonomy, as it helps an effective therapy of the patient - without some kind of stereotyping, every therapy would start from scratch; having a stereotype (or taxonomy) helps to differentiate possible therapy paths to choose from.
It's also very open to the individual context. A married patient being in love with another person and wanting to marry them can be a distress, no matter if you're living in a country where multi-partner marriages are allowed or not (distress of not wanting to hurt the first partner). Being monogamous but living in a polyamorous group can be as stressful as being polyamorous in a monogamous group. Note that this is still the individual level, because no other person is affected so far - it's just "in the patients head", and they need a way to cope with their own expectations, assessments and distress.
On the _inter-personal level_, it's a lot harder - and this is where it is indeed impossible to get a pure taxonomy. This again can be split into two subcategories: What _society constitutes_ as distressed and harmful for the individual, and what _society constitutes_ to be distressing and/or harmful for other people, where others have to be protected - in extreme cases "for their own good".
The latter first: A woman wearing jeans (and being comfortable and non-distressed about it) can be deemed stressful for the society by some societal power. Or at what age it is appropriate to take mind-altering substances, getting married, join the military (increasing the individual risk of getting killed by a few orders of magnitude!) or have sex... That's as political as it gets and we'll never have a pure taxonomy here for what constitutes as a behavioural disorder or not.
The former subcategory is harder, but it still would be possible to have a _mostly_ pure taxonomy. I agree that we'll never get 100% there, i.e.: At what distress level of gender dysphoria is a life-altering and permanent sex change okay? What security should be build into the evaluation process to ensure, that there is no less invasive way to solve a patients distress - or that the persons evaluating it are being driven by other means (being payed by the institutions performing sex change operations)? At what age do we deem a person capable of that?
As for the "we need taxonomy to decide what needs to be payed by society": that's unnecessary. Having a look at other countries than the U.S.A. with a free healthcare system, a behavioural disorder (on the personal level) is payed for without any taxonomy¹ - e.g. germany. And that's as pure of a taxonomy as it gets - you're in distress (mentally or physically), society should help you (happy workers are less sick and work better and so forth). The opposite part - society does not want to pay for a (ineffective) psychotherapy forever - usually has a process attached (again germany: there's restrictions on how many therapy sessions you can get before they need to be renewed, and after two renewals there's special review protocols, etc. etc.), and that process again will be different from society to society... But still: _taxonomy is not needed for insurance coverage_. That's just _one_ possible solution - and a bad one IMHO.
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¹ granted, the insurances will be more likely to ask for additional diagnostics, if the therapist applies for a therapy to be covered and only puts down the general category, but they'll have to pay nevertheless.
I was under the impression that the DSM was primarily a tool for classifying various psychological ailments, and outlining the different methods of treatment for them. For this functionality, I see no reason why ethics or politics should play a role in the classification. Suppose a homosexual started talking to their therapist because they earnestly wanted to become straight. If there's it turns out that there's no relevant biological difference between homosexuality and pedophilia, wouldn't he be "treated" the same way a pedophile would be treated? What's so bad about having an entry in a mental disorder classification scheme that says so?
I agree that it's good to have a classification of mental disorders that prioritizes ethics and practicality, but I can also see value in having a more wide-ranging taxonomy of mental disorders that covers other ailments that aren't broadly stigmatized by society as "bad things." If people are uppity about the stigma behind the term "mental disorder," I suppose the classification system can refer to its entries as something else.
I have to admit this article was extremely unconvincing for me.
Suppose that there was a substantial minority of politically organized people born one-handed, say, 0.5 percent. Would you think it reasonable if they demand that being born one-handed should not be considered a developmental abnormality because it is not a moral/political issue?
To me, it is obvious that the correct stance towards it would be that it is in fact an abnormality, that this is important because not only they might need specific help for it itself, but developmental abnormalities tend to go together and we'd probably find a number of other abnormalities that this group will disproportionally hold, and they will need support for those, too. Any compendium of developmental abnormalities should clearly include them.
At the same time, we shouldn't morally lambast them for it. Nor should we force help upon them if they don't want it. If someone is fine being one-handed, just let them be. It also makes sense to accommodate them to some degree.
The same obviously applies to mental disorders. Homosexuality is clearly some kind of attraction misfiring. Yes, that means homosexuals will probably hold certain other disorders disproportionally (and there is substantial evidence for this as well). Yes, that means homosexuals need special help and accommodation (the most obvious being that can only have children through adoption or other nonstandard approaches). No, it does not mean we should discriminate them.
As long as we conflate biological and moral/political, we will fail to understand humans fully. That does not mean we should ignore the moral, merely that we should be able to consider them separately. I wouldn't mind separate compendiums for the biological and the moral side, nor if a single compendium would include both but with appropriate labelling. But the current positions where we pretend something isn't a biological disorder because we do not consider it a moral failing is nonsensical.
[Apologies for my bad English] "Scott Alexander did it again. This time he put homosexuality on an equal footing with pedophilia but he has improved his technique: now he asks not to take it out of context by using unintelligible signs between words"
My conclusion: we cannot negotiate with the Cathedral.
Congrat's on getting back to posts you'll regret writing. They've been sorely missed.
>So N, should N your N purely N biological N, apolitical N, taxonomy N of N mental N disorders N classify N homosexuality N as N a mental N illness, N or N should N it N refuse N to N classify N pedophilia N as N a N mental N illness?
You just answered your own question: if my taxonomy don't classify H as a mental illness, it's not doing it's job, is being political, and is catering to political needs. That the mental illness is relatively harmless is irrelevant. Palilalia, for instance, is even more harmless, it's still a mental illness.
Addiction is a mental illness as well, be it to crack or to twitter. Even an addiction with beneficial side-effects (Have there been artists who produced masterpieces against their will, unable to stop? Maybe, but we can just fall back on the more grounded workaholic who -in some cases- create a lot more wealth than my lazy ass, and should receive both our gratitude and our help) would be a mental illness.
Refusing to cateforize mental illness as such in order to prevent social stigma seems a great way to end up with mentally ill people uncared for, and still socially shunned precisely because they're uncared-for. In fact I don't really buy that the DSM is driving the loss of social stigma, rather than simply people collectively changing their mind.
And then there's the idea that "it with insurances" line of thought, that's a recipe for disaster, from one side (insurances lobbying to declassify what they don't want to pay for) as from the other (lobbying to classify non-illness in order to get it reimbursed by insurances). You may argue "Psychiatrists & insurers are responsible enough to not have it happen", but this entire post stems from how self-serving & vulnerable you (as in, psychiatrists in general) are to social pressure & will classify or declassify illness according to "well i really want these guys to get reimbursed".
Scott, if you're that worried about being taken out of context, either don't say it or rephrase it to be more innocuous. You're a smart guy, you could just describe homosexuality as a sexual targeting error that doesn't harm anyone, and then in a separate paragraph discuss sexual targeting errors that we object to for moral reasons. At the very least, the amount of ellipses required to stitch together an Out-Of-Context quote would be suspicious.
I think the issue is that you want to write provocative things for impact (which is not a bad thing, it's part of engaging writing), but also don't want them to be taken out of context and used against you, and those are clearly in a trade-off - interspacing letters into the sentence means it loses whatever impact on the reader you were hoping it would have, and I can still paraphrase this article as "While discussing the flaws of a purely biological, apolitical taxonomy of mental disorders, Scott compares homosexuality to paedophilia", because nobody clicks links anyway.
If people want to attack you for political/personal reasons, you've already given them more than enough ammunition, and I don't think it's a great idea to spend however long you continue blogging in fear of your own words being thrown back at you, because they will be anyway.
To steelman the position that transgender is not stigmatised by the DSM: gender dysphoria is caused by the assignment of the gender being wrong, not by the experienced/expressed gender being wrong, and could be prevented by developing a technique for assigning the correct gender (ie the one this person will experience/express as an adult) at birth.
So the fault is not in the person, but they are being driven mentally ill by society and their body not being in alignment with their experienced/expressed gender.
I read the title very literally, and my immediate thought was that the obvious issue with purely biological, apolitical classification is that mental disorders are about how people function within a society, whereas a biological taxonomy would talk in terms of the underlying causes: genes and metabolic pathways and cell damage and head trauma.
I'm sure that, many decades (centuries?) in the future we'll understand enough about how the mind works to construct such a taxonomy, in the same way that we know that "deafness" can be caused by a variety of different genetic mutations, or by aging, or by bacterial infection, or by damage to the inner ear caused by loud sounds. This will be great to know, but the practical implications of this level of understanding for the deaf community seem to be pretty limited - obviously the distinction between being born deaf and progressive hearing loss is significant, but we know that already! I expect that understanding the exact causes of schizophrenia will also be restricted in its impact.
I work in gov't employment agency myself and 20% of my job is assessing if sick people are capable of work. We use the diagnostic system for this too, and things outside it don't practically exist to us, even though the symptoms are really real and hell for people. And that sucks, but we live in a society and if we didn't have it we'd have to make a lot of really complicated decisions and we'd fail hard at that.
Diagnoses inform multiple governmental needs, from care and treatment to identifying beneficiaries of welfare to insurance and actuarial decisions, and they're laden with serious moral/political weight, because they impact people's lives in so many ways.
I do understand the general motivation behind this thinking, but semi-equating "political" with "pragmatic and ethical" less so, and the example with punching bags and kittens completely lost me.
The biology of muscle movements is the same, but the effects are not: one inflicts suffering, the other one doesn't. Now, I understand the argument: "'suffering is bad' is a moral/ethical judgment, and we want to do without those". But is that really true? Why then not go on to claim that pain is, in principle, no different from any other sensory perception? And why the label of "disease" and "disorder"? Heck, what's with all that fuss about "pure biology"? Isn't biology just a man-made and thus political label applied to some physical and chemical processes and phenomena which obey the very same laws as everything else in the universe, "dead" or "alive"? So how could it possibly be pure?
Obviously, this would be a ~wrong~ useless basis for any such taxonomy, or even any conversation about disorders, mental or otherwise. "Disorder" always implies some judgment. I get that this post is fundamentally about how hard it is to decide whether some concrete phenomenon is a disorder or not, but this is not the same as saying "disorder as a concept is meaningless independently of how it is defined", which would be the more consequential position. "Pain and suffering are bad" to me seems like a reasonably minimal assumption to overcome this meaninglessness, and I think it would be fair to grant at least that to the authors without accusing them of politicizing.
If we accept that:
1. biology as a concept makes sense
2. some or all biological organisms have subjective experiences
3. some of those experiences, that we label "pain" and "suffering", are "bad", i.e., we seek to reduce or avoid them
then it becomes fairly easy to distinguish between punching a punching bag and a kitten, or between consensual homosexuality and pedophilia. It's easy to see that one of those actions statistically increases the overall experienced suffering much more than the other.
It's probably net-negative for your Substack income to put the Ns in. You've already lost anyone who cares about what the outrage machine thinks; all the Ns do is annoy the people who remain - and either avoid or discourage the people who come here precisely *because* they're defying the outrage machine. Remember, you got a whole pile of new subscribers from that NYT article.
You're on the Blue Tribe's shitlist. Sunk cost. Relish in the freedom to ignore that sunk cost.
How about a less sensitive example: left-handedness. Nobody considers that a disorder, mental or otherwise, today. But when my father was a child, his teachers would slap his hand with a ruler any time they saw him write left-handed. (It worked, sort of: he still prefers to use his left hand when nobody is threatening to slap him with a ruler, but he ended up being ambidextrous.)
So would it be correct to say that left-handedness is not a disorder today, but it was back then, because of the problems of living in a society which did not accept it? Or should we say that no, those teachers were just stupid, left-handedness is not a disorder and it never was.
How about if you lived in a stone-age tribe where it is super important that everybody is able to hunt with a bow and arrow, and all their bows are made to be used right-handed and for some good practical reason it would be super inconvenient if the tribe had to make and maintain a separate left-handed bow just for you? Would left-handedness be legitimately classified as a disorder then?
I don't actually know what point I am trying to make with this analogy -- I just figured it can't hurt to have an example to discuss which doesn't map to a topic that's already a political hot potato..
> It’s just the claims to be able to avoid political bias in what is vs. isn’t a disorder that I find compelling.
There's a "don't" missing from that sentence, isn't there?
Also, I've seen you use "transgender" as a noun on a lot of occasions and that feels weird to me. I don't think I've ever seen it used like that by transgender people themselves; they use it exclusively as an adjective. I'd use "transgenderness", maybe "transgenderism" at a push.
There is a fair amount of sophistry at work here. You are effectively asking to subordinate biological taxonomy to the rules governing insurance policies. I would like to think it would be easier to change insurance rules than biology. If something is harming an individual or others around them ,it needs to be addressed by the society, whether or not it is a biological disorder. Conversely, some biological disorders are harmless and require no treatment.
Linking homosexuality and paedophilia as targeting errors by reference to heterosexuality as a default is a naturalistic fallacy (note that "error" is normative), and even foregoing that, it's a just-so story. Natural selection doesn't require the proliferation of exclusive sex-based attraction targeting in order to guarantee adaptive heterosexual behaviour. And who's to say that there aren't child-rearing and social hierarchy benefits to having population subsets (including grannies) who are not competing for offspring?
In other words, you can't baldly assume that the only adaptive sexual behaviours are ones with the potential to result in conception. That simplification is normally the purview of Bible-thumpers.
Also, even if you don't burden yourself with the worry of thinking through population genetics, the concept of sexual orientation itself is obviously a political construct inherited from categories of modern Western religious persecution, so you can't just load it into a psychological theory and apply evolutionary thinking. It's easier to argue that homosexuality doesn't exist as a biological category at all than it is to conjecture about its evolutionary fitness.
Is it necessary that these 3 things are all the same?
- being a mental disorder
- getting insurance coverage
- be viewed as a problem to be solved
In an alternative world could we have a DSM that talks about things that are unusual to help with destigmatizing (not just "disorders") and then have some subset get insurance help because they're serious enough? It would be a bigger tent, so people wouldn't feel bad about homosexuality or being trans being included, and whether treatment was covered would be an independent axis.
One of the core problems with the taxonomy of mental disorders is that our conception of a mental disorder involves causing dysfunction for the person within the major areas of what we consider to be living a fulfilling, independent life, and whether a behavioral or thought pattern causes that is intrinsically dependent on the surrounding culture. It can be what causes the dysfunction is societal treatment.
This isn't a novel observation and psychiatry and abnormal psychology try very hard to separate out what appear to be arbitrary cultural factors, but this is a difficult task.
A substance use disorder - a drug addiction if you prefer - is at its root a compulsion to engage in a behavior despite the negative consequences it invites. Addictive chemicals work because their biochemistry has a quirk that allows them to trigger the mammalian reward-motivation pathways in the brain and produces reinforced behavior. The negative consequences part; however, cannot be completely disentangled from societal response to this. Certain substance use disorders are much worse because people will risk severely harmful consequences that the state actively dispenses in response to use.
But suppose a state banned women reading books under threat of long prison sentences. Would women persist in trying to read books despite this penalty? I bet they would. Would this prove that women reading books is a mental disorder because they are compelled to do it despite the negative consequences it invites leading to a loss of global functioning? I think the answer is plainly no, but why that might be is interesting. I think the answers to this question outside of, "Well, we just don't find that legitimate" to be not compelling. You can't escape making moral judgments about what society ought to do and how that interacts with human behavior.
> But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!
Isn't the problem here that our current culture derives its morality/ethics in part from the psychological classification system? That seems the fundamental error at play here. People should stop doing that. To develop true ethics you need to actually know how the world is. Classification systems are about learning how the world actually is. Morality/ethical systems are a different thing. I am a short male. This could be considered stigmatizing to me. The culture accepts that as an accurate description despite the danger of stigma. Morally/Ethically everyone pretty much agrees not to be a jerk to me because of my height but we don't feel the need to reclassify me as "normal height-ed" or to avoid using rulers.
What would really be great is clinicians actually being able to diagnose mental conditions, not just guess by symptoms. Maybe MRI will allow this one day, or some technology that hasn’t been invented yet.
My rephrasing of Scott's observation is that tying specific complex instincts/behaviors down to genes is impractical for nature, that nature can either hardcode simple rules which leads to e.g. birds misidentifying their parents, or rely on higher-level cognition filling in the details of a fuzzier idea, which leads to e.g. mistargeting. A few thoughts that lead me to find the idea unsatisfying, despite having a pretty compelling premise.
Caveat emptor: I'm not certain I've entirely pinned down Scott's idea. To avoid accidentally equivocating, let me try to define biological here as a characteristic, or a change in a characteristic, with enough impact on effective reproduction and a solid enough grounding in genetic material that it can ends up naturally selected for or against in a meaningful sense, in a reasonable time-frame. By contrast let define a moral as something that is mostly left up to society by default of nature not biasing it very much one way or the other.
>If this is accurate, the N relevant N difference N between N homosexuality N and N pedophilia N is N moral N, not N biological. Both are sexual targeting errors, but one re-targets sexuality onto other people who can consent and won’t be harmed, so it’s fine. The other targets people who can’t consent and will be harmed, so it’s bad.
Under the sexual targeting error hypothesis, it would seem that homosexuality is not determined biologically, rather something that develops from a different interpretation of our fuzzy instincts and drives.
That there must be environmental causes, before sexual drives are fully developed, that pushes them to unfold in a different way.
1/ Wikipedia estimates a quarter of black swan — Cygnus atratus — couples are homosexual. It describes males as larger, with a straighter and longer bill. Presumably it is not exceptionally hard for natural selection to unearth genes that visibly differentiate male and females, so that I wouldn't expect hacks of the same kind that some species of birds use to recognize their parents to be exceptionally harder when it comes to recognizing potential sexual partners. Pedophilia in nature, or at least in black swans, seems much less notable than homosexuality.
We should expect making females birds instinctively recognizable as sexual partners in DNA to be in the same category of difficulty as than making younglings and parents instinctively recognizable, so instincts being hard is not a compelling explanation for why the sexual-partner-identification instinct would have been pushed to cognition in birds.
2/ But let's assume sexual targeting has a good reason to be pushed to cognition, perhaps because parent recognition is needed from a very early age and needs a hardcoded rule more than sexual targeting does, and I can try to make a different point.
It seems to me that given nontrivial reward, we should still expect natural selection in birds to not have had a great difficulty in unearthing some sort of hardcoded anti-homosexuality distaste in birds, or that the difficulty of conjuring this hardcoded rule should not be much greater in the case of homosexuality than for pedophilia.
If homosexuality and pedophilia are equal and purely moral differences, with no biological basis, all else equal we would not expect the rate of homosexuality in birds to be very much higher than the other. And it seems vaguely reasonable to assume all else is roughly equal, or close enough to not matter too much.
So, it may not be inconsistent to hypothesize that the rate of pedophilia being lower than the rate of homosexuality — at least in birds — could have a biological basis. Possibly, and I may be going out on a limb here, pedophilia bad. To an extent where it would be selected against with categorically more urgency than homosexuality, way upstream of the effect of any moral constructions or culture war topics.
3/ I'd like to hand-wave something about how you may be a little quick to dismiss harm as a biological issue, because trust and social cohesion is good, as we know. If you have to isolate some subgroup of birds from the other birds to avoid scary bad outcomes, maybe this is meaningful to point to in a less subjective sense than purely calling it a moral issue.
4/ Back to talking about people directly, there it makes more sense to me that we would generally have fuzzy instincts over hardcoded rules for picking sexual partners. We have complex societies, what makes a good partner in a human is more complex than in a bird. We've likely greater-or-equal cognitive capacity available for evaluating fuzzy instincts than birds do.
But, it's not clear to me that it should be exceptionally hard to add a hardcoded rule on top of the fuzzy instinct, if that were beneficial. Our fear instinct is fuzzy rather than hardcoded — we can fear complex abstract things at our core, and with intensity — but we also have hardcoded fears on top of that (say the sight of blood, insects, mice), and those vary with considerable individuality!
Here's how I would try to refine the idea of instincts being hard: It is impractical to try to encode firm rules for the selection of sexual partners in DNA, so we have fuzzy rules that are more open to interpretation. In the same way that not everyone has the same instinctive fears, despite fears having a fairly uncontroversial tie back to reproductive fitness, there may exist a set of more specific fuzzy rules to refine sexual targeting. This may be without those rules having to be either entirely hardcoded or entirely open to interpretation.
It is presumably hard to find a genetic correlate for specific instinctive fears, and presumably the same would be true for pedophilia, or homosexuality. Still, there is a real sense in which explaining instincts as untethered from biology doesn't make for a very compelling explanation, regardless of how hard a time we have looking for those ties.
It is possible that pedophilia or homesexuality are natural variations on either the *specificity* of an instinct (in a sort of "openness to experience" sense, perhaps how much an instinct is open to interpretation is itself a variable trait), or more directly variations in strength of components that compose the instincts for sexual preferences.
This variation would still reflect the reality of instincts being hard.
The key factor that puts me in a rage over this subject is the bit about imprinting. Many schools are encouraging experimentation with homosexual acts at an early age -- when the hormones are raging and imprinting is possible.
I used to be a Libertarian, and worked on the campaigns of gay candidates.
The current effort by the alphabet community to imprint children in a gay direction has changed my mind dramatically on the subject. I now miss the Moral Majority and was to bring back sodomy laws. Take this a data point. Helnlein's prediction of Crazy Years followed by a Cromwellian revolution could well happen.
1) I work in the deaf community. Its not just these people do not hear as you would think. Especially if you do not hear from when you were born, you will have hard time to read thw "written language" and visual languge (sign language) will be natural for you. You will very probably be part of "Deaf community" which involves a specific culture and you will have your way of cognitive processing. To feel better, the "Deaf community" uses "D" and not "d" and is holding the idea that "deafness" is not a disease but just a human variety and the reason is prevent others to stigmatize them. At the same time in many countries these people have state half-rent, social help and insurance coverage for various conected problems happily using this (because they are not disabled (they can do everything but do not hear) but they are disabled (they are foreigners in their country - can not communicate with people around them and often also psychiatroc problems are involved...well....not from deafness but from depression that follows it?) You see, it is a perfect parallel to this post.
2) I know there are probably many evolutionists here but actually many astronomers and other field scientists **secretly** believe there is an engineer behind life (or maybe a group of engineers). If so, we are biological machines and it seems we consist of a hardware and software. What is making this more complicated, we can produce (involving a small factory in women to produce other machines) and there is adaptation and other weird mechanisms. Let us say, our friend Elon Musk would miniaturize his factory and place it in a car booth, so the car itself can produce another car. The car would also adapt, evolve to some extent etc. Building would be based on a design plan called MNA (Musk DNA). No one can deny, after some thousands of years, Elon would be capable of constructing such a car (there is just no motivation, where would come the profit from??). Now, these cars start to reproduce, adapt etc and small mistakes show here and there. A car is born without wheels. A car is born with a software for a cattle. Etc. How would you call these? How do we know it was Elon's plan or it is too deviated from his plan? Etc. Let us say, we can not meet with Elon. We just have understand from how the cars look and what they do etc.
> "The authors of these apolitical taxonomies want an incoherent thing. They want something which doesn’t think about politics at all, and which simultaneously is more politically correct than any other taxonomy."
It's not incoherent if their politics is the one good, true politics derived scientifically from nature. In that case, the taxonomy will follow nature, just as the politics follows nature, and each will be aligned perfect with the other without any effort beyond what's required for true knowledge of nature. The one true natural scientific taxonomy will be 100% politically correct, without thinking about politics at all, because the politics is also the one true natural scientific politics.
Reading over that, it sounds to me like I'm being ironic, but I'm genuinely not trying for irony. Lots of people really think that their politics is derived scientifically from nature. And to them, an apolitical taxonomy such as Scott describes here isn't incoherent at all. It's only incoherent under the assumption that their politics isn't the one true natural scientific politics.
Some people look too much to manuals like the DSM to inform their opinion of whether or not something is bad or not. Pedophilia's badness has nothing to do with whether it is in the DSM. Making it a diagnosis makes it something that it is considered appropriate for health care professionals to treat. It's not really even a statement about what kind of thing pedophilia is.
Similarly, in my opinion, some people misinterpret what it means when it is said, e.g. "alcoholism is a disease". They think this is a scientific discovery that we have made about alcoholism that takes it from one category and puts it in another (like discovering that coral is an animal and not a plant). This isn't really true. Saying alcoholism is a disease doesn't mean we have discovered it is just the same kind of thing as influenza or thyroid cancer. "Alcoholism is a disease" means that we consider it is something that is a distinct entity that is appropriately treated by (among other people) health care professionals, who need to make it into a diagnosis because that is how medicine works. Sure, thinking this way is informed by scientific discoveries, but it doesn't depend on them. We could consider alcoholism a disease even if we knew nothing about its etiology or pathophysiology.
Also, sometimes people think that mental disorders aren't as real as somatic ones because they aren't as well defined. However, it is easy to forget that the distress caused by somatic disorders is also subjective, and the distress is actually why people get treatment, not something objective about the disease. Acne is just as clearly a disease, objectively, as cancer (by this I mean it is possible to identify parts of the body that are abnormal), but for a supermodel to have acne is a much greater problem (for the patient) than for some random guy who doesn't care at all.
(Of course, whether or not the DSM actually categorizes mental disorders correctly is another question.)
> a common claim is that the DSM says transgender itself is not a mental disorder, but the distress it produces is. This doesn’t seem especially destigmatizing to me - you’re the wrong gender, but you’re crazy for being unhappy about it? Also, I can’t find support for this distinction in a literal reading of the DSM criteria themselves
The DSM says that there must be evidence of distress about the incongruence between a person's assigned and experienced gender for a gender dysphoria diagnosis. If someone is transgender but does not experience distress, they are not suffering from a mental disorder according to the DSM. I would probably put myself in this category, as a non-binary/agender person who doesn't experience any gender.
I think the same principal should be applied to everything. If a condition doesn't cause distress or impairment to the person who has it, it should not be seen as a mental disorder. This means that I think the definition of mental disorders should be individual rather than political or societal.
A test for whether someone is suffering from a mental disorder could be whether they are experiencing significant distress or impairment, and whether they would still be experiencing significant distress or impairment if they were transported to an alternate universe where everyone was like them. I believe only people where the answer is 'yes' to both questions are suffering from a mental disorder. Perhaps the definition could be made more precise if expanded to take account of whether one condition impairs the ability to feel distressed about something associated with another condition (e.g. a paedophile with ASPD who doesn't feel distress about their paedophilia because of ASPD), but I think even the simplified version makes more sense than any definition that pathologizes dissent to societal norms.
Fascinating post! I was just these days thinking about exactly this topic.
So, to sum up: if homosexuality and paedophilia are congenital, biological and immutable (as it seems we are supposed to believe these days), yet paedophilia is clearly morally illegitimate, then the fact that a trait is congenital, biological and immutable does not automatically make it morally legitimate (as is the case being made for homosexuality).
On the other hand, if these traits are not congenital nor immutable, that means they are at least partly (mostly?) sociocultural, in which case, whether they are to be encouraged/discouraged become a matter of individual ideology, no?
If something as basic as taxonomy is based on practicality and ethics, rather than science, then is anything about clinical psychology scientific? Are some disorders more scientific than others, schizophrenia perhaps?
What in principle distinguishes therapy from the kind of ethical and practical counseling you might get from a priest or a fortune teller? What justifies the professional licensure of therapists, when we wouldn't dream of licensing priests and fortune tellers? I get that psychiatry is different, you're prescribing drugs, you have to know what's safe, and what might be effective. That's got to be based on evidence. Is therapy really medical or scientific at all? Or is it just talking to someone about your problems?
Hey Scott - I've been thinking this for years and I'm so glad that you've written it out. To discuss this is very taboo.
"Born this way" as a criteria of whether a behavior or identity is moral is an extremely conservative idea. In regard to LBGT identities, for conservatives this criteria was fulfilled by reproductive ability between a pair. Progressive people decided to not question the criteria, but instead cultivated evidence that the brains or early-age behavior of LBGT individuals are different from others, which indicated biological determinism of their identities. So, weirdly, conservatives and many progressives agree on the criteria, and simply disagree on what evidence should used for determining that the criteria are fulfilled.
The truly progressive thing to do would be to question whether this is the right criteria to use. And, its definitely a terrible criteria, because too many undesirable behaviors have biological components, like mental illness and addiction. Honestly, most human behavior is a combination of biological and social inputs, so it feels pretty meaningless to create a dichotomy based on those qualities.
Plus the biological determinism approach to describing LBGT identities has always struck me as sad, because it implies you would be different if you could actually chose, and it undersells the tremendous creative work humans put into developing their identities.
Morality should just be how your actions effect other people and yourself. There shouldn't be a component of fatalism or biological determinism. But a lot of people believe in God, so fatalism and determinism are important to their worldview.
What if we just strictly defined "mental disease" as something that impairs the functioning of the mind or causes distress in the individual with the disease (defined by the individual in question), just as we do for bodily diseases.
Paedophilia N wouldn't N necessarily N be N a N disease by that metric, but that doesn't matter as coercing and punishing people is the job of the justice system, not the health industry.
This would also make clear that psychosis etc on it's own is not a thoughtcrime and does not deserve punishment or a forced cure.
The two choices you present for "purely biological, apolitical taxonomy..." seem clearly delineated, and I think we ought to just choose the 2nd one without any problem. Your language is also very clear: "things which don't deserve stigma", "make everyone mad at you", "have everyone end up thinking you're even more political" (not concerned with the 'truth'; if you had said these things about the conclusions of a physicist, he might say 'why should I care?'). Consistent with this, you are very mindful and careful of the fact that e.g. in (certain) biological terms, homosexuality and pedophilia share a taxonomy, AND you are clear that this is NOT in itself a moral/ethical fact (in particular because each treat the matter of consent differently). The fact alone that you write about this distinction means that there is (at least in your mind) a 'matter of fact' about the taxonomical approach, AND that there is a corresponding social/political/etc. pressure exerting itself regarding this approach. So in the sense that you are arguing against pursuing apolitical taxonomies, you nonetheless appeal to some external biological approach & show that it does not give a complete moral account --i.e. it does not tell us what we ought to do.
You say also "That is, we want our definition of “mental disorder” to be ethical (eg not stigmatize people who don’t deserve stigma). And we want it to be practical (eg identify a group of people who need and deserve care)."... In the first sense, what I am asking is 'why can't we have a non-ethical taxonomy?' Obviously, there is no need to ask this question in spheres of thought which don't concern the (practical) affairs of human lives. And obviously the possibility of "stigmatiz[ing] people who don't deserve stigma" is the reason we want to be "ethical". However, let's be good analysts and forget all the nice and pleasant work "being ethical" is doing for us here: ""[t]hat is, we want our definition of “mental disorder” to ... not stigmatize people who don’t deserve stigma". So now we can see the operation of this sentence properly. But in the sense of answering the question about a taxonomy and its definitions, it still is difficult to see how the former part relates to the latter. Turn to your fellow mathematician and tell him you want his definitions not to stigmatize people who don't deserve it.
(1) -- Our definitions are erroneous, people who do not need to be 'cured' are labelled as in-need-of a cure. (But don't we think this problem can be solved within the scientific framework?)
(2) -- Our definitions are _correct_, in that the delineate without much error treatment-wise, but outsiders make use of our terms in a moral sense and cause harm to those our definitions concern.
If we were talking about (1) the actual meaning of the quoted sentence (avoiding creating stigma) is that we ought to censor scientific work -- which then represents the meaning of "being ethical".
So since we are probably talking about (2), what if we replaced "mental disorder" with some distant and cold terminology bereft of meaning? After all, its purpose is only to delineate "in need of cure" from "does not need medical treatment". (And perhaps now we see that the symbol isn't so relevant as the fact that we have the "sick" and the "healthy".)
No: stimga, stigmatizing... These are not what is at stake, here. What is at stake is treating those who do not need treatment. In the case of homosexuality and its perception, what has changed is that it was once indistinguishable from 'unhealthy', 'sick'. The fact that this was overcome is their main victory.
There is a good debate (https://sounds.bl.uk/Arts-literature-and-performance/ICA-talks/024M-C0095X0856XX-0100V0) involving Paglia here, and Watney here attacks her (around 45:30 mins, if you can bear it) & the British government etc. for a lack of education and spending in healthcare for gay men. The point is that it doesn't matter how massive a disaster the HIV/AIDS pandemic was/is, the government(s) are totally responsible for it because they are assumed to have the power to effectively prevent it. Without the condition of responsibility, one cannot be held morally responsible; hence the pandemic has to be within the government's power. Similarly, here, the one addressed by my moral speech designates the responsible one. The diagnostic methods, and all the structures by which the doctors abide, are precisely what allow us to make the doctors and the medical world accountable for all the sufferings we can throw at them.
What I want to say is that already we live in a culture which designates the medical approach to mental issues, or issues of the behaviour rather than the physical; when a suffering is easy to see (heroin addiction) we can trust the medical response, but in nearby cases (Twitter addiction, infamous deaths playing video games, where we cannot literally see the needle going into the arm or whatever) we cannot, because the ethical system decides first. Likewise the issue at hand for mental health is not "you are stigmatizing me," and so on, but "you are not offering me the cure to my condition which I demand".
We are now more than ever in need of explicit, cold, taxonomy, but already by the title of this article we can feel how the medical establishment is somewhat defeated by this goal .. "can we really practice today the science of mental disorder, when already we inherit so many mistakes and biases, my god...". If there is this entity, taxonomy, which speaks to us from some scientific perspective, which places demands and limitation upon us morally, OK then we ask the question: to what extent ought we to obey it, blah blah.. but THAT question is moral, and relies on taxonomy practicing freely (which is to say non-ethically). To say again what I am saying: either we have (as this article seems) given up on being able to practice taxonomy for fear of saying something dangerous (note the special care this article pays to being misquoted), OR we believe that taxonomy is possible, is clear, but is nonetheless itself dangerous... in which case I am pessimistic about my next doctors appointment, when he already will tell me exactly what I want to hear..!
Ah - the weight of proper classification in a social-political lodestone. Reminds me of the uncertainly principal in that the more closely we attempt to define one aspect, tge more slippery the rest becomes. I N did N chuckle N at N your N solution.
So, the question boils down to: How can we get groups that we like everything that they want and nothing that they don't? How can we consider these surgeries and treatments medically necessary, non-elective when there is nothing medically wrong with these people and we don't want to say that there is something wrong with them mentally?
I feel very uncomfortable in this middle aged out of shape body. I identify as young and athletic. Why won't you pay for my surgeries?
No matter how afraid you all are of the dudes in skirts you eventually have to tell them that if they eat their cake it ain't still on the counter.
Isn't the obvious solution simply to consider whether the condition causes harm to oneself or others? If it does, then it's a disorder. If it doesn't, then it isn't.
This would exclude homosexuality but include gender dysphoria due to it's high incidence of suicide, and pedophilia due to the mental distress and possibility of child molestation.
All rants against "politicizing" are hypocritical. The speaker wants to make his own political assertions, then preemptively prohibit counterargumentation.
You know, you could just rename it "Taxonomy of Human Psychologies," without any implication that some genera are bad and some good, and all the PR problems would go away. Can't see how the insurance industry would care either, they just need a number to write down on a form somewhere.
This seems to me like a psychiatrist/psychologist guild own goal, and that you can solve the problem any time you like. One assumes it suits the field somehow to keep the contraversy alive and periodically visibly fret about it.
You've convinced me that I do want a purely biological, apolitical taxonomy of mental disorders. Sorry for all the people in the world who feel stigmatized, but it sounds really useful.
Regarding the "pedophilia as a sexual targeting error" debate: I recently read an article about a man dating an adult woman who looks like a small child, and it's caused an enormous amount of controversy and heated debate. (https://nypost.com/2023/01/23/im-dating-a-23-year-old-woman-who-looks-like-an-8-year-old-girl/) On one side, there are people saying that he's not doing anything wrong, since she's a consenting adult. This is obviously true in the legal sense (he hasn't committed any crime) and in a consequentialist moral sense (she's a consenting adult of sound mind, so there's no harm being done to her). On the other side, there are people arguing that having a romantic and sexual attraction to someone who looks like a child is a sign of innate pedophilic desires. So even if he's not breaking the law or hurting anyone directly, they still consider him a pedophile at heart, which is effectively synonymous with "bad person" in their eyes. Maybe they think he's more likely to pursue actual children in the future, maybe they just think it's gross. Then there are counter-arguments from disability activists, who say that expecting this woman to be totally celibate because of her appearance is extremely unfair to her; if you condemn anyone who has sex with her, that's functionally the same as saying she shouldn't be allowed to have sex at all, which amounts to severe discrimination against someone with a medical abnormality.
Now, I strongly disagree with the idea that this guy must secretly be a pedophile. He's had prior romantic relationships with physiologically-normal adult women, and there's zero evidence that he's ever shown any sort of sexual interest in children. I think there's a very good chance that he isn't actually attracted to childlike bodies at all, he just happened to develop a relationship with this particular woman and was willing to look past her physiological abnormalities. But even if he was specifically attracted to her body type in particular, I still don't think he'd be a pedophile, because pedophilia is "attraction to children," not "attraction to adults with childlike bodies." Classifying him as a pedophile would be a category error or, at most, an example of the non-central fallacy (https://www.lesswrong.com/posts/yCWPkLi8wJvewPbEp/the-noncentral-fallacy-the-worst-argument-in-the-world). He'd be more comparable to disability fetishists, like the sorts of people attracted to amputees. And while disability fetishists are considered very weird, and sometimes seen as off-putting or socially problematic, they still aren't viewed as inherently sick or evil the way that pedophiles are.
I don't think that "sexual targeting errors" should ever be considered a mental illness in themselves, especially because it's not entirely clear what even counts as an "error." While we don't know for sure yet, there's some evidence that homosexuality is evolutionarily advantageous to the homosexual's family and tribe, in which case it's not an error at all. And even if that theory turns out to be false, there are major problems with the idea that any preference for non-reproductive sex constitutes a mental illness. If homosexuality is a mental illness, then what about a straight person with a fetish for oral or anal sex? What about a man exclusively attracted to older woman who are no longer fertile? Should the DSM include a category for men who browse the GILF category on PornHub? The reasons why pedophilia should be considered a mental illness go well beyond any issues with "sexual targeting," and for some (possibly many) pedophiles, it seems to be a largely or purely pathological issue that might have nothing to do with sexual targeting at all.
Szasz. His book on my shelf. At the end of this article the author makes a very odd – not at all the prediction one would make from all that came before in said article – where what he would, if consistent, see as socio-economic conditions. It is worth th read. I recommend it.
In the past, Alexander wrote a controversial piece on homosexuality and mental illness. In this article, he obscures his meaning with a strange code to protect himself from public scrutiny. According to a leading Alexander scholar, Emile Torres, the decrypted version is the following:
On the point about not wanting to be taken out of context, I can see the comparison you wanted to make and don't misunderstand it, even though I think it doesn't have a sound basis in fact or logic. But I also think it's fair for readers to look at the way you pieced things together as either wreckless (which goes against your stated caution) or wilfully provocative.
At the very least, you might have made a distinction between paedophilia and sexual attraction to children, seeing as your argument is completely centred on mental experience and not actual sexual behaviour, criminal or otherwise. The fact that the word 'paedophile' is strongly associated with criminal behaviour, setting aside any paltry excuses about etymological literalism, and yet you didn't attempt any such distinction means that you just reached for a ready-made obscene parallel drawn by bigots and want to lay the blame for easy misreadings elsewhere.
Was it because of laziness or because you wanted to be misread? I don't know. But it's pretty clear that this wasn't the only succinct way of putting things and I was surprised at the (faux?) naivete regarding media ethics. This is not an example of clear critical thinking.
This is probably something that others have thought of and that has been articulated and more fully fleshed out elsewhere, but while reading this, something clicked for me about why efforts to change language in order to avoid stigmatizing a group have always seemed misguided to me.
The core issue is that a group gets stigmatized primarily because some people want to stigmatize the group, and only secondarily because of the language used to refer to or describe the group. Changing the language used to refer to a group will only help destigmatize the group among people who already don't want the group stigmatized, but as long as there are enough people who continue to want to stigmatize a group, even the new language will (eventually) start to seem like it stigmatizes the group, and the language will need to be changed again.
I'm sure it's more complicated than just this (e.g., there's probably a role for preference falsification, it's easy to imagine the ways in which the act of proposing destigmatizing language would be mocked), but it seems pretty reasonable to me to put the responsibility for stigma on the people doing the stigmatizing rather than the words used to do it.
There are already too many comments on here for anyone to ever read this, but what the hey. What I can determine from use of ctrl-f is that folx have been discussing evolution without plucking the obvious, low-hanging fruit. This will sound sarcastic, but I am serious when I say that:
1) a la Henrich, the real watershed period was when culture-gene co-evolution took off, creating a feedback loop different in kind than with other previous changes due to evolutionary pressure
2) we can solve both the insurance problem and the stigma problem by categorizing everything that our common ancestor with the chimpanzee would not have recognized immediately as ordinary.
3) "but leo, insurance can't pay for the treatment of every single human trait" well no obviously not. But insurance only pays for clinicians to treat people who are in enough distress to seek treatment. If someone is in enough distress because of an excessive tendency towards imitative learning or copious sweating or needing to buy clothes to cover his hairless body, I say treat him -- him and every other person with distress from any human-specific condition.
4) "But leo! Bonobos constantly exhibit homosexual and pedophiliac behaviors! Are you saying pedophilia isn't a mental disorder?" Yeah thos are bonobos. Our common ancestor with chimps would have classified that whole species as a bunch of slutty little weirdos.
I'm going to think about conditions where you become at risk of damage by factors in one's environment which have no significant effect on most people.
" If I understand journalistic ethics correctly, they can’t edit the sentence to remove the Ns"
Journalists have ethics?
Yeah, I can see why this is something Scott needs to be VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY careful about because oh me, oh my.
I'm glad to be sufficiently obscure that I could express an honest opinion and nobody would care because nobody knows me. But starting a fire in the comment thread here is not a good thing to do, so I'll just shut up now.
To be fair to the HiTOP authors, the problem (if it is a problem) of stigma/bias in the DSM isn't one of the big issues they're trying to address. They're more interested in technical problems like the DSM's arbitrary diagnostic cut points etc. I included this because it's a common criticism of the DSM that I believe is partly addressed by HiTOP.
What the HiTOP offers that the DSM doesn't is continuity with ordinary human experience. Anxiety isn't some weird catchable virus, it's something that everyone feels sometimes - it only becomes a problem when it begins to significantly impact a person's life. This perspective is built into the HiTOP, and is why I think it reduces (but doesn't eliminate) the potential for stigma.
That said, I do agree with what you've said here. As long as there's power and/or funding tied to the diagnosis of mental disorders, it can never be a passionless academic exercise. I wasn't around at the time, but my understanding is that the removal of homosexuality from the DSM was largely a social/political decision with a thin layer of scientific backing, not the other way around. The debate about transgender/gender dysphoria seems to be something similar, except that there are actually medical treatments and funding available for people with GD, so no diagnosis might mean no treatment.
Many of these issues are high-level consequences of deeply flawed systems. It's just what happens when post-agricultural primates industrialize the entire goddamn planet. A postmodern society built on false meritocracies and the illusion of scarcity.
> This doesn’t seem especially destigmatizing to me - you’re the wrong gender, but you’re crazy for being unhappy about it?
This is coming from someone who has never read a diagnostic manual, but: one would assume that it's possible to be in so much distress that it constitutes a mental illness, even though you're not crazy and the degree of distress is justified by the circumstances.
Or are mental illnesses usually defined so as to exclude “normal” / “expected” reactions to difficult life experiences?
It's weird how when you read a new book, with new ideas (new to you.) it tends to color all your thoughts for a while. Such is the case with "The Goodness Paradox" which I've almost finished (chapter 12 of 13) One of the main ideas in the book is that humans self-domesticated themselves, and in this case domestication means specifically, being selected for less aggressive behavior. The classic example is silver foxes. https://en.wikipedia.org/wiki/Domesticated_silver_fox Now being domesticated (less aggression) has all these other traits, which get dragged along with it. These are mostly just details of our development process... floppy ears, white spots, smaller heads... And one of the traits is increased sexuality and homosexuality. Huh. I'm not sure this makes any difference to the above discussion, but less aggression and increased sexuality, is just part of who we are.
(This blogger sometimes, for idiosyncratic reasons, inserts a capital 'N' between every word in a sentence. To preserve readability, these 'N's have been omitted from quotations.)
> That means that a purely biological apolitical taxonomy of mental disorders which classifies all things with similar biological causes in the same way would also probably classify homosexuality as a mental disorder. But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!
That is certainly not the whole point of wanting a purely biological taxonomy of mental illness. One point might be (indeed, should be) to try to stop using the same treatment on unlike problems that show similar symptoms (when that treatment is differentially effective). One point might be to inform our views of what we should properly consider a mental illness -- why are we sure that, when the old DSM and the new DSM disagree, the new DSM is necessarily right?
"But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!"
I mean, it wasn't an error, so the apolitical taxonomy would, by definition, not correct this.
My thoughts immediately went to issues like depression and ADHD, which are multicausal, and defined by their symptoms. It's hard to look at something as a proper cause when it is defined as "a collection of symptoms that impede normal function without a single or even any specific known cause".
Agree with the general point, but I don’t think the idea of a purely evolutionary or biological view of human sexuality is that coherent either.
Most of the sex that people actually have is an error if you mean anything that doesn’t directly result in reproduction. A lot of those sex acts could have some indirect evolutionary benefit in the right context, that we'll never be able to prove. Why draw the line at homosexuality and not eg. oral sex? I've read plausible evolutionary benefits for both.
Sex is partly a social thing for humans. (So too for some other social animals, or have I been very mislead on what hyenas and bonobos get up to?) Sex acts are gestures, they have meaning. Those meanings vary widely between cultures, and within cultures there are smaller disagreements.
It seems significant here that autistic people are more likely to be asexual!
When I say that the meaning of sexual acts is social and subjective I'm not saying that it should be anything goes - if someone waves a swastika flag around in public in a western country and their defence is that it meant something positive in India then they’re an edgelord at best. In their own home though, why not? When you’re little if an older kid tells you that showing your middle finger to people means hello and you decide to do it to everyone you meet then you’ll be mortified when you find out what the consensus is on that meaning.
I'm grateful Scott brought this up. Like nearly all the jargon associated with gender ideology, changing the public ideation of homosexuality by changing the DSM was a blatantly political act. Queer Civil Union doesn't have the cache of Gay Marriage. But Pregnant Persons is a bit much.
The question of "purely biological " vs politicized (culturally inflected) concepts of mental disorder was nicely tackled by philosopher/psychologist Jerome Wakefield in his 1992 article "The concept of mental disorder: On the boundary between biological facts and social values" (https://psycnet.apa.org/record/1992-23607-001). Wakefield proposed that in order for a condition to count as a mental disorders it must meet TWO criteria: It must be the result of a biological dysfunction, AND it must be deemed as harmful - and what we deem harmful is inevitably is a matter of social values..
Some conditions may be the result of a dysfunction but, if we agree they are not harmful, under Wakefield's analysis, they are not a disorders.. For instance, homosexuality. Conversely, some conditions may not be the result of a dysfunction, but we agree they are harmful!. These are also not disorders. Surprisingly, an example might be antisocial personality - a very adaptive social strategy that parasitizes social cooperation. We would not find it in a manual of "disorders", but that would not mean we wound not be justified in "treating it" - say, in persuading the sociopath to change.
So, we need three "diagnostic" manuals! :1) A manual of mental conditions that are indeed mental disorders -they are harmful dysfunctions 2) A manual of mental conditions that are mere biological dysfunctions that are not harmful (it may be of scientific interest to classify them somewhere) and 3) A manual of mental conditions that are not dysfunctions, but are harmful - these conditions are of great social interest, and merit "treatment". That is, we are justified in trying to change them.
"That is, we want our definition of “mental disorder” to be ethical (eg not stigmatize people who don’t deserve stigma). And we want it to be practical (eg identify a group of people who need and deserve care). But things that are biologically similar can be ethically and practically different”
After you’ve clearly demonstrated that “mental disorder” is NOT a moral matter, I don’t understand why you aren’t insisting that it is NOT a moral matter, and lobbying your professional organizations to insist the same. That way, people who have “mental disorders” would not be stigmatized.
Moral issues are clearly involved in a subset of “mental disorders” (again, as you have clearly shown), so why can’t they be classified distinctly, as, say, ”harm-inducing mental disorders” or some such? Then only that group will be stigmatized, as wished for.
I think if ya’ll would hold that line long enough, the public would come around.
To me, this seems to be the *easy* part of the demarcation - if it's not a problem for the subject or a problem for society, how can it even be called a disorder? To me, at least, this seems straightforward.
The tricky part is surely the *other* side of this - what issues that *are* a problem for the subject or for society are still not mental disorders?
Example: A pyromaniac who is obsessively unable to keep from starting fires would certainly seem to suffer from a mental disorder. But what about someone who simply loves to see things burn enough that he keeps doing it out of choice even though he could probably refrain from it at a loss of personal satisfaction? Or someone taking revenge on society for imagined slights through repeated arson?
I agree completely, especially with the broader principle that it is important to maintain the distinction between the biological and the moral, but I think a potentially solution to the issue presented of insurance coverage is specifically designating those (fairly few, I would assume) things that experience discrepancies between fitting the biological, practical, and moral definitions of mental illnesses as special cases that get insurance care but without being technically considered a mental illness. I do recognize the massive political and bureaucratic hurdles to such a systems, and the complications of infinitely designating exceptions, so maybe this solution is more ideal than practical. Oh well.
I saw a lecture where the author talked about how "crazy" is culturally defined. But in some cultures we will say people are crazy, in others they will say oh this person is possessed by a demon. Pedal to the metal, both cultures have to deal with someone who isn't fitting in.
We could also just admit, as Thomas Szasz said, that all mental health diagnoses are ethical/moral/political.
Psychiatry is all about labeling "problems in living." They sought to medicalize social problems, to transform political problems into purely technical ones. E.g., children don't like school because it's boring? Call it ADHD. A housewife won't submit to her husband's demands? Call her schizophrenic and give her ECT until she is docile.
The changing treatment of homosexuals by the DSM is just one more example of how psychiatry is defined by ethics, not medical science.
The function of psychiatry has always been to dominate and control those who do not meet society's expectations.
So let's just admit that all mental health disorders are social, political, and ethical, not medical. Just admit that psychiatry is a social science that works in tandem with the police state, not a medical science. Let's call a spade a spade.
Then, we can say that pedophilia is treated differently because of homosexuality because of its ethics.
Humans evolved in small hunter-gatherer groups in competition with other groups of humans for limited resources (food, water and land).
In "good times" -- and by "times" I mean time periods spanning a generation or more -- when resources were plentiful and competition not intense, it was advantageous to have heterosexual offspring who would mate, produce more offspring, found new groups, or join other nearby groups. Surplus resources make the raising and feeding of children practical and sustainable by the group, and expectant mothers would be under conditions of little stress.
But in bad times, when resources were scarce or when competing groups threatened the group, having many babies, children and expectant mothers would be a disadvantageous burden upon a group fighting for survival. Pregnant mothers would be under stress, and that stress would select for homosexual offspring who would be less likely to reproduce and have families of their own, and more likely to become adults free to help care for their siblings, neices, and nephews, or participate in food-gathering or war-making activities on behalf of the group.
Hence, homosexuality is an advantage in groups facing hard times. The group is more likely to survive to see good times in the future thanit would be if burdened by the urges and outcomes of rampant heterosexuality.
Maybe just reconteztualize 'mental illness' as 'sufficient mental and/or emotional suffering to warrant treatment' so we can just move on without stigma.
A fun side effect of your disclaimer: I was curious how bad the sentences were out of context, so I skimmed the post, only read the sentences with Ns and then got distracted and forgot I had this tab open.
Going to read the rest of the article now, though. Definitely won't get distracted this time. Definitely.
"Acting on your desires on someone who doesn't share or can't consent" is a crime. pedophilia is a failure of understanding when your desires shouldn't be acted upon.
It's the same regardless if we're talking about children, animals or grownups that do not consent. We just call it different names.
If it's not helpful to combine Biological and Apolitical, then let's separate into 2 concepts:
- Homosexuality is a Biological disorder that does not Require Treatment
- Pedophilia is a Biological disorder that does Require Treatment
in which, "Require Treatment" come from our society's concensus (aka politic), which come from various considerations such as technical feasilibity to treat the symptom, the cost-vs-benefit to society, the personal freedom of choice etc...
The question is: Whether marking someone as "Require Treatment" stigmatize them?
The big assumption this article is making is that the DSM or HiTOP or whatever we collectively use to understand mental health disorders decides what is a "mental illness" and therefore what is covered by insurance. This is true in the current system — but the article then goes on to say that a biological and apolitical taxonomy of mental health would not be a good thing because of this. Well maybe it is the current system rather than the biological understanding of mental health that is the problem.
You should probably write "NO" all over these parts of text instead of "N". N's just look like a weird gimmick. NO's , taken out of context, hint that you dissaprove of sentences' meaning, which is true for cases when they are quoted poorly.
I doubt I'm the first person on this ball, but no, the premise of this is incorrect. I'm fine with classing homosexuality as a mental disorder. Just note in the description of it that although technically a disorder of targeting, it almost never causes actual distress and that treatment is therefore contraindicated.
EDIT: Also, preventing stigma is a silly and nonsensical ambition to have in general, and particularly in a dry medical text. Anybody can call anything stigmatizing, heeding that is just a way of yielding power to society's whiniest, which I oppose. And if people really are stigmatizing mental disorders, confront that at the social level, not in the diagnostic manual. (If inclusion in the manual is stigmatizing, surely schizophrenia shouldn't be in there either, or bipolar disorder, or...?)
Homosexuality is most *obviously* a mental illness. And it is your cowardice and conformism which prevent frankly admitting it.
This essay (along with the "Gay Rites" one) amount to little more than a brief for perverting politics and science and promulgating lies for progressive ends.
SO many people here are convinced that homosexuality is a evolutionary strategy.
Putting aside the fact that even if it made sense it would still be simply a speculative hypothesis, it in fact makes no sense for two main reasons.
1. A gene that codes for infertile offspring *cannot possibly be selected for*. Genes are selected for when they get replicated successfully. Infertility by definition prevents replication. There is no mechanism for replicating something that prevents replication.
It doesn't matter if gay aunts and uncles help the group overall. It doesn't matter if you share most of your genes with your non-gay family members. Gay kids as a survival strategy *cannot be passed down*. Even if your group benefits, the ones without the gay-kid genes/epigenes will be selected for, meaning that subseuqent generations will be dominated by genes/epigenes which don't code for infertility. Even if the trait helps the group in one generation, it by definition cannot be passed to subsequent generations and therefore cannot be selected for. Even if the whole group benefits from individuals being infertile, the individuals who are most fertile will necessarily be selected for and the strategy dies out after one generation.
2. It doesn't even make sense as an evolutionary strategy!
If gay babies are made due to stress during pregnancy e.g. a famine, it makes sense to have less kids, not less fertile kids. Infertile kids still consume resources, and so this "strategy" is based on a benefit existing 2 generations after the acute stress was experienced by a pregnant mother.
Gay offspring will consume as much resources as non-gay offspring, so there can only possibly be a resource saving benefit in the second generation when the gay offspring aren't having kids.
Not only is this contradictory in that it says resource-consuming gay aunts and uncles are beneficial in one generation but not the next, it also means that it's better to save resource two generations after a mother experiences famine, rather than the first generation which is closest to the famine.
Evolution is not going to reward this weird delayed infertility that does nothing to save resources for an entire generation after an acute stress is experienced.
Why are resource-consuming uncles beneficial in one generation because they help raise other kids, but the next generation suddenly such people would be a resource drain? Why wouldn't kids of their own have the same benefit even though they're consuming the same amount of resources as their parents (except this time, further away from the famine).
Having shorter kids due to malnutrition makes sense, because there's an immediate resource saving that directly INCREASES the likelihood that this short height gene/epigene gets passed on. But a gene for infertility cannot possibly be propagated regardless of how much it helps your group because it is by definition a gene that prevents its own replication.
All of this positively reeks of ideologically driven people desperately looking for a way for homosexuality not to be a disorder or 'mistake'. I have nothing against gays, but I am completely opposed to people proposing incoherent scientific hypotheses because it suits their ideology better than the alternative. I'm not even saying its a deliberate act of dishonesty. I'm just saying that no smart person would engage in such sloppy thinking if their ideology wasn't getting in the way of them seeing things clearly.
What about classifying pretty much everything as a disorder, and leaving the political and insurance problems outside the classification? Would such classification be useless?
By "everything" I mean not just "pedophilia" or "homosexuality", but also any fetishes, and even "having sex not for procreation", or any "being dysphoric in own body".
This post continues Scotts tradition of having jarringly different Ideas about what relationship categories have to truth than me. Scott is of the opinion that categories are just word games and that technocrats should be able to shift their borders are any time to maximize public utility. Being rhetorically gifted as he is he describes this position well. There is no natural force that decides whether whales are fish or some other category so we ought to define fish however this best serves us. It's a difficult position to assail. And yet...
I think firstly that there is such a thing as a natural category. These are things people can intuit about the territory, like canyons etched by the simple combined implications of gravity causing water to flow down hill and precipitation taking that water back uphill. This forms natural borders between things. Creatures capable of flight are an intuitively useful category, people use it for things like determining if a wall is going to keep that creature out. This kind of category cannot and will not bend to our word games. We may call it something different or create new categories that mostly but don't exactly match this category(maybe you'd like to include or exclude insects based on some further need) but the natural category remains.
What people want out of things like the DSM is for it to have as its first goal to reflect a natural category. And there are a few options here, I think whether we pick a natural category that includes or excludes homosexuality is an important debate that could go either way. But it should be about which category to pick, not whether we should shift between different categorical systems from line to line. Because if you're switching up the justifying for inclusion from one definition to the next the actually underlying category is just "Whatever I find expedient" which is a maximally bad fit for a document meant to describe reality. It makes a farse of the whole project and in the end it turns the DSM into just another locus of power in the culture war with no more legitimacy than a piece of paper that says "I do what I want".
I'm very confused. I thought biological and psychological were used as counterpart- and sometimes opposite- terms, where psychological areas are classified primarily by personal accounts and functionality in society even if the underlying biological causes have been partially identified. Given that, what does a purely biological psychological disorder mean?? Doesn't Scott, as a psychiatrist, look at a little checklist ten times a week about how much mental states are effecting the ability to function in day-to-day life to determine level of order or disorder?
Given that, it feels incredibly disingenuous to say "don't quote me out of context for saying these two topics are not functionally different, but also they're not functionally different only politically different." Is there a reason the resulting actions from expressing mental states with or against other people isn't being measured as a type of functionality here? I would think a consensual action that doesn't harm another person could be called more functional than a nonconsensual action that does harm another person & thus results in said person needing mental and/or physical treatment to be well/successful. That's simply a measurement: that's as apolitical as it gets.
(And given this straightforward way of measuring, it makes perfect sense to me to say "severe distress causing depression, discomfort, self-harm, etc. from untreated dysphoria results in low functionality and therefor is a disorder" and "a person that doesn't currently experience severe distress and happens to be wearing a dress doesn't result in low functionality therefor it is not a disorder". That's very simple logic, not some type of mess of caveats.)
This feels like a weirdly unconstructive article for such a charged topic.
The entire idea that any illness should be treated if a treatment exists and no treatment may be done absent an illness, consists of bureaucrats/technocrats trying to force a multi-faceted and complex question into an objective measurement. But no one likes the outcome of any objective measurement, which cannot capture the actual nuances and factors that exist, so then they covertly introduce politics into the objective measurement or slyly use the measurement differently in some cases.
If you look at the legal system, then they are much more sane (than healthcare) by not simply jailing everyone with aberrant behavior, but actually judging the impact on others and the acceptability to society, not based on a 'objective' standard, but based on a standard that is recognized as being political.
Could we not do some magic and label body dysphoria as a bodily disorder rather than a mental one? (If it really is a disconnect btwn mind and body, but -maybe politically- we choose the mind part to be truer?)
I'd still prefer to imagine an ideal body of law with which we can base a taxonomy off of. In that case, the society- gov and moral conscious included- is like the environment for which a trait is best adapted for. I'm really only stuck on this because I'm sad to have to say that concepts can't be organized logically, and let non rationalists win :(.
also, from a collectivist perspective, pedophilia is still much more of a disbenefit if it causes harm to others, unlike queerness. One might respond that evolutionarily it only matters to have an individualist perspective; not so if the gene is spread among the population.
, it clusters with most other mental disorders . So if we are interested in the scientific project of identifying natural kinds, there is an obvious candidate for the meaning of “mental disorder” , that includes homosexuality. Obviously this a verbal dispute and nothing FORCES us to give “mental disorder” this meaning, but it seems like a fairly natural category we’d probably want a name for anyway.
Now, for me, it’s not that classifying homosexuality as a mental disorder is necessarily “stigmatizing”, more that it may come with the presumption that it is somehow irrational not to mind being homosexual, or that if it were possible I would be mistaken in not becoming heterosexual. This is simply mistaken. There is a very wide range of rationally permissible preferences. As long as I don’t have to deal with annoying paternalists who think they know better than me how I should want my mind to be, I don’t really care if people call homosexuality a disorder.
I largely like and agree with this post. I think the post’s comparison of pedophilia and homosexuality is debatable, but plausible, and certainly not unreasonable, and I won’t comment further on it. But I am bothered by the comments—not because many of them advocate ideas that are false, unreasonable, and harmful (though many of them *do*), but rather because they are mostly repeating debates that have already happened at a MUCH higher quality elsewhere, and it sure looks like nobody has mentioned this fact in over 1,000 comments.
VERY well-developed versions of these same debates have already been taking place for DECADES—in fields such as philosophy of medicine, philosophy of psychiatry, and sociology. I’ve skimmed hundreds of comments in this thread, and only a few people have mentioned any of the relevant literature. A few people have mentioned Szasz (though not so much his critics, who are possibly even more important!), and a grand total of one (1) person (singular!) has mentioned Jerome Wakefield, and not much else has been brought up.
I hate people who dismiss everyone else’s ideas by saying “Read the literature!” because this sort of comment is generally condescending and unhelpful. But I’m going to do it. Please read the literature. At least a little bit of it. Or at least become aware that it exists. For starters, I recommend glancing over the following SEP articles—
These articles provide decent overviews of, and extensive sources for, many of the debates being brought up again and again in the comments here. For one thing, look at the section 8 “Values and Mental Disorder” in the “Mental Disorder (Illness)” article. And for more generic discussion that I think can help reduce diseased thinking about disease, there’s also the following—
I don’t mean to endorse all the literature cited in these articles, or the articles themselves, in their entirety. They’re summary overviews with their own biases in what they cover and how they cover it. My point is more that they illustrate how these topics have been discussed extensively and for a long time, and at a high level of complexity—covering a great many topics discussed here, and doing so in a thoughtful and well-developed way. There’s no need to reinvent the wheel alone here. There is a cumulative tradition and set of communities and epistemic practices—resources of arguments, paradigms, theories, and criticisms, for copious object-level and meta-level issues here! There are specialist discourses on these topics that are worth engaging with, replete with useful conceptual distinctions and theoretical arguments which can be examined, adopted, rejected, criticized, and modified, for purposes of enriching the inquiry.
There is also, of course, a lot of meta-level debate over whether physical disorders are basically the same kind of thing as mental disorders, and/or whether we should engage in classification similarly or differently in these two areas.
The most notorious philosopher of mental illness might be Thomas Szasz, who advocates an extreme skepticism about mental disorders altogether. I’m pretty sure Scott is very much an anti-Szaszian. Szasz’s arguments probably don’t successfully apply to some more recent theories of mental disorders, so a lot of his ideas have been superseded. Hanna Pickard (a philosopher and psychotherapist) has defended a neo-Szaszian view in her book-chapter “Mental Illness is Indeed a Myth,” but she still shows that Szasz’s particular arguments and version of his theory were incorrect.
In the rest of this comment, I’ll discuss two anti-Szaszian theories of mental disorder (or disease more broadly, which is related) which I’ll discuss because I’m familiar with them and consider them fruitful to explore to improve the discourse. The first is a unified theory (Jerome Wakefield) which is realist and attempts to track the commonsense concept of disease or disorder. The second is a pluralist and pragmatist theory (Quill Kukla)—which I actually think closely resembles Scott’s revisionary pragmatist account given in “Diseased Thinking: Dissolving Questions about Disease.”
One major theorist is Jerome Wakefield (no relation to the anti-vax guy), known for his “Harmful Dysfunction” Analysis of mental disorder (HDA). (I’m pretty sure Wakefield also thinks the HDA is true of physical disorder, but he focuses mainly on mental disorder.) The HDA attempts to combine the need for a “biological” component (“dysfunction,” here a neutral term for, roughly, a failure of some bodily or mental element to perform its adapted evolutionary function) and a “normative” component (“harm”).
The HDA is supposed to apply to both physical and mental disorders. Wakefield has also compellingly argued that not all mental disorders are identical to, nor caused by, physical disorders. There can be mental disorder without (say) brain disorder. Nevertheless, this does not commit him to any kind of mind-body dualism. It is rather similar to how there can be software malfunctions even in the absence of hardware malfunctions, yet without any metaphysically dubious dualism that would say the software is a soul or anything like that. On this, see Wakefield’s article “Addiction and the Concept of Disorder, Part 2: Is every Mental Disorder a Brain Disorder?”
Not all harmful conditions are medical disorders at all, so something like a “dysfunction” component seems needed. But not all failures to perform evolutionary functions are bad, and (arguably!) it is misleading to call something a mental disorder if it is not at all bad—so something like a “harm” component seems needed. These statements are, of course, controversial.
Still, the HDA, or some variant of it, clearly has the ability to clarify a lot of the confusions that are messing up people’s thinking in some of the comments below Scott’s post—at the very least, by providing a body of empirically informed & logically rigorous argumentation and theory that can provide the basis for further discourse and debate! I think it should also disillusion some people of some beliefs they are highly confident in.
For example, some people in the thread have claimed it is “obvious” that homosexuality is a mental disorder, and that sheer political correctness is the only thing that prevents experts from admitting this fact. But really it is far from obvious that homosexuality is (or isn’t) a mental disorder—insofar as [1] it is far from obvious whether Wakefield’s harmful dysfunction account is correct or incorrect, and [2] it is unclear whether the HDA would imply that homosexuality is a disorder, because [2A] it is unclear whether homosexuality is a “dysfunction” in the right kind of evolutionary way; and [2B] the harm associated with homosexuality is caused by homophobia rather than homosexuality itself, and it is not entirely clear whether Wakefield’s analysis allows or disallows such extrinsically-caused harm to count as the right kind of harm to make a “dysfunction” qualify as a “disorder”.
Of course, the HDA has problems, and there is a lot of debate over it, and many theorists disagree with it. For an extensive recent anthology of chapters by Wakefield and fellow scholars who disagree with various aspects of his theory, see “Defining Mental Disorder: Wakefield and His Critics.” I haven't read much of it yet, beyond the intro chapter, but it looks fantastic and seems to be entirely open-access.
I understand how most of the N'd sentences would sound bad without context, but one stood out to me.
"... it’s N important N for N your N sexual N partners N to N be N able N to N consent." At the very least, this particular clause seems quite safe to quote without context, and overall the whole N'd section prior also seems far more safe than all the other N'd sentences.
Good point on the general principle, but wrong on the specifics. Just as with homosexuality back in the day (pre-Hooker), most research on pedophilia uses hopelessly biased clinical and forensic samples, while statistical analysis of what good data exist shows that in the absence of coercion, negative outcomes are associated with social stigma and condemnation rather than with the contacts/relationships themselves.
Do psychoanalysts still believe homosexuality is a psychological dysfunction?
I suspect nothing will actually stop the NYT taking you out of context. You’ll probably just get something stupider about the Ns being a dog whistle: “Scott Alexander drops N bombs in article comparing pedophilia to homosexuality.”
Yes, this has always been a weird thing about "Born this Way" moral arguments. Each of us is born with certain tendencies we want very much to transcend, some of which would be immoral to indulge. You can't sidestep ethics with appeals to biology.
"the relevant difference between homosexuality and pedophilia is moral, not biological." (edited for clarity) <- I believe this is how you quote it out of context.
N this N was N a N great N post N.
The inserted 'N's make parts of this virtually illegible. Honestly, at this point, does it really make a material difference to you if some media outlet takes something you said out of context, yet again?
Have you ever delved into likely theories of what may driv emale obligate homosexuality? Do you find Greg Cochran's 'germ' theory plausible? https://jaymans.wordpress.com/2014/02/26/greg-cochrans-gay-germ-hypothesis-an-exercise-in-the-power-of-germs/
Oh, but Scott, I do want the taxonomy that correctly identifies mental disorders the way your N'd statements above do. I want that very much. That would be psychology finally getting off its ass and doing something useful. You could have a dual-classification scheme: 1) is this maladaptive in the patient's current environs? and 2) is there reason to think it's biologically maladaptive in the EEA? In the case of your two listed sexual targeting errors, the answer is overall yes to 1 and 2 for both.
Tagged "a post I will regret having written" I assume.
I think in the future you should use a marker other than "N". Having the word "a" surrounded by Ns looks like "N a N" which makes me think of NaN, the floating point number value. And "all N things N" makes me think of a mathematical theorem.
Maybe you can use the Hebrew letter aleph, or one of the weirder Greek letters like the one that's not Zeta?
Fully agreed. Trying to come up with fully biological explanations for human behavior seems to be mostly some kind of "Hard Sciences Fetish", a silly attempt to remove humanness from human behavior. In the end of the day pooping is completely biologically determined, but if you pooped your pants on a board meeting that biological explanation wouldn't go very far.
Scott, any opinion on the rapid rise in teenage girls claiming gender disphoria? It certainly looks like a social contagion.
Since homosexuality pretty clearly is a mental disorder (in addition to the obvious evolutionary mismatch, there's a very high rate of comorbidity with other mental disorders), the problem here seems straightforward. Psychiatry is under the influence of politically motivated activists. As is the rest of the academy. As long as that continues to be the case, squaring the circle of empirical science and politics will be impossible. Indeed as you note, politics and science are intrinsically irreconcilable, so a better way of putting it is: so long as ideologically motivated actors insist on twisting science into pretzels to conform to their preferences about how the world should be, attempts to develop things like biological taxonomies of mental disorders are doomed from the outset.
The solution is quite obvious but a lot of people won't like it.
The DSM at least makes a half-decent attempt at defining mental disorder, RDoC and HiTOP don’t even bother articulating a coherent notion of psychopathology nor do they address the demarcation problem. I am convinced that there is no value-free biological answer to the demarcation problem. I reviewed some of the philosophical issues around this in a journal article “Mental disorder and social deviance” for International Review of Psychiatry: https://www.tandfonline.com/doi/full/10.1080/09540261.2020.1815666 (you can access pdf here: https://www.awaisaftab.com/uploads/9/8/4/3/9843443/aftab___rashed_mental_disorder_and_social_deviance_irp_2021.pdf )
Isn't the main difference that pedophilia is a criminal act if the desire is acted upon?
I don't really understand why homosexuality wouldn't be classified as a paraphilia (aside from influential people who were into it successfully lobbying to have it reclassified). "Can consent and won't be harmed" does not seem to be a consistent delineation between paraphilia and "variants of normal sexuality." Case in point, coprophilia/coprophagia is still classified as a paraphilia in the DSM. "Men kissing men is okay but poop is icky" is hardly a consistent principle. Same case for zoophilia.
If you just optimize for truth and don't get irrationally angry at things you like sharing categories with things you don't like you are able to just wipe all of these downsides away like so much irrelevant screeching. Sure, homosexuality is a mental disorder, it has a clear downside if you would like to have biological children with your preferred partner. It shares a category with pedophilia as well as being unreasonably kind and self sacrificing. This is not a category on the moral dimension.
Optimizing for truth is nice, you spend far less time playing naval gazing word games terrified that the total nonsense you made up so that you could have your cake and eat it too comes back to bite you.
I’m not convinced Twitter is any better for you than meth
Journalist: "We can't edit quotes!" Editor: "We can selectively pick fonts for emphasis and readability! Use a transparent font for N and say that you blipped out the N-word."
The underlying issue is that having a mental disorder doesn't warrant stigma, while having an untreated mental disorder which poses a danger to oneself or others *does* warrant stigma proportional to the likelihood and magnitude of danger posed.
Please go ahead and label things mental disorders that you want to have treated by mental health professionals. Please don't stigmatize any of them any more than is necessary. I recognize that this is a hard problem that we don't and won't agree on the boundaries of. This does not absolve us from making our best efforts.
Have you read the HiTOP proposal? Unless I missed something, the HiTop is not proposing a strictly biologically based taxonomy of mental disorders at all nor is anyone serious.
The DSM and any future taxonomy can effectively distinguish between pedophilia and homosexuality and the other conditions you list with the harm criteria, which requires the presence of distress, impairment in functioning, or involvement of non-consenting victims.
> *takes shot*
> Ctrl+F N
> bring it on
Kudos for this. BTW, companion issue, so to speak:
- Homosexuality: "Born this way" good.
- Gender: "Born this way" bad.
Any comments?
I agree with the thrust of this post, as nicely summarized by Leah Libresco Sargeant in her comment.
That said, if you're concerned about a comparison between homosexuality and pedophilia being taken out of context, it seems prudent to at least to give that comparison a thorough examination. Much has been written on how
some rate of homosexuality may be evolutionarily adaptive, but to my knowledge there is no equivalent corpus for pedophilia. Of course, setting out to prove such a theory would be somewhat taboo, but so was the earlier research on homosexuality - to the extent that it lacked an implicit or explicit condemnation of homosexuals - and yet the work exists. I certainly don't see how sexual targeting of sexually immature individuals could be adaptive.
Not exactly addressing the point, but some thoughts:
If I could use gene editing to modify embryos of my future offspring, I think I would select against every mental disorder if possible.
I think that transgender people and pedophiles have more difficulty lives.
If given the decision between homosexual and heterosexual, I would choose for my offspring to be heterosexual. I think even many homosexuals would do the same, although I’m not certain of that.
If conversion therapy from homosexual to heterosexual were painless and possible, I would think insurance should subsidize it.
I don’t think homosexuality is immoral but I don’t think being anxious and depressed is immoral. It’s just I wouldn’t want to be those things and most people wouldn’t either. It seems to reduce quality of life.
Although this is kind of “word games” of a sort and there aren’t good exact definitions of ordinary language.
In before the hit piece gets written with "Scott Alexander wrote: "from a biological point of view, homosexuality and pedophilia are probably pretty similar. Both are “sexual targeting errors” [letters removed for clarity]."
On a more serious note, are we thinking about mental illness incorrectly? As far as I understand, physical illnesses are *diagnosed* by their symptoms - mental illness are *defined* by their symptoms. [This is because a mental illness is a malfunction of the mind, and the mind is not an organ, but a function.]
It is perfectly cogent to speak of a broken bone that is not causing symptoms, but it would be meaningless to speak of mental illness that is not causing symptoms.
If so, the criterion for "mental illness" should not be the underlying biological cause, but rather a superset of symptoms.
A reasonable candidate seems to be a way of thinking that causes a person harm. A broader definition might be a way of thinking that causes a person or others harm.
A corollary, is that all discrete mental illnesses would be thought of as clusters of symptoms all of which are gradational, rather than binary. Diagnostic criteria would thus be useful for convenience, rather than as observations in a Bayesian framework used to diagnose a physical condition. [e.g. if the "illness" is a broken bone, one could have a list of diagnostic criteria such that it is sufficiently unlikely that someone would have some number of symptoms without the underlying cause of a broken bone. But in the case of mental illness, there is no objective "state of being diseased;" rather, there are experiences / ways of thinking that can be counterproductive and treated.]
A corollary would be that a given behavior could be a mental illness or not, depending on conditions. Perhaps there could have been a time or place in human history where kleptomania would have been a useful trait [assuming the definition that mental illness = detrimental to the sufferer, rather than to others]. There could also be times and places where it is a maladaptive trait.
This would seemingly go against the whole conceptual underpinning of the DSM as I understand it. But it would also probably go against these DSM alternatives, as I understand them.
I don't think it is useful to conflate biology and misfunction for the same reason - it misses the point, which is the impact on the sufferer [and others.] The distinction between e.g. pedophilia, which from a biological perspective could be looked at as an aberration, since it does not facilitate reproduction, and a compulsion to engage in heterosexual rape - not an aberration since it can lead to reproduction seems rooted in the state of affairs under which humans evolved millions of years ago, which seems unhelpful if the goal is treatment. Today, even ignoring the harm to others, being a rapist probably does not make someone any likelier to pass on their genes (as emergency contraception, etc. are available). And let's say some study would find that actually being a rapist increases the probability of passing on genes by 5%, would that be a reason to not treat it as a problem? If one uses the criterion of hurting others, it surely hurts others, genes be damned. And even using the criterion of causing unwanted effects to the sufferer, being a rapist causes all sorts of negative ramifications to the rapist (e.g. increases the chances of him being stuck in prison).
The reader may question this model on the ground that certain "mental illnesses" correlate to genes. E.g. someone with gene X is much likelier to have mental illness X, or vice verse. This fits with the model of the mental illness being an underlying characteristic, and challenges the mental illnesses merely being conveniently clustered symptoms.
However, I think that neither objection is a problem. As far as the first, it may well be that underlying phenomena affect the frequency of certain symptoms. But I think it is still useful to conceptualize the symptoms as distinct from the cause.
More importantly, the existence of correlation between genes and named mental illnesses does not prove that superiority of the "discrete illness" model rather than the "arbitrary but useful symptom cluster model," since we would expect the same effect with an actual arbitrary but useful symptom cluster model!
E.g. if we were to divide the human population into two groups - the worst 2.2% of runners, and the other 97.8% of people, it seems extremely likely that we would find systemic genetic differences between the two populations. That doesn't mean that "WorstTwoPointTwoPercentofRunnersism" represents a meaningful Platonic "syndrome" rather than an arbitrary, if perhaps useful categorization.
[The same could be said for observed differences in fMRI. They can correlate with diagnoses, even shedding light on them, without legitimizing the model of equating mental illness with physical illness.]
Is my way of looking at mental illness a useful model, and have I correctly understood the existing frameworks?
“ If you call something a mental disorder, insurance has to cover treatment for it, which is good.
But if you call something a mental disorder, people will accuse you of trying to stigmatize them, which is bad.”
I kind of think we should just bite the bullet on the second part and say “stigma is bad mmmkay” and get on with it? The first part is much more important anyway, so it should dominate the “is it a disorder?” question. Lots of weird stuff in the brain - the stuff that creates problems for the sufferer or people around them are disorders.
Thus, homosexuality is not a mental disorder, because it requires no treatment - just go be gay. Pedophilia is a disorder because it often needs to be treated or controlled to prevent the afflicted from victimizing children. Gender dysphoria is a mental disorder, because it requires treatment (social and or physical gender transition). I get the urge to not call transgender people “mentally ill” but having already declared “stigma bad, mmkay”, it feels quite natural to say that a transgender person is “an individual who has undergone a successful intervention for gender dysphoria”.
If a thing in your brain will make you want to kill yourself if you don’t intervene, it seems very silly to not call it a “mental disorder”.
Re “This doesn’t seem especially destigmatizing to me - yes, you’re the wrong gender, but you’re crazy for being unhappy about it?”
Unless you’re willing to suggest that someone can be “in” the wrong body, Gregor Samsa style, how can anyone’s gender be wrong _except_ that the person be unhappy about it?
People’s bodies just...are what they are. If you’re a supermodel, you’re probably much more satisfied with your body than the ugliest person on the planet. Maybe the ugliest personal is even dysphoric about his appearance. But is either one of those people “in” the wrong body?
One is hard pressed even to find evidence that “Trans brains are different though.” Not really.
What could “being trans” be, other than a mental state characterized by emotional distress about one’s body? If one were cool with one’s body, one wouldn’t be trans. One would be gender nonconforming, which is arguably emotionally healthier than being “dysphoric” about the body one has.
In any case, emotional distress that disrupts one’s life is squarely in the domain of the mental health professions. So “being trans” (gender dysphoric) makes sense as part of the DSM.
Similarly, the reason homosexuality is not in the the DSM and pedophilia is, is because homosexuality rarely causes anyone any problems in the 21st century. You’re just gay or lesbian, you go along with your life, no mental health assistance needed.
(There probably is the rare gay or lesbian out there who is dysphoric about their sexual preference and who wishes they were straight. That would be something to explore with a mental health professional too, even if there were no specific DSM diagnosis for it.
But if you’re a pedophile, your desires are against the law, and if you’re a decent human, you realize they’re morally wrong too. No decent person wants relations with a partner who can’t consent, so if that’s what they’re wired to want sexually, I suppose this conflict would cause a lot of emotional distress -- again, the domain of mental health.
Maybe I’m missing something, but the distinctions don’t seem very challenging to make?
Is the person experiencing emotional distress that disrupts their life?
But I Do Want A Purely Biological, Apolitical Taxonomy Of Mental Disorders, now I'm pretty unusual in this respect but that's fine with me. I haven't actually read Thomas Szasz but this seems to get at a similar point (he made lots of points) he was making (and maybe Caplan), that is in the public conscious the term mental disorder has been too medicalized that is it carries the same sort of weight/sense as medical disorders as opposed to being explicitly there for pragmatic purposes such as social control. Not sure if this is a correct interpretation of Szasz but I recall him saying something similar in a interview. Personally I think a lot of people conceive of mental disorders in a way similar to evil spirits in the mind (sort of abstract maybe physical like entities, similar in some respects to many Platonist or realist positions in philosophy). I think a lot of people would object to this characterisation but it's the general sense I've gotten looking at people, a good example in my personal life would be when my school counsellor told me that the WHO just classified gaming disorder as a thing (something she and others thought I had), her reaction seemed not to be consistent with the view that the WHO thinks gaming disorder is a new social problem that needs to be tackled or something similar rather her reaction seemed more consistent with the view that the WHO after doing extensive research discovered some part of (or thing in) the brain that proved gaming disorder was a real thing. For her I was not just a child with unusual and perhaps counterproductive habits/preferences rather I had this thing in my mind that had been suspected to exist and had recently been discovered to exist, that needed to be removed/fixed. I should also add that I don't think pedophilia in the contemporary ordinary language meaning of the term is a "targeting error" that is it seems to be not only consistent with but a fairly obvious prediction of evolution by natural selection. Of course with respects to the technical meaning of the term that is, a strong persistent or exclusive sexual attraction to prepubescent individuals, the view that this is a targeting error seems very likely but of course basically no one uses the word pedophile like this and the broadening of the term is only increasing over time.
The DSM doesn't actually categorize pedophilia itself as a mental illness. It instead has Pedophilic Disorder, defined as being pedophilia+they either did something illegal or are distressed about it.
I don't think the solution to the general problem of 'people who need treatment cannot get it paid for by the insurance companies unless what they are suffering from is classified as a mental illness contained in this book of mental illnesses' can be solved by playing Whack-a-Mole and rapidly patching the book to contain each new thing that people turn up in the doctor's office with. If somebody shows up in your office with a compulsion to steal Telsa automobiles and crash them into trees, the proper response isn't 'oops, not in the book', surely?
NYT are going to describe this as you dropping N bombs while comparing homosexuality and pedophilia.
the "this is needed because else health insurance will not cover necessary interventions" is an horrifying kludge on multiple levels.
and proves too much: if a queer got deluded into believing social conservative memes, then treating their distress (with e.g. drugs known to delete libido) would be as justifiable as transgender treatments for dysphoria.
Ever consider letting Alex Anderscott co-write your blog? Last I heard he was hanging out with Tyrone Cowen.
Completely agree with your take, Scott. There are many inconsistencies and absurdities in DSM. Some of the ones that I ruminate about a lot:
One intuitively plausible definition of illness is that it is something that causes the ill person to suffer, and many of the things labelled psychiatric disorders fit that criterion: Anxiety and depression, for instance certainly do. But then how do we think about disorders that do not cause suffering, or at least would not if the individual was allowed to act as he pleases, suffering neither interference nor censure? Homosexuality, pedophilia and in fact all of the paraphilias fall into this category. In fact, is there any reason to think that indulging one’s kink gives less pleasure than vanilla sex gives non-kinksters? Actually, my impression from talking with a lot of kinksters is that their sexual pleasure is unusually intense. It’s as though they’ve found the sexual motherlode. From that point of view, people with sexual kinks are exceptionally high functioning.
How about drug addiction? Seems like that some addictive drugs have quite a pleasant effect, and that people addicted to them would be content and able to function reasonably well if they were supplied with the gradually increasing doses they need to maintain the drug’s effect. Of course using the drug in ever-increasing doses will probably harm their health — but so do the surgeries and drugs required for changing one’s gender.
Should we think of gender dysphoria as a form of Body Dysmorphic Disorder? According to the DSM, surgery to change the defect that preoccupies people with BDD rarely decreases their distress.
Why aren’t the experiences small children have with doctors thought of as being similar to the experiences of sexually abused childen? I don't think I was any more horrified by doctor visits than the average preschooler, but I still have vivid memories of the horrors my pediatrician perpetrated upon me when I was a small child. I was often forced to be naked except for my underpants and felt vulnerable and embarrassed to be seen undressed. And even the underwear usually came off before the end. He stuck things into my ears and nose and throat that really hurt, and the things in my throat also made me gag and feel like I could not breath. He pushed down hard on sore injuries and poured stuff that burned into raw wounds. He jabbed me with spikes in the butt and pushed a glass rod up my butthole. He looked at my genitals. And all the while he acted friendly and plied me with candy and gave explanations for the humiliations and tortures he visited on me that somehow fooled my parents. I truly believe that I would have been less distressed by visits to the pediatrician if the doctor had, instead of doing medical exams and procedures, fondled my genitals and shown me his penis. Of course I do realise that child sexual abuse often includes other toxic elements besides fondling, etc. I am speaking here just about the effects of an adult imposing his will on a child’s body.
It seems that deciding that homosexuality shouldn't be considered a mental disorder to avoid stigma its just as much a political decision as deciding that it is a mental disorder because of stigma. I suspect that some people just assume that an unbiased, apolitical process will just end up confirming their own political commitments because they believe that their own political commitments are unbiased.
" It’s just the claims to be able to avoid political bias in what is vs. isn’t a disorder that I find compelling."
... compelling? Or problematic?
Also, maybe the problem is that 'disorder' has a non-technical meaning. If we just called gender dysphoria a 'potential subject of treatment' or used some clunky term that didn't have a popular meaning and was awkward enough to not seep immediately into the popular lexicon then maybe that would buy us some time.
>We may want to categorize being addicted to meth differently from being addicted to Twitter, even if the neurobiology behind both addictions turns out to be similar, just because meth addicts have the bad luck to be addicted to something that’s really bad for them and for society.
I'm not sure whether the phrasing of this was meant to be subtly darkly humorous or not, but I can't help reading it that way.
What if I want a purely biological, apolitical definition of mental disorders and I'm willing to bite the bullet of calling homosexuality a mental disorder?
Let's assume I don't really care if people are mad at me, I just want to have an accurate and consistent model of the world.
Bravo on the novel anti-out-of-context quote measure, I'm honestly very curious to see how it turns out.
>>To avoid that, I will be replacing spaces with the letter “N”, standing for “NOT TO BE TAKEN OUT OF CONTEXT”. <<
Try "O" instead of "N" (standing for Out) because it looks a little more like a space.
Seems like it is a lot easier just to bite the bullet and say that, yes, homosexuality is a mental disorder, that DSM declassified for political reason. I mean, it is what the history books tell us happened, and homosexuality has strong loadings on mental illness symptoms, so it is rather obvious once you put on the evolutionary psychiatry glasses.
Another curiosity here is that the opposite of pedophilia, gerontophilia, is not in the DSM, despite also being a targeting error. https://en.wikipedia.org/wiki/Gerontophilia In fact, it might be a bigger error when men are doing it, as old women are never fertile and cannot become so, while girls might be, and at least will be at some later point.
>>(a common claim is that the DSM says transgender itself is not a mental disorder, but the distress it produces is. This doesn’t seem especially destigmatizing to me<<
It seems straightforward to me, to understand this as saying that biased public reactions to trans people pruduces stress which is unhealthy.
Outside of psychiatry, there are things covered by medical insurance that do not constitute a disorder. Anything that has to do with birth control or childbirth comes to mind.
Perhaps there should be a way to decouple "should be covered by insurance" from "constitutes a mental disorder"?
(Oh, and nothing will ever prevent people who believe they get to tell everyone what to think from quoting you out of context. Anyone who is happy to lie to get their point across will also think it's OK to misquote.)
The explanation for homosexuality I’ve found most interesting is that the combination of genes and in utero hormone exposure that cause homosexuality at the extreme, lead to higher reproductive success at lower levels. For example, if your goal was to have as many surviving defendants as possible, would you trade a 3% chance of a child being gay if it came with a 6% increase in the rate of your children reaching adulthood - assuming the world that held for most of human history where child mortality was extremely high.
"If you call something a mental disorder, insurance has to cover treatment for it, which is good."
Good for who? Why?
>If this is accurate, the N relevant N difference N between N homosexuality N and N pedophilia N is N moral N, not N biological. Both are sexual targeting errors, but one re-targets sexuality onto other people who can consent and won’t be harmed, so it’s fine. The other targets people who can’t consent and will be harmed, so it’s bad.
The fact that you said this shows that either you didn't even have serious doubts about it or you're just lying. Maybe you lied in order to make people think their way to the truth more efficiently than if you had told the truth, but I don't see how they would, besides by your inviting a tiny number of implausibly courageous souls to object to it.
I don't want to spend too much text telling you how viscerally bad it made me feel that you said this; the sheer hopelessness that overcomes me when I think that you of all people cannot discover, through curiosity or by simply attending to the neurotypically-unspeakable strangeness of the world, the totality of clues on this matter.
How many characters short should my paragraphs be? How many paragraphs per post can I give you that you won't reject them for being too long? Will you just round me off as crazy if I have a mountain of anecdotal clues that humanity is collectively delusional about this topic? If our epistemic institutions and socialization are riddled with incentives to be carelessly misleading, it does not make reality and its clues any less real!
>If I understand journalistic ethics correctly, they can’t edit the sentence to remove the Ns - and if they kept them, people would probably at least wonder what was up.
You don't understand journalism ethics correctly. And again, you're behaving like a quokka. When they quoted you out of context before, they were *intentionally misrepresenting* you. Anything that a layman would call ethics has already been violated. When they say that they didn't change the words, that's an *excuse*; they say that because a ton of people who like to make excuses for journalists will say "sure, they didn't change any words, so they're not lying". (See also, previous Scott article denying that the media lies).
It's conflict theory all the way down. Whether they would remove extra N's is not based on "journalistic ethics"--it's based on "if we removed the N's, and got caught doing so, would there be backlash that inconveniently calls us liars". There won't be such backlash, so the journalists will have no problem removing the Ns.
Should we consider transexuality a physical disorder rather than a mental one?
From my point of view, a transgender person's mind is fine. Their body just doesn't match. That sounds physical, not mental to me.
Perhaps the DSM is the wrong place to define it, and doing so elsewhere would avoid the need for the "this is bad and should be covered by insurance" and "this is not a mental disorder" inconsistency.
I don't think "gender dysphoria is a mental disorder but transgender isn't" is really a contradiction. The two are different conditions - if you successfully transition, you no longer have dysphoria but you're still trans.
Presuming a perfectly biological taxonomy is impossible, how much politics is ok and what are its limiting principles?
I mean, I get it, pure political neutrality is a myth, but on the spectrum between a purely biological taxonomy and a purely political taxonomy, where do we fall and what determines that as we change the taxonomy? Because the logically consistent thing seems to be a political knife fight to the bottom but that's not, yet at least, what I see and biological realities seem to be driving a lot of it. For example, while the exact dividing line on when someone goes from "weird" to "mentally ill" seems pretty socially constructed but people in the midst of a psychotic break are pretty unambiguously "wrong" or "off". At what point on that line, or similar lines, does the biological reality outweigh political considerations, if it does?
Since this post is a can-of-worms-a-thon anyway, shall we open another one? How about "some degree of stigmatization of mental disorders is beneficial for society"?
I see some indications that the pendulum has swung from "mental disorders are bad, having them is a disgrace, we should not talk about them" to "mental disorders are cool and interesting, and we need to announce we have them (even if maybe we actually don't)"... which leads to impressionable young people brainwashing themselves into displaying (and probably feeling) ADHD, PTSD, ASD, gender dysphoria etc - to their own and their families' detriment.
Of course it sucks for someone who genuinely has a mental disorder if society stigmatizes them or doesn't even know what the issue is, but from a utilitarian perspective, if the alternative is to multiply the number of sufferers, maybe it's the lesser of two evils (or we should at least think about finding the optimal middle ground)?
> We may want to categorize being addicted to meth differently from being addicted to Twitter, even if the neurobiology behind both addictions turns out to be similar, just because meth addicts have the bad luck to be addicted to something that’s really bad for them and for society.
...and Twitter addicts don't? (SCNR.)
Can definitely see why you had to put those Ns in! Hope the trick works out for you. On the note of honosexuality being weakly linked to genetics, I thought that was actually quite strong. I remember studying that they found sex-linked genes on the X chromosome that could significantly predict it, also I recall that identical twins have very high chances of being gay if the other is (something like 50%), is that not true?
I think there *is* and we should *strive* for a purely biological, apolitical taxonomy (I'll abbreviate with "pure") possible, but that we will never achieve it. Because humans.
Let's start with a definition of "behavioural disorder": "A disruptive behaviour, causing distress or harm for the patient or their surroundings". So a behavioural disorder is already defined in two different levels: the *individual level* and the *inter-personal level*.
On an _individual level_, we can and should have a pure taxonomy, as it helps an effective therapy of the patient - without some kind of stereotyping, every therapy would start from scratch; having a stereotype (or taxonomy) helps to differentiate possible therapy paths to choose from.
It's also very open to the individual context. A married patient being in love with another person and wanting to marry them can be a distress, no matter if you're living in a country where multi-partner marriages are allowed or not (distress of not wanting to hurt the first partner). Being monogamous but living in a polyamorous group can be as stressful as being polyamorous in a monogamous group. Note that this is still the individual level, because no other person is affected so far - it's just "in the patients head", and they need a way to cope with their own expectations, assessments and distress.
On the _inter-personal level_, it's a lot harder - and this is where it is indeed impossible to get a pure taxonomy. This again can be split into two subcategories: What _society constitutes_ as distressed and harmful for the individual, and what _society constitutes_ to be distressing and/or harmful for other people, where others have to be protected - in extreme cases "for their own good".
The latter first: A woman wearing jeans (and being comfortable and non-distressed about it) can be deemed stressful for the society by some societal power. Or at what age it is appropriate to take mind-altering substances, getting married, join the military (increasing the individual risk of getting killed by a few orders of magnitude!) or have sex... That's as political as it gets and we'll never have a pure taxonomy here for what constitutes as a behavioural disorder or not.
The former subcategory is harder, but it still would be possible to have a _mostly_ pure taxonomy. I agree that we'll never get 100% there, i.e.: At what distress level of gender dysphoria is a life-altering and permanent sex change okay? What security should be build into the evaluation process to ensure, that there is no less invasive way to solve a patients distress - or that the persons evaluating it are being driven by other means (being payed by the institutions performing sex change operations)? At what age do we deem a person capable of that?
As for the "we need taxonomy to decide what needs to be payed by society": that's unnecessary. Having a look at other countries than the U.S.A. with a free healthcare system, a behavioural disorder (on the personal level) is payed for without any taxonomy¹ - e.g. germany. And that's as pure of a taxonomy as it gets - you're in distress (mentally or physically), society should help you (happy workers are less sick and work better and so forth). The opposite part - society does not want to pay for a (ineffective) psychotherapy forever - usually has a process attached (again germany: there's restrictions on how many therapy sessions you can get before they need to be renewed, and after two renewals there's special review protocols, etc. etc.), and that process again will be different from society to society... But still: _taxonomy is not needed for insurance coverage_. That's just _one_ possible solution - and a bad one IMHO.
---
¹ granted, the insurances will be more likely to ask for additional diagnostics, if the therapist applies for a therapy to be covered and only puts down the general category, but they'll have to pay nevertheless.
The most controversial claim here is that a Twitter addiction isn't bad for the person or society 😂
I was under the impression that the DSM was primarily a tool for classifying various psychological ailments, and outlining the different methods of treatment for them. For this functionality, I see no reason why ethics or politics should play a role in the classification. Suppose a homosexual started talking to their therapist because they earnestly wanted to become straight. If there's it turns out that there's no relevant biological difference between homosexuality and pedophilia, wouldn't he be "treated" the same way a pedophile would be treated? What's so bad about having an entry in a mental disorder classification scheme that says so?
I agree that it's good to have a classification of mental disorders that prioritizes ethics and practicality, but I can also see value in having a more wide-ranging taxonomy of mental disorders that covers other ailments that aren't broadly stigmatized by society as "bad things." If people are uppity about the stigma behind the term "mental disorder," I suppose the classification system can refer to its entries as something else.
I have to admit this article was extremely unconvincing for me.
Suppose that there was a substantial minority of politically organized people born one-handed, say, 0.5 percent. Would you think it reasonable if they demand that being born one-handed should not be considered a developmental abnormality because it is not a moral/political issue?
To me, it is obvious that the correct stance towards it would be that it is in fact an abnormality, that this is important because not only they might need specific help for it itself, but developmental abnormalities tend to go together and we'd probably find a number of other abnormalities that this group will disproportionally hold, and they will need support for those, too. Any compendium of developmental abnormalities should clearly include them.
At the same time, we shouldn't morally lambast them for it. Nor should we force help upon them if they don't want it. If someone is fine being one-handed, just let them be. It also makes sense to accommodate them to some degree.
The same obviously applies to mental disorders. Homosexuality is clearly some kind of attraction misfiring. Yes, that means homosexuals will probably hold certain other disorders disproportionally (and there is substantial evidence for this as well). Yes, that means homosexuals need special help and accommodation (the most obvious being that can only have children through adoption or other nonstandard approaches). No, it does not mean we should discriminate them.
As long as we conflate biological and moral/political, we will fail to understand humans fully. That does not mean we should ignore the moral, merely that we should be able to consider them separately. I wouldn't mind separate compendiums for the biological and the moral side, nor if a single compendium would include both but with appropriate labelling. But the current positions where we pretend something isn't a biological disorder because we do not consider it a moral failing is nonsensical.
[Apologies for my bad English] "Scott Alexander did it again. This time he put homosexuality on an equal footing with pedophilia but he has improved his technique: now he asks not to take it out of context by using unintelligible signs between words"
My conclusion: we cannot negotiate with the Cathedral.
Just curious, is "some journalist quoting Scott Alexander on politics" something that happened more than once, that is outside of that incident?
It’s N appalling N you N have N to N do N this.
Congrat's on getting back to posts you'll regret writing. They've been sorely missed.
>So N, should N your N purely N biological N, apolitical N, taxonomy N of N mental N disorders N classify N homosexuality N as N a mental N illness, N or N should N it N refuse N to N classify N pedophilia N as N a N mental N illness?
You just answered your own question: if my taxonomy don't classify H as a mental illness, it's not doing it's job, is being political, and is catering to political needs. That the mental illness is relatively harmless is irrelevant. Palilalia, for instance, is even more harmless, it's still a mental illness.
Addiction is a mental illness as well, be it to crack or to twitter. Even an addiction with beneficial side-effects (Have there been artists who produced masterpieces against their will, unable to stop? Maybe, but we can just fall back on the more grounded workaholic who -in some cases- create a lot more wealth than my lazy ass, and should receive both our gratitude and our help) would be a mental illness.
Refusing to cateforize mental illness as such in order to prevent social stigma seems a great way to end up with mentally ill people uncared for, and still socially shunned precisely because they're uncared-for. In fact I don't really buy that the DSM is driving the loss of social stigma, rather than simply people collectively changing their mind.
And then there's the idea that "it with insurances" line of thought, that's a recipe for disaster, from one side (insurances lobbying to declassify what they don't want to pay for) as from the other (lobbying to classify non-illness in order to get it reimbursed by insurances). You may argue "Psychiatrists & insurers are responsible enough to not have it happen", but this entire post stems from how self-serving & vulnerable you (as in, psychiatrists in general) are to social pressure & will classify or declassify illness according to "well i really want these guys to get reimbursed".
Scott, if you're that worried about being taken out of context, either don't say it or rephrase it to be more innocuous. You're a smart guy, you could just describe homosexuality as a sexual targeting error that doesn't harm anyone, and then in a separate paragraph discuss sexual targeting errors that we object to for moral reasons. At the very least, the amount of ellipses required to stitch together an Out-Of-Context quote would be suspicious.
I think the issue is that you want to write provocative things for impact (which is not a bad thing, it's part of engaging writing), but also don't want them to be taken out of context and used against you, and those are clearly in a trade-off - interspacing letters into the sentence means it loses whatever impact on the reader you were hoping it would have, and I can still paraphrase this article as "While discussing the flaws of a purely biological, apolitical taxonomy of mental disorders, Scott compares homosexuality to paedophilia", because nobody clicks links anyway.
If people want to attack you for political/personal reasons, you've already given them more than enough ammunition, and I don't think it's a great idea to spend however long you continue blogging in fear of your own words being thrown back at you, because they will be anyway.
To steelman the position that transgender is not stigmatised by the DSM: gender dysphoria is caused by the assignment of the gender being wrong, not by the experienced/expressed gender being wrong, and could be prevented by developing a technique for assigning the correct gender (ie the one this person will experience/express as an adult) at birth.
So the fault is not in the person, but they are being driven mentally ill by society and their body not being in alignment with their experienced/expressed gender.
I read the title very literally, and my immediate thought was that the obvious issue with purely biological, apolitical classification is that mental disorders are about how people function within a society, whereas a biological taxonomy would talk in terms of the underlying causes: genes and metabolic pathways and cell damage and head trauma.
I'm sure that, many decades (centuries?) in the future we'll understand enough about how the mind works to construct such a taxonomy, in the same way that we know that "deafness" can be caused by a variety of different genetic mutations, or by aging, or by bacterial infection, or by damage to the inner ear caused by loud sounds. This will be great to know, but the practical implications of this level of understanding for the deaf community seem to be pretty limited - obviously the distinction between being born deaf and progressive hearing loss is significant, but we know that already! I expect that understanding the exact causes of schizophrenia will also be restricted in its impact.
I work in gov't employment agency myself and 20% of my job is assessing if sick people are capable of work. We use the diagnostic system for this too, and things outside it don't practically exist to us, even though the symptoms are really real and hell for people. And that sucks, but we live in a society and if we didn't have it we'd have to make a lot of really complicated decisions and we'd fail hard at that.
Diagnoses inform multiple governmental needs, from care and treatment to identifying beneficiaries of welfare to insurance and actuarial decisions, and they're laden with serious moral/political weight, because they impact people's lives in so many ways.
I do understand the general motivation behind this thinking, but semi-equating "political" with "pragmatic and ethical" less so, and the example with punching bags and kittens completely lost me.
The biology of muscle movements is the same, but the effects are not: one inflicts suffering, the other one doesn't. Now, I understand the argument: "'suffering is bad' is a moral/ethical judgment, and we want to do without those". But is that really true? Why then not go on to claim that pain is, in principle, no different from any other sensory perception? And why the label of "disease" and "disorder"? Heck, what's with all that fuss about "pure biology"? Isn't biology just a man-made and thus political label applied to some physical and chemical processes and phenomena which obey the very same laws as everything else in the universe, "dead" or "alive"? So how could it possibly be pure?
Obviously, this would be a ~wrong~ useless basis for any such taxonomy, or even any conversation about disorders, mental or otherwise. "Disorder" always implies some judgment. I get that this post is fundamentally about how hard it is to decide whether some concrete phenomenon is a disorder or not, but this is not the same as saying "disorder as a concept is meaningless independently of how it is defined", which would be the more consequential position. "Pain and suffering are bad" to me seems like a reasonably minimal assumption to overcome this meaninglessness, and I think it would be fair to grant at least that to the authors without accusing them of politicizing.
If we accept that:
1. biology as a concept makes sense
2. some or all biological organisms have subjective experiences
3. some of those experiences, that we label "pain" and "suffering", are "bad", i.e., we seek to reduce or avoid them
then it becomes fairly easy to distinguish between punching a punching bag and a kitten, or between consensual homosexuality and pedophilia. It's easy to see that one of those actions statistically increases the overall experienced suffering much more than the other.
Scott:
It's probably net-negative for your Substack income to put the Ns in. You've already lost anyone who cares about what the outrage machine thinks; all the Ns do is annoy the people who remain - and either avoid or discourage the people who come here precisely *because* they're defying the outrage machine. Remember, you got a whole pile of new subscribers from that NYT article.
You're on the Blue Tribe's shitlist. Sunk cost. Relish in the freedom to ignore that sunk cost.
How about a less sensitive example: left-handedness. Nobody considers that a disorder, mental or otherwise, today. But when my father was a child, his teachers would slap his hand with a ruler any time they saw him write left-handed. (It worked, sort of: he still prefers to use his left hand when nobody is threatening to slap him with a ruler, but he ended up being ambidextrous.)
So would it be correct to say that left-handedness is not a disorder today, but it was back then, because of the problems of living in a society which did not accept it? Or should we say that no, those teachers were just stupid, left-handedness is not a disorder and it never was.
How about if you lived in a stone-age tribe where it is super important that everybody is able to hunt with a bow and arrow, and all their bows are made to be used right-handed and for some good practical reason it would be super inconvenient if the tribe had to make and maintain a separate left-handed bow just for you? Would left-handedness be legitimately classified as a disorder then?
I don't actually know what point I am trying to make with this analogy -- I just figured it can't hurt to have an example to discuss which doesn't map to a topic that's already a political hot potato..
> It’s just the claims to be able to avoid political bias in what is vs. isn’t a disorder that I find compelling.
There's a "don't" missing from that sentence, isn't there?
Also, I've seen you use "transgender" as a noun on a lot of occasions and that feels weird to me. I don't think I've ever seen it used like that by transgender people themselves; they use it exclusively as an adjective. I'd use "transgenderness", maybe "transgenderism" at a push.
There is a fair amount of sophistry at work here. You are effectively asking to subordinate biological taxonomy to the rules governing insurance policies. I would like to think it would be easier to change insurance rules than biology. If something is harming an individual or others around them ,it needs to be addressed by the society, whether or not it is a biological disorder. Conversely, some biological disorders are harmless and require no treatment.
Linking homosexuality and paedophilia as targeting errors by reference to heterosexuality as a default is a naturalistic fallacy (note that "error" is normative), and even foregoing that, it's a just-so story. Natural selection doesn't require the proliferation of exclusive sex-based attraction targeting in order to guarantee adaptive heterosexual behaviour. And who's to say that there aren't child-rearing and social hierarchy benefits to having population subsets (including grannies) who are not competing for offspring?
In other words, you can't baldly assume that the only adaptive sexual behaviours are ones with the potential to result in conception. That simplification is normally the purview of Bible-thumpers.
Also, even if you don't burden yourself with the worry of thinking through population genetics, the concept of sexual orientation itself is obviously a political construct inherited from categories of modern Western religious persecution, so you can't just load it into a psychological theory and apply evolutionary thinking. It's easier to argue that homosexuality doesn't exist as a biological category at all than it is to conjecture about its evolutionary fitness.
You said meth instead of Twitter as the addiction that's clearly bad for both self and society, but that appears to be backwards.
Is it necessary that these 3 things are all the same?
- being a mental disorder
- getting insurance coverage
- be viewed as a problem to be solved
In an alternative world could we have a DSM that talks about things that are unusual to help with destigmatizing (not just "disorders") and then have some subset get insurance help because they're serious enough? It would be a bigger tent, so people wouldn't feel bad about homosexuality or being trans being included, and whether treatment was covered would be an independent axis.
One of the core problems with the taxonomy of mental disorders is that our conception of a mental disorder involves causing dysfunction for the person within the major areas of what we consider to be living a fulfilling, independent life, and whether a behavioral or thought pattern causes that is intrinsically dependent on the surrounding culture. It can be what causes the dysfunction is societal treatment.
This isn't a novel observation and psychiatry and abnormal psychology try very hard to separate out what appear to be arbitrary cultural factors, but this is a difficult task.
A substance use disorder - a drug addiction if you prefer - is at its root a compulsion to engage in a behavior despite the negative consequences it invites. Addictive chemicals work because their biochemistry has a quirk that allows them to trigger the mammalian reward-motivation pathways in the brain and produces reinforced behavior. The negative consequences part; however, cannot be completely disentangled from societal response to this. Certain substance use disorders are much worse because people will risk severely harmful consequences that the state actively dispenses in response to use.
But suppose a state banned women reading books under threat of long prison sentences. Would women persist in trying to read books despite this penalty? I bet they would. Would this prove that women reading books is a mental disorder because they are compelled to do it despite the negative consequences it invites leading to a loss of global functioning? I think the answer is plainly no, but why that might be is interesting. I think the answers to this question outside of, "Well, we just don't find that legitimate" to be not compelling. You can't escape making moral judgments about what society ought to do and how that interacts with human behavior.
> But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!
Not to Greg Cochran, who says diseases should be conceived of in terms of reducing Darwinian fitness. https://westhunt.wordpress.com/2013/01/06/paternal-age-and-homosexuality/
By that standard, pedophilia is LESS of a mental disorder: https://www.overcomingbias.com/2010/10/pedophiles-are-long-term-maters.html
Isn't the problem here that our current culture derives its morality/ethics in part from the psychological classification system? That seems the fundamental error at play here. People should stop doing that. To develop true ethics you need to actually know how the world is. Classification systems are about learning how the world actually is. Morality/ethical systems are a different thing. I am a short male. This could be considered stigmatizing to me. The culture accepts that as an accurate description despite the danger of stigma. Morally/Ethically everyone pretty much agrees not to be a jerk to me because of my height but we don't feel the need to reclassify me as "normal height-ed" or to avoid using rulers.
What would really be great is clinicians actually being able to diagnose mental conditions, not just guess by symptoms. Maybe MRI will allow this one day, or some technology that hasn’t been invented yet.
My rephrasing of Scott's observation is that tying specific complex instincts/behaviors down to genes is impractical for nature, that nature can either hardcode simple rules which leads to e.g. birds misidentifying their parents, or rely on higher-level cognition filling in the details of a fuzzier idea, which leads to e.g. mistargeting. A few thoughts that lead me to find the idea unsatisfying, despite having a pretty compelling premise.
Caveat emptor: I'm not certain I've entirely pinned down Scott's idea. To avoid accidentally equivocating, let me try to define biological here as a characteristic, or a change in a characteristic, with enough impact on effective reproduction and a solid enough grounding in genetic material that it can ends up naturally selected for or against in a meaningful sense, in a reasonable time-frame. By contrast let define a moral as something that is mostly left up to society by default of nature not biasing it very much one way or the other.
>If this is accurate, the N relevant N difference N between N homosexuality N and N pedophilia N is N moral N, not N biological. Both are sexual targeting errors, but one re-targets sexuality onto other people who can consent and won’t be harmed, so it’s fine. The other targets people who can’t consent and will be harmed, so it’s bad.
Under the sexual targeting error hypothesis, it would seem that homosexuality is not determined biologically, rather something that develops from a different interpretation of our fuzzy instincts and drives.
That there must be environmental causes, before sexual drives are fully developed, that pushes them to unfold in a different way.
1/ Wikipedia estimates a quarter of black swan — Cygnus atratus — couples are homosexual. It describes males as larger, with a straighter and longer bill. Presumably it is not exceptionally hard for natural selection to unearth genes that visibly differentiate male and females, so that I wouldn't expect hacks of the same kind that some species of birds use to recognize their parents to be exceptionally harder when it comes to recognizing potential sexual partners. Pedophilia in nature, or at least in black swans, seems much less notable than homosexuality.
We should expect making females birds instinctively recognizable as sexual partners in DNA to be in the same category of difficulty as than making younglings and parents instinctively recognizable, so instincts being hard is not a compelling explanation for why the sexual-partner-identification instinct would have been pushed to cognition in birds.
2/ But let's assume sexual targeting has a good reason to be pushed to cognition, perhaps because parent recognition is needed from a very early age and needs a hardcoded rule more than sexual targeting does, and I can try to make a different point.
It seems to me that given nontrivial reward, we should still expect natural selection in birds to not have had a great difficulty in unearthing some sort of hardcoded anti-homosexuality distaste in birds, or that the difficulty of conjuring this hardcoded rule should not be much greater in the case of homosexuality than for pedophilia.
If homosexuality and pedophilia are equal and purely moral differences, with no biological basis, all else equal we would not expect the rate of homosexuality in birds to be very much higher than the other. And it seems vaguely reasonable to assume all else is roughly equal, or close enough to not matter too much.
So, it may not be inconsistent to hypothesize that the rate of pedophilia being lower than the rate of homosexuality — at least in birds — could have a biological basis. Possibly, and I may be going out on a limb here, pedophilia bad. To an extent where it would be selected against with categorically more urgency than homosexuality, way upstream of the effect of any moral constructions or culture war topics.
3/ I'd like to hand-wave something about how you may be a little quick to dismiss harm as a biological issue, because trust and social cohesion is good, as we know. If you have to isolate some subgroup of birds from the other birds to avoid scary bad outcomes, maybe this is meaningful to point to in a less subjective sense than purely calling it a moral issue.
4/ Back to talking about people directly, there it makes more sense to me that we would generally have fuzzy instincts over hardcoded rules for picking sexual partners. We have complex societies, what makes a good partner in a human is more complex than in a bird. We've likely greater-or-equal cognitive capacity available for evaluating fuzzy instincts than birds do.
But, it's not clear to me that it should be exceptionally hard to add a hardcoded rule on top of the fuzzy instinct, if that were beneficial. Our fear instinct is fuzzy rather than hardcoded — we can fear complex abstract things at our core, and with intensity — but we also have hardcoded fears on top of that (say the sight of blood, insects, mice), and those vary with considerable individuality!
Here's how I would try to refine the idea of instincts being hard: It is impractical to try to encode firm rules for the selection of sexual partners in DNA, so we have fuzzy rules that are more open to interpretation. In the same way that not everyone has the same instinctive fears, despite fears having a fairly uncontroversial tie back to reproductive fitness, there may exist a set of more specific fuzzy rules to refine sexual targeting. This may be without those rules having to be either entirely hardcoded or entirely open to interpretation.
It is presumably hard to find a genetic correlate for specific instinctive fears, and presumably the same would be true for pedophilia, or homosexuality. Still, there is a real sense in which explaining instincts as untethered from biology doesn't make for a very compelling explanation, regardless of how hard a time we have looking for those ties.
It is possible that pedophilia or homesexuality are natural variations on either the *specificity* of an instinct (in a sort of "openness to experience" sense, perhaps how much an instinct is open to interpretation is itself a variable trait), or more directly variations in strength of components that compose the instincts for sexual preferences.
This variation would still reflect the reality of instincts being hard.
The key factor that puts me in a rage over this subject is the bit about imprinting. Many schools are encouraging experimentation with homosexual acts at an early age -- when the hormones are raging and imprinting is possible.
I used to be a Libertarian, and worked on the campaigns of gay candidates.
The current effort by the alphabet community to imprint children in a gay direction has changed my mind dramatically on the subject. I now miss the Moral Majority and was to bring back sodomy laws. Take this a data point. Helnlein's prediction of Crazy Years followed by a Cromwellian revolution could well happen.
1) I work in the deaf community. Its not just these people do not hear as you would think. Especially if you do not hear from when you were born, you will have hard time to read thw "written language" and visual languge (sign language) will be natural for you. You will very probably be part of "Deaf community" which involves a specific culture and you will have your way of cognitive processing. To feel better, the "Deaf community" uses "D" and not "d" and is holding the idea that "deafness" is not a disease but just a human variety and the reason is prevent others to stigmatize them. At the same time in many countries these people have state half-rent, social help and insurance coverage for various conected problems happily using this (because they are not disabled (they can do everything but do not hear) but they are disabled (they are foreigners in their country - can not communicate with people around them and often also psychiatroc problems are involved...well....not from deafness but from depression that follows it?) You see, it is a perfect parallel to this post.
2) I know there are probably many evolutionists here but actually many astronomers and other field scientists **secretly** believe there is an engineer behind life (or maybe a group of engineers). If so, we are biological machines and it seems we consist of a hardware and software. What is making this more complicated, we can produce (involving a small factory in women to produce other machines) and there is adaptation and other weird mechanisms. Let us say, our friend Elon Musk would miniaturize his factory and place it in a car booth, so the car itself can produce another car. The car would also adapt, evolve to some extent etc. Building would be based on a design plan called MNA (Musk DNA). No one can deny, after some thousands of years, Elon would be capable of constructing such a car (there is just no motivation, where would come the profit from??). Now, these cars start to reproduce, adapt etc and small mistakes show here and there. A car is born without wheels. A car is born with a software for a cattle. Etc. How would you call these? How do we know it was Elon's plan or it is too deviated from his plan? Etc. Let us say, we can not meet with Elon. We just have understand from how the cars look and what they do etc.
> "The authors of these apolitical taxonomies want an incoherent thing. They want something which doesn’t think about politics at all, and which simultaneously is more politically correct than any other taxonomy."
It's not incoherent if their politics is the one good, true politics derived scientifically from nature. In that case, the taxonomy will follow nature, just as the politics follows nature, and each will be aligned perfect with the other without any effort beyond what's required for true knowledge of nature. The one true natural scientific taxonomy will be 100% politically correct, without thinking about politics at all, because the politics is also the one true natural scientific politics.
Reading over that, it sounds to me like I'm being ironic, but I'm genuinely not trying for irony. Lots of people really think that their politics is derived scientifically from nature. And to them, an apolitical taxonomy such as Scott describes here isn't incoherent at all. It's only incoherent under the assumption that their politics isn't the one true natural scientific politics.
Some people look too much to manuals like the DSM to inform their opinion of whether or not something is bad or not. Pedophilia's badness has nothing to do with whether it is in the DSM. Making it a diagnosis makes it something that it is considered appropriate for health care professionals to treat. It's not really even a statement about what kind of thing pedophilia is.
Similarly, in my opinion, some people misinterpret what it means when it is said, e.g. "alcoholism is a disease". They think this is a scientific discovery that we have made about alcoholism that takes it from one category and puts it in another (like discovering that coral is an animal and not a plant). This isn't really true. Saying alcoholism is a disease doesn't mean we have discovered it is just the same kind of thing as influenza or thyroid cancer. "Alcoholism is a disease" means that we consider it is something that is a distinct entity that is appropriately treated by (among other people) health care professionals, who need to make it into a diagnosis because that is how medicine works. Sure, thinking this way is informed by scientific discoveries, but it doesn't depend on them. We could consider alcoholism a disease even if we knew nothing about its etiology or pathophysiology.
Also, sometimes people think that mental disorders aren't as real as somatic ones because they aren't as well defined. However, it is easy to forget that the distress caused by somatic disorders is also subjective, and the distress is actually why people get treatment, not something objective about the disease. Acne is just as clearly a disease, objectively, as cancer (by this I mean it is possible to identify parts of the body that are abnormal), but for a supermodel to have acne is a much greater problem (for the patient) than for some random guy who doesn't care at all.
(Of course, whether or not the DSM actually categorizes mental disorders correctly is another question.)
> a common claim is that the DSM says transgender itself is not a mental disorder, but the distress it produces is. This doesn’t seem especially destigmatizing to me - you’re the wrong gender, but you’re crazy for being unhappy about it? Also, I can’t find support for this distinction in a literal reading of the DSM criteria themselves
The DSM says that there must be evidence of distress about the incongruence between a person's assigned and experienced gender for a gender dysphoria diagnosis. If someone is transgender but does not experience distress, they are not suffering from a mental disorder according to the DSM. I would probably put myself in this category, as a non-binary/agender person who doesn't experience any gender.
I think the same principal should be applied to everything. If a condition doesn't cause distress or impairment to the person who has it, it should not be seen as a mental disorder. This means that I think the definition of mental disorders should be individual rather than political or societal.
A test for whether someone is suffering from a mental disorder could be whether they are experiencing significant distress or impairment, and whether they would still be experiencing significant distress or impairment if they were transported to an alternate universe where everyone was like them. I believe only people where the answer is 'yes' to both questions are suffering from a mental disorder. Perhaps the definition could be made more precise if expanded to take account of whether one condition impairs the ability to feel distressed about something associated with another condition (e.g. a paedophile with ASPD who doesn't feel distress about their paedophilia because of ASPD), but I think even the simplified version makes more sense than any definition that pathologizes dissent to societal norms.
“teleology is a mistress to a biologist: he cannot live without her, but he is unwilling to be seen with her in public”
Fascinating post! I was just these days thinking about exactly this topic.
So, to sum up: if homosexuality and paedophilia are congenital, biological and immutable (as it seems we are supposed to believe these days), yet paedophilia is clearly morally illegitimate, then the fact that a trait is congenital, biological and immutable does not automatically make it morally legitimate (as is the case being made for homosexuality).
On the other hand, if these traits are not congenital nor immutable, that means they are at least partly (mostly?) sociocultural, in which case, whether they are to be encouraged/discouraged become a matter of individual ideology, no?
If something as basic as taxonomy is based on practicality and ethics, rather than science, then is anything about clinical psychology scientific? Are some disorders more scientific than others, schizophrenia perhaps?
What in principle distinguishes therapy from the kind of ethical and practical counseling you might get from a priest or a fortune teller? What justifies the professional licensure of therapists, when we wouldn't dream of licensing priests and fortune tellers? I get that psychiatry is different, you're prescribing drugs, you have to know what's safe, and what might be effective. That's got to be based on evidence. Is therapy really medical or scientific at all? Or is it just talking to someone about your problems?
Hey Scott - I've been thinking this for years and I'm so glad that you've written it out. To discuss this is very taboo.
"Born this way" as a criteria of whether a behavior or identity is moral is an extremely conservative idea. In regard to LBGT identities, for conservatives this criteria was fulfilled by reproductive ability between a pair. Progressive people decided to not question the criteria, but instead cultivated evidence that the brains or early-age behavior of LBGT individuals are different from others, which indicated biological determinism of their identities. So, weirdly, conservatives and many progressives agree on the criteria, and simply disagree on what evidence should used for determining that the criteria are fulfilled.
The truly progressive thing to do would be to question whether this is the right criteria to use. And, its definitely a terrible criteria, because too many undesirable behaviors have biological components, like mental illness and addiction. Honestly, most human behavior is a combination of biological and social inputs, so it feels pretty meaningless to create a dichotomy based on those qualities.
Plus the biological determinism approach to describing LBGT identities has always struck me as sad, because it implies you would be different if you could actually chose, and it undersells the tremendous creative work humans put into developing their identities.
Morality should just be how your actions effect other people and yourself. There shouldn't be a component of fatalism or biological determinism. But a lot of people believe in God, so fatalism and determinism are important to their worldview.
What if we just strictly defined "mental disease" as something that impairs the functioning of the mind or causes distress in the individual with the disease (defined by the individual in question), just as we do for bodily diseases.
Paedophilia N wouldn't N necessarily N be N a N disease by that metric, but that doesn't matter as coercing and punishing people is the job of the justice system, not the health industry.
This would also make clear that psychosis etc on it's own is not a thoughtcrime and does not deserve punishment or a forced cure.
The two choices you present for "purely biological, apolitical taxonomy..." seem clearly delineated, and I think we ought to just choose the 2nd one without any problem. Your language is also very clear: "things which don't deserve stigma", "make everyone mad at you", "have everyone end up thinking you're even more political" (not concerned with the 'truth'; if you had said these things about the conclusions of a physicist, he might say 'why should I care?'). Consistent with this, you are very mindful and careful of the fact that e.g. in (certain) biological terms, homosexuality and pedophilia share a taxonomy, AND you are clear that this is NOT in itself a moral/ethical fact (in particular because each treat the matter of consent differently). The fact alone that you write about this distinction means that there is (at least in your mind) a 'matter of fact' about the taxonomical approach, AND that there is a corresponding social/political/etc. pressure exerting itself regarding this approach. So in the sense that you are arguing against pursuing apolitical taxonomies, you nonetheless appeal to some external biological approach & show that it does not give a complete moral account --i.e. it does not tell us what we ought to do.
You say also "That is, we want our definition of “mental disorder” to be ethical (eg not stigmatize people who don’t deserve stigma). And we want it to be practical (eg identify a group of people who need and deserve care)."... In the first sense, what I am asking is 'why can't we have a non-ethical taxonomy?' Obviously, there is no need to ask this question in spheres of thought which don't concern the (practical) affairs of human lives. And obviously the possibility of "stigmatiz[ing] people who don't deserve stigma" is the reason we want to be "ethical". However, let's be good analysts and forget all the nice and pleasant work "being ethical" is doing for us here: ""[t]hat is, we want our definition of “mental disorder” to ... not stigmatize people who don’t deserve stigma". So now we can see the operation of this sentence properly. But in the sense of answering the question about a taxonomy and its definitions, it still is difficult to see how the former part relates to the latter. Turn to your fellow mathematician and tell him you want his definitions not to stigmatize people who don't deserve it.
(1) -- Our definitions are erroneous, people who do not need to be 'cured' are labelled as in-need-of a cure. (But don't we think this problem can be solved within the scientific framework?)
(2) -- Our definitions are _correct_, in that the delineate without much error treatment-wise, but outsiders make use of our terms in a moral sense and cause harm to those our definitions concern.
If we were talking about (1) the actual meaning of the quoted sentence (avoiding creating stigma) is that we ought to censor scientific work -- which then represents the meaning of "being ethical".
So since we are probably talking about (2), what if we replaced "mental disorder" with some distant and cold terminology bereft of meaning? After all, its purpose is only to delineate "in need of cure" from "does not need medical treatment". (And perhaps now we see that the symbol isn't so relevant as the fact that we have the "sick" and the "healthy".)
No: stimga, stigmatizing... These are not what is at stake, here. What is at stake is treating those who do not need treatment. In the case of homosexuality and its perception, what has changed is that it was once indistinguishable from 'unhealthy', 'sick'. The fact that this was overcome is their main victory.
There is a good debate (https://sounds.bl.uk/Arts-literature-and-performance/ICA-talks/024M-C0095X0856XX-0100V0) involving Paglia here, and Watney here attacks her (around 45:30 mins, if you can bear it) & the British government etc. for a lack of education and spending in healthcare for gay men. The point is that it doesn't matter how massive a disaster the HIV/AIDS pandemic was/is, the government(s) are totally responsible for it because they are assumed to have the power to effectively prevent it. Without the condition of responsibility, one cannot be held morally responsible; hence the pandemic has to be within the government's power. Similarly, here, the one addressed by my moral speech designates the responsible one. The diagnostic methods, and all the structures by which the doctors abide, are precisely what allow us to make the doctors and the medical world accountable for all the sufferings we can throw at them.
What I want to say is that already we live in a culture which designates the medical approach to mental issues, or issues of the behaviour rather than the physical; when a suffering is easy to see (heroin addiction) we can trust the medical response, but in nearby cases (Twitter addiction, infamous deaths playing video games, where we cannot literally see the needle going into the arm or whatever) we cannot, because the ethical system decides first. Likewise the issue at hand for mental health is not "you are stigmatizing me," and so on, but "you are not offering me the cure to my condition which I demand".
We are now more than ever in need of explicit, cold, taxonomy, but already by the title of this article we can feel how the medical establishment is somewhat defeated by this goal .. "can we really practice today the science of mental disorder, when already we inherit so many mistakes and biases, my god...". If there is this entity, taxonomy, which speaks to us from some scientific perspective, which places demands and limitation upon us morally, OK then we ask the question: to what extent ought we to obey it, blah blah.. but THAT question is moral, and relies on taxonomy practicing freely (which is to say non-ethically). To say again what I am saying: either we have (as this article seems) given up on being able to practice taxonomy for fear of saying something dangerous (note the special care this article pays to being misquoted), OR we believe that taxonomy is possible, is clear, but is nonetheless itself dangerous... in which case I am pessimistic about my next doctors appointment, when he already will tell me exactly what I want to hear..!
Ah - the weight of proper classification in a social-political lodestone. Reminds me of the uncertainly principal in that the more closely we attempt to define one aspect, tge more slippery the rest becomes. I N did N chuckle N at N your N solution.
So, the question boils down to: How can we get groups that we like everything that they want and nothing that they don't? How can we consider these surgeries and treatments medically necessary, non-elective when there is nothing medically wrong with these people and we don't want to say that there is something wrong with them mentally?
I feel very uncomfortable in this middle aged out of shape body. I identify as young and athletic. Why won't you pay for my surgeries?
No matter how afraid you all are of the dudes in skirts you eventually have to tell them that if they eat their cake it ain't still on the counter.
Isn't the obvious solution simply to consider whether the condition causes harm to oneself or others? If it does, then it's a disorder. If it doesn't, then it isn't.
This would exclude homosexuality but include gender dysphoria due to it's high incidence of suicide, and pedophilia due to the mental distress and possibility of child molestation.
I read all the "N"s as clapping emojis, and that made this much more fun!
All rants against "politicizing" are hypocritical. The speaker wants to make his own political assertions, then preemptively prohibit counterargumentation.
Substack drinking game: take a shot every time a flood of transphobes show up in the comments
Can we all agree that twitter is just as bad for individuals and society.. lol
You know, you could just rename it "Taxonomy of Human Psychologies," without any implication that some genera are bad and some good, and all the PR problems would go away. Can't see how the insurance industry would care either, they just need a number to write down on a form somewhere.
This seems to me like a psychiatrist/psychologist guild own goal, and that you can solve the problem any time you like. One assumes it suits the field somehow to keep the contraversy alive and periodically visibly fret about it.
You've convinced me that I do want a purely biological, apolitical taxonomy of mental disorders. Sorry for all the people in the world who feel stigmatized, but it sounds really useful.
Regarding the "pedophilia as a sexual targeting error" debate: I recently read an article about a man dating an adult woman who looks like a small child, and it's caused an enormous amount of controversy and heated debate. (https://nypost.com/2023/01/23/im-dating-a-23-year-old-woman-who-looks-like-an-8-year-old-girl/) On one side, there are people saying that he's not doing anything wrong, since she's a consenting adult. This is obviously true in the legal sense (he hasn't committed any crime) and in a consequentialist moral sense (she's a consenting adult of sound mind, so there's no harm being done to her). On the other side, there are people arguing that having a romantic and sexual attraction to someone who looks like a child is a sign of innate pedophilic desires. So even if he's not breaking the law or hurting anyone directly, they still consider him a pedophile at heart, which is effectively synonymous with "bad person" in their eyes. Maybe they think he's more likely to pursue actual children in the future, maybe they just think it's gross. Then there are counter-arguments from disability activists, who say that expecting this woman to be totally celibate because of her appearance is extremely unfair to her; if you condemn anyone who has sex with her, that's functionally the same as saying she shouldn't be allowed to have sex at all, which amounts to severe discrimination against someone with a medical abnormality.
Now, I strongly disagree with the idea that this guy must secretly be a pedophile. He's had prior romantic relationships with physiologically-normal adult women, and there's zero evidence that he's ever shown any sort of sexual interest in children. I think there's a very good chance that he isn't actually attracted to childlike bodies at all, he just happened to develop a relationship with this particular woman and was willing to look past her physiological abnormalities. But even if he was specifically attracted to her body type in particular, I still don't think he'd be a pedophile, because pedophilia is "attraction to children," not "attraction to adults with childlike bodies." Classifying him as a pedophile would be a category error or, at most, an example of the non-central fallacy (https://www.lesswrong.com/posts/yCWPkLi8wJvewPbEp/the-noncentral-fallacy-the-worst-argument-in-the-world). He'd be more comparable to disability fetishists, like the sorts of people attracted to amputees. And while disability fetishists are considered very weird, and sometimes seen as off-putting or socially problematic, they still aren't viewed as inherently sick or evil the way that pedophiles are.
I don't think that "sexual targeting errors" should ever be considered a mental illness in themselves, especially because it's not entirely clear what even counts as an "error." While we don't know for sure yet, there's some evidence that homosexuality is evolutionarily advantageous to the homosexual's family and tribe, in which case it's not an error at all. And even if that theory turns out to be false, there are major problems with the idea that any preference for non-reproductive sex constitutes a mental illness. If homosexuality is a mental illness, then what about a straight person with a fetish for oral or anal sex? What about a man exclusively attracted to older woman who are no longer fertile? Should the DSM include a category for men who browse the GILF category on PornHub? The reasons why pedophilia should be considered a mental illness go well beyond any issues with "sexual targeting," and for some (possibly many) pedophiles, it seems to be a largely or purely pathological issue that might have nothing to do with sexual targeting at all.
I think Necrophilia is another interesting example, where there isn't even as big a consent problem, but it's still taboo.
Szasz. His book on my shelf. At the end of this article the author makes a very odd – not at all the prediction one would make from all that came before in said article – where what he would, if consistent, see as socio-economic conditions. It is worth th read. I recommend it.
https://www.psychologytoday.com/us/blog/freud-fluoxetine/201806/revisiting-szasz-myth-metaphor-and-misconception
New York times article from 2025:
In the past, Alexander wrote a controversial piece on homosexuality and mental illness. In this article, he obscures his meaning with a strange code to protect himself from public scrutiny. According to a leading Alexander scholar, Emile Torres, the decrypted version is the following:
On the point about not wanting to be taken out of context, I can see the comparison you wanted to make and don't misunderstand it, even though I think it doesn't have a sound basis in fact or logic. But I also think it's fair for readers to look at the way you pieced things together as either wreckless (which goes against your stated caution) or wilfully provocative.
At the very least, you might have made a distinction between paedophilia and sexual attraction to children, seeing as your argument is completely centred on mental experience and not actual sexual behaviour, criminal or otherwise. The fact that the word 'paedophile' is strongly associated with criminal behaviour, setting aside any paltry excuses about etymological literalism, and yet you didn't attempt any such distinction means that you just reached for a ready-made obscene parallel drawn by bigots and want to lay the blame for easy misreadings elsewhere.
Was it because of laziness or because you wanted to be misread? I don't know. But it's pretty clear that this wasn't the only succinct way of putting things and I was surprised at the (faux?) naivete regarding media ethics. This is not an example of clear critical thinking.
This is probably something that others have thought of and that has been articulated and more fully fleshed out elsewhere, but while reading this, something clicked for me about why efforts to change language in order to avoid stigmatizing a group have always seemed misguided to me.
The core issue is that a group gets stigmatized primarily because some people want to stigmatize the group, and only secondarily because of the language used to refer to or describe the group. Changing the language used to refer to a group will only help destigmatize the group among people who already don't want the group stigmatized, but as long as there are enough people who continue to want to stigmatize a group, even the new language will (eventually) start to seem like it stigmatizes the group, and the language will need to be changed again.
I'm sure it's more complicated than just this (e.g., there's probably a role for preference falsification, it's easy to imagine the ways in which the act of proposing destigmatizing language would be mocked), but it seems pretty reasonable to me to put the responsibility for stigma on the people doing the stigmatizing rather than the words used to do it.
There are already too many comments on here for anyone to ever read this, but what the hey. What I can determine from use of ctrl-f is that folx have been discussing evolution without plucking the obvious, low-hanging fruit. This will sound sarcastic, but I am serious when I say that:
1) a la Henrich, the real watershed period was when culture-gene co-evolution took off, creating a feedback loop different in kind than with other previous changes due to evolutionary pressure
2) we can solve both the insurance problem and the stigma problem by categorizing everything that our common ancestor with the chimpanzee would not have recognized immediately as ordinary.
3) "but leo, insurance can't pay for the treatment of every single human trait" well no obviously not. But insurance only pays for clinicians to treat people who are in enough distress to seek treatment. If someone is in enough distress because of an excessive tendency towards imitative learning or copious sweating or needing to buy clothes to cover his hairless body, I say treat him -- him and every other person with distress from any human-specific condition.
4) "But leo! Bonobos constantly exhibit homosexual and pedophiliac behaviors! Are you saying pedophilia isn't a mental disorder?" Yeah thos are bonobos. Our common ancestor with chimps would have classified that whole species as a bunch of slutty little weirdos.
I agree with your analogy.
I need to think this through.
I'm going to think about conditions where you become at risk of damage by factors in one's environment which have no significant effect on most people.
" If I understand journalistic ethics correctly, they can’t edit the sentence to remove the Ns"
Journalists have ethics?
Yeah, I can see why this is something Scott needs to be VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY VERY careful about because oh me, oh my.
I'm glad to be sufficiently obscure that I could express an honest opinion and nobody would care because nobody knows me. But starting a fire in the comment thread here is not a good thing to do, so I'll just shut up now.
Hey Scott, thanks for sharing my post!
To be fair to the HiTOP authors, the problem (if it is a problem) of stigma/bias in the DSM isn't one of the big issues they're trying to address. They're more interested in technical problems like the DSM's arbitrary diagnostic cut points etc. I included this because it's a common criticism of the DSM that I believe is partly addressed by HiTOP.
What the HiTOP offers that the DSM doesn't is continuity with ordinary human experience. Anxiety isn't some weird catchable virus, it's something that everyone feels sometimes - it only becomes a problem when it begins to significantly impact a person's life. This perspective is built into the HiTOP, and is why I think it reduces (but doesn't eliminate) the potential for stigma.
That said, I do agree with what you've said here. As long as there's power and/or funding tied to the diagnosis of mental disorders, it can never be a passionless academic exercise. I wasn't around at the time, but my understanding is that the removal of homosexuality from the DSM was largely a social/political decision with a thin layer of scientific backing, not the other way around. The debate about transgender/gender dysphoria seems to be something similar, except that there are actually medical treatments and funding available for people with GD, so no diagnosis might mean no treatment.
Many of these issues are high-level consequences of deeply flawed systems. It's just what happens when post-agricultural primates industrialize the entire goddamn planet. A postmodern society built on false meritocracies and the illusion of scarcity.
/grumblegrumble
> This doesn’t seem especially destigmatizing to me - you’re the wrong gender, but you’re crazy for being unhappy about it?
This is coming from someone who has never read a diagnostic manual, but: one would assume that it's possible to be in so much distress that it constitutes a mental illness, even though you're not crazy and the degree of distress is justified by the circumstances.
Or are mental illnesses usually defined so as to exclude “normal” / “expected” reactions to difficult life experiences?
It's weird how when you read a new book, with new ideas (new to you.) it tends to color all your thoughts for a while. Such is the case with "The Goodness Paradox" which I've almost finished (chapter 12 of 13) One of the main ideas in the book is that humans self-domesticated themselves, and in this case domestication means specifically, being selected for less aggressive behavior. The classic example is silver foxes. https://en.wikipedia.org/wiki/Domesticated_silver_fox Now being domesticated (less aggression) has all these other traits, which get dragged along with it. These are mostly just details of our development process... floppy ears, white spots, smaller heads... And one of the traits is increased sexuality and homosexuality. Huh. I'm not sure this makes any difference to the above discussion, but less aggression and increased sexuality, is just part of who we are.
(This blogger sometimes, for idiosyncratic reasons, inserts a capital 'N' between every word in a sentence. To preserve readability, these 'N's have been omitted from quotations.)
> That means that a purely biological apolitical taxonomy of mental disorders which classifies all things with similar biological causes in the same way would also probably classify homosexuality as a mental disorder. But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!
That is certainly not the whole point of wanting a purely biological taxonomy of mental illness. One point might be (indeed, should be) to try to stop using the same treatment on unlike problems that show similar symptoms (when that treatment is differentially effective). One point might be to inform our views of what we should properly consider a mental illness -- why are we sure that, when the old DSM and the new DSM disagree, the new DSM is necessarily right?
"But the whole point of wanting a purely biological apolitical taxonomy of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!"
I mean, it wasn't an error, so the apolitical taxonomy would, by definition, not correct this.
My thoughts immediately went to issues like depression and ADHD, which are multicausal, and defined by their symptoms. It's hard to look at something as a proper cause when it is defined as "a collection of symptoms that impede normal function without a single or even any specific known cause".
Agree with the general point, but I don’t think the idea of a purely evolutionary or biological view of human sexuality is that coherent either.
Most of the sex that people actually have is an error if you mean anything that doesn’t directly result in reproduction. A lot of those sex acts could have some indirect evolutionary benefit in the right context, that we'll never be able to prove. Why draw the line at homosexuality and not eg. oral sex? I've read plausible evolutionary benefits for both.
Sex is partly a social thing for humans. (So too for some other social animals, or have I been very mislead on what hyenas and bonobos get up to?) Sex acts are gestures, they have meaning. Those meanings vary widely between cultures, and within cultures there are smaller disagreements.
It seems significant here that autistic people are more likely to be asexual!
When I say that the meaning of sexual acts is social and subjective I'm not saying that it should be anything goes - if someone waves a swastika flag around in public in a western country and their defence is that it meant something positive in India then they’re an edgelord at best. In their own home though, why not? When you’re little if an older kid tells you that showing your middle finger to people means hello and you decide to do it to everyone you meet then you’ll be mortified when you find out what the consensus is on that meaning.
"We have to classify pedophilia as a mental illness, because we want insurance to pay for treatment"
Scott, most insurance payers including Medicare and Medicaid exclude paying for treatment of pedophilia. People have to self pay.
I'm grateful Scott brought this up. Like nearly all the jargon associated with gender ideology, changing the public ideation of homosexuality by changing the DSM was a blatantly political act. Queer Civil Union doesn't have the cache of Gay Marriage. But Pregnant Persons is a bit much.
The question of "purely biological " vs politicized (culturally inflected) concepts of mental disorder was nicely tackled by philosopher/psychologist Jerome Wakefield in his 1992 article "The concept of mental disorder: On the boundary between biological facts and social values" (https://psycnet.apa.org/record/1992-23607-001). Wakefield proposed that in order for a condition to count as a mental disorders it must meet TWO criteria: It must be the result of a biological dysfunction, AND it must be deemed as harmful - and what we deem harmful is inevitably is a matter of social values..
Some conditions may be the result of a dysfunction but, if we agree they are not harmful, under Wakefield's analysis, they are not a disorders.. For instance, homosexuality. Conversely, some conditions may not be the result of a dysfunction, but we agree they are harmful!. These are also not disorders. Surprisingly, an example might be antisocial personality - a very adaptive social strategy that parasitizes social cooperation. We would not find it in a manual of "disorders", but that would not mean we wound not be justified in "treating it" - say, in persuading the sociopath to change.
So, we need three "diagnostic" manuals! :1) A manual of mental conditions that are indeed mental disorders -they are harmful dysfunctions 2) A manual of mental conditions that are mere biological dysfunctions that are not harmful (it may be of scientific interest to classify them somewhere) and 3) A manual of mental conditions that are not dysfunctions, but are harmful - these conditions are of great social interest, and merit "treatment". That is, we are justified in trying to change them.
I would suggest there is a biological difference between homosexuality an paedophilia.
First, I think everyone is a little bit gay - or put better, humans are on a continuum of sexual attraction between homo and hetero.
I would go further and say that all women are essentially bisexual.
I don't think that everyone is a little bit paedophile.
Also, while homosexual attraction is biologically sub-optimal at the individual level, some have theorised that it had benefits at the group level.
There is no such benefit of paedophilia.
I don't think that homosexual attraction is just a case of incorrect sexual imprinting.
"That is, we want our definition of “mental disorder” to be ethical (eg not stigmatize people who don’t deserve stigma). And we want it to be practical (eg identify a group of people who need and deserve care). But things that are biologically similar can be ethically and practically different”
After you’ve clearly demonstrated that “mental disorder” is NOT a moral matter, I don’t understand why you aren’t insisting that it is NOT a moral matter, and lobbying your professional organizations to insist the same. That way, people who have “mental disorders” would not be stigmatized.
Moral issues are clearly involved in a subset of “mental disorders” (again, as you have clearly shown), so why can’t they be classified distinctly, as, say, ”harm-inducing mental disorders” or some such? Then only that group will be stigmatized, as wished for.
I think if ya’ll would hold that line long enough, the public would come around.
To me, this seems to be the *easy* part of the demarcation - if it's not a problem for the subject or a problem for society, how can it even be called a disorder? To me, at least, this seems straightforward.
The tricky part is surely the *other* side of this - what issues that *are* a problem for the subject or for society are still not mental disorders?
Example: A pyromaniac who is obsessively unable to keep from starting fires would certainly seem to suffer from a mental disorder. But what about someone who simply loves to see things burn enough that he keeps doing it out of choice even though he could probably refrain from it at a loss of personal satisfaction? Or someone taking revenge on society for imagined slights through repeated arson?
I agree completely, especially with the broader principle that it is important to maintain the distinction between the biological and the moral, but I think a potentially solution to the issue presented of insurance coverage is specifically designating those (fairly few, I would assume) things that experience discrepancies between fitting the biological, practical, and moral definitions of mental illnesses as special cases that get insurance care but without being technically considered a mental illness. I do recognize the massive political and bureaucratic hurdles to such a systems, and the complications of infinitely designating exceptions, so maybe this solution is more ideal than practical. Oh well.
I saw a lecture where the author talked about how "crazy" is culturally defined. But in some cultures we will say people are crazy, in others they will say oh this person is possessed by a demon. Pedal to the metal, both cultures have to deal with someone who isn't fitting in.
Just a heads up, I am not sure that your N trick will work. 'Most reporters and editors see no harm in “cleaning up” quotes.' E.g. see https://ethicscasestudies.mediaschool.indiana.edu/cases/handling-sources/the-great-quote-question.html#:~:text=Most%20reporters%20and%20editors%20see,in%20%E2%80%9Ccleaning%20up%E2%80%9D%20quotes.
Also in law, it is now ok to use (cleaned up) syntax after cleaning up a quote https://k-glaw.com/blog/the-cleaned-up-parenthetical-a-new-way-to-tackle-ungainly-citations/#:~:text=But%20%E2%80%9Ccleaned%20up%E2%80%9D%20basically%20means,distracting%20them%20with%20the%20irrelevant.
We could also just admit, as Thomas Szasz said, that all mental health diagnoses are ethical/moral/political.
Psychiatry is all about labeling "problems in living." They sought to medicalize social problems, to transform political problems into purely technical ones. E.g., children don't like school because it's boring? Call it ADHD. A housewife won't submit to her husband's demands? Call her schizophrenic and give her ECT until she is docile.
The changing treatment of homosexuals by the DSM is just one more example of how psychiatry is defined by ethics, not medical science.
The function of psychiatry has always been to dominate and control those who do not meet society's expectations.
So let's just admit that all mental health disorders are social, political, and ethical, not medical. Just admit that psychiatry is a social science that works in tandem with the police state, not a medical science. Let's call a spade a spade.
Then, we can say that pedophilia is treated differently because of homosexuality because of its ethics.
I wrote a reply to this saying that Scott should bite the bullet. https://kirkegaard.substack.com/p/homosexuality-is-a-mental-illness
Homosexuality is not a mistake. It is an evolutionarily advantageous adaptation.
People are born homosexual in response to prenatal stress hormones while they were in their mother's wombs. (https://en.wikipedia.org/wiki/Prenatal_hormones_and_sexual_orientation)
Humans evolved in small hunter-gatherer groups in competition with other groups of humans for limited resources (food, water and land).
In "good times" -- and by "times" I mean time periods spanning a generation or more -- when resources were plentiful and competition not intense, it was advantageous to have heterosexual offspring who would mate, produce more offspring, found new groups, or join other nearby groups. Surplus resources make the raising and feeding of children practical and sustainable by the group, and expectant mothers would be under conditions of little stress.
But in bad times, when resources were scarce or when competing groups threatened the group, having many babies, children and expectant mothers would be a disadvantageous burden upon a group fighting for survival. Pregnant mothers would be under stress, and that stress would select for homosexual offspring who would be less likely to reproduce and have families of their own, and more likely to become adults free to help care for their siblings, neices, and nephews, or participate in food-gathering or war-making activities on behalf of the group.
Hence, homosexuality is an advantage in groups facing hard times. The group is more likely to survive to see good times in the future thanit would be if burdened by the urges and outcomes of rampant heterosexuality.
Maybe just reconteztualize 'mental illness' as 'sufficient mental and/or emotional suffering to warrant treatment' so we can just move on without stigma.
Diagnosis: Human
It’s weird that you didn’t talk more about the car real potential of psych diagnoses: “you’re crazy, so you shouldn’t be heard” is a potent argument.
A fun side effect of your disclaimer: I was curious how bad the sentences were out of context, so I skimmed the post, only read the sentences with Ns and then got distracted and forgot I had this tab open.
Going to read the rest of the article now, though. Definitely won't get distracted this time. Definitely.
pedophilia N is N not N a N mental N disorder.
"Acting on your desires on someone who doesn't share or can't consent" is a crime. pedophilia is a failure of understanding when your desires shouldn't be acted upon.
It's the same regardless if we're talking about children, animals or grownups that do not consent. We just call it different names.
If it's not helpful to combine Biological and Apolitical, then let's separate into 2 concepts:
- Homosexuality is a Biological disorder that does not Require Treatment
- Pedophilia is a Biological disorder that does Require Treatment
in which, "Require Treatment" come from our society's concensus (aka politic), which come from various considerations such as technical feasilibity to treat the symptom, the cost-vs-benefit to society, the personal freedom of choice etc...
The question is: Whether marking someone as "Require Treatment" stigmatize them?
The big assumption this article is making is that the DSM or HiTOP or whatever we collectively use to understand mental health disorders decides what is a "mental illness" and therefore what is covered by insurance. This is true in the current system — but the article then goes on to say that a biological and apolitical taxonomy of mental health would not be a good thing because of this. Well maybe it is the current system rather than the biological understanding of mental health that is the problem.
You should probably write "NO" all over these parts of text instead of "N". N's just look like a weird gimmick. NO's , taken out of context, hint that you dissaprove of sentences' meaning, which is true for cases when they are quoted poorly.
I doubt I'm the first person on this ball, but no, the premise of this is incorrect. I'm fine with classing homosexuality as a mental disorder. Just note in the description of it that although technically a disorder of targeting, it almost never causes actual distress and that treatment is therefore contraindicated.
EDIT: Also, preventing stigma is a silly and nonsensical ambition to have in general, and particularly in a dry medical text. Anybody can call anything stigmatizing, heeding that is just a way of yielding power to society's whiniest, which I oppose. And if people really are stigmatizing mental disorders, confront that at the social level, not in the diagnostic manual. (If inclusion in the manual is stigmatizing, surely schizophrenia shouldn't be in there either, or bipolar disorder, or...?)
Homosexuality is most *obviously* a mental illness. And it is your cowardice and conformism which prevent frankly admitting it.
This essay (along with the "Gay Rites" one) amount to little more than a brief for perverting politics and science and promulgating lies for progressive ends.
To your undying shame.
Comparisons to gay people misses a key point.
Bob likes men is a fact.
Bob is a woman is a lie.
SO many people here are convinced that homosexuality is a evolutionary strategy.
Putting aside the fact that even if it made sense it would still be simply a speculative hypothesis, it in fact makes no sense for two main reasons.
1. A gene that codes for infertile offspring *cannot possibly be selected for*. Genes are selected for when they get replicated successfully. Infertility by definition prevents replication. There is no mechanism for replicating something that prevents replication.
It doesn't matter if gay aunts and uncles help the group overall. It doesn't matter if you share most of your genes with your non-gay family members. Gay kids as a survival strategy *cannot be passed down*. Even if your group benefits, the ones without the gay-kid genes/epigenes will be selected for, meaning that subseuqent generations will be dominated by genes/epigenes which don't code for infertility. Even if the trait helps the group in one generation, it by definition cannot be passed to subsequent generations and therefore cannot be selected for. Even if the whole group benefits from individuals being infertile, the individuals who are most fertile will necessarily be selected for and the strategy dies out after one generation.
2. It doesn't even make sense as an evolutionary strategy!
If gay babies are made due to stress during pregnancy e.g. a famine, it makes sense to have less kids, not less fertile kids. Infertile kids still consume resources, and so this "strategy" is based on a benefit existing 2 generations after the acute stress was experienced by a pregnant mother.
Gay offspring will consume as much resources as non-gay offspring, so there can only possibly be a resource saving benefit in the second generation when the gay offspring aren't having kids.
Not only is this contradictory in that it says resource-consuming gay aunts and uncles are beneficial in one generation but not the next, it also means that it's better to save resource two generations after a mother experiences famine, rather than the first generation which is closest to the famine.
Evolution is not going to reward this weird delayed infertility that does nothing to save resources for an entire generation after an acute stress is experienced.
Why are resource-consuming uncles beneficial in one generation because they help raise other kids, but the next generation suddenly such people would be a resource drain? Why wouldn't kids of their own have the same benefit even though they're consuming the same amount of resources as their parents (except this time, further away from the famine).
Having shorter kids due to malnutrition makes sense, because there's an immediate resource saving that directly INCREASES the likelihood that this short height gene/epigene gets passed on. But a gene for infertility cannot possibly be propagated regardless of how much it helps your group because it is by definition a gene that prevents its own replication.
All of this positively reeks of ideologically driven people desperately looking for a way for homosexuality not to be a disorder or 'mistake'. I have nothing against gays, but I am completely opposed to people proposing incoherent scientific hypotheses because it suits their ideology better than the alternative. I'm not even saying its a deliberate act of dishonesty. I'm just saying that no smart person would engage in such sloppy thinking if their ideology wasn't getting in the way of them seeing things clearly.
What about classifying pretty much everything as a disorder, and leaving the political and insurance problems outside the classification? Would such classification be useless?
By "everything" I mean not just "pedophilia" or "homosexuality", but also any fetishes, and even "having sex not for procreation", or any "being dysphoric in own body".
This post continues Scotts tradition of having jarringly different Ideas about what relationship categories have to truth than me. Scott is of the opinion that categories are just word games and that technocrats should be able to shift their borders are any time to maximize public utility. Being rhetorically gifted as he is he describes this position well. There is no natural force that decides whether whales are fish or some other category so we ought to define fish however this best serves us. It's a difficult position to assail. And yet...
I think firstly that there is such a thing as a natural category. These are things people can intuit about the territory, like canyons etched by the simple combined implications of gravity causing water to flow down hill and precipitation taking that water back uphill. This forms natural borders between things. Creatures capable of flight are an intuitively useful category, people use it for things like determining if a wall is going to keep that creature out. This kind of category cannot and will not bend to our word games. We may call it something different or create new categories that mostly but don't exactly match this category(maybe you'd like to include or exclude insects based on some further need) but the natural category remains.
What people want out of things like the DSM is for it to have as its first goal to reflect a natural category. And there are a few options here, I think whether we pick a natural category that includes or excludes homosexuality is an important debate that could go either way. But it should be about which category to pick, not whether we should shift between different categorical systems from line to line. Because if you're switching up the justifying for inclusion from one definition to the next the actually underlying category is just "Whatever I find expedient" which is a maximally bad fit for a document meant to describe reality. It makes a farse of the whole project and in the end it turns the DSM into just another locus of power in the culture war with no more legitimacy than a piece of paper that says "I do what I want".
Why can't we have separate lists of
A) neurologically atypical behaviors
B) behaviors which are unethical and thus stigmatized
Lord bless us all with the power to decouple
I'm very confused. I thought biological and psychological were used as counterpart- and sometimes opposite- terms, where psychological areas are classified primarily by personal accounts and functionality in society even if the underlying biological causes have been partially identified. Given that, what does a purely biological psychological disorder mean?? Doesn't Scott, as a psychiatrist, look at a little checklist ten times a week about how much mental states are effecting the ability to function in day-to-day life to determine level of order or disorder?
Given that, it feels incredibly disingenuous to say "don't quote me out of context for saying these two topics are not functionally different, but also they're not functionally different only politically different." Is there a reason the resulting actions from expressing mental states with or against other people isn't being measured as a type of functionality here? I would think a consensual action that doesn't harm another person could be called more functional than a nonconsensual action that does harm another person & thus results in said person needing mental and/or physical treatment to be well/successful. That's simply a measurement: that's as apolitical as it gets.
(And given this straightforward way of measuring, it makes perfect sense to me to say "severe distress causing depression, discomfort, self-harm, etc. from untreated dysphoria results in low functionality and therefor is a disorder" and "a person that doesn't currently experience severe distress and happens to be wearing a dress doesn't result in low functionality therefor it is not a disorder". That's very simple logic, not some type of mess of caveats.)
This feels like a weirdly unconstructive article for such a charged topic.
The entire idea that any illness should be treated if a treatment exists and no treatment may be done absent an illness, consists of bureaucrats/technocrats trying to force a multi-faceted and complex question into an objective measurement. But no one likes the outcome of any objective measurement, which cannot capture the actual nuances and factors that exist, so then they covertly introduce politics into the objective measurement or slyly use the measurement differently in some cases.
If you look at the legal system, then they are much more sane (than healthcare) by not simply jailing everyone with aberrant behavior, but actually judging the impact on others and the acceptability to society, not based on a 'objective' standard, but based on a standard that is recognized as being political.
Good points made,
Could we not do some magic and label body dysphoria as a bodily disorder rather than a mental one? (If it really is a disconnect btwn mind and body, but -maybe politically- we choose the mind part to be truer?)
I'd still prefer to imagine an ideal body of law with which we can base a taxonomy off of. In that case, the society- gov and moral conscious included- is like the environment for which a trait is best adapted for. I'm really only stuck on this because I'm sad to have to say that concepts can't be organized logically, and let non rationalists win :(.
also, from a collectivist perspective, pedophilia is still much more of a disbenefit if it causes harm to others, unlike queerness. One might respond that evolutionarily it only matters to have an individualist perspective; not so if the gene is spread among the population.
I realized how strange it is to me that this article throws out the hairdryer theorem, arguing ethics over biology and ignoring utility.
Hairdryer approach had really gotten through to my dad more than anything else.
Homosexuality is obviously a *biological malfunctioning*, and as Emil Kierkegaard points out https://emilkirkegaard.dk/en/2023/01/homosexuality-is-a-mental-illness/
, it clusters with most other mental disorders . So if we are interested in the scientific project of identifying natural kinds, there is an obvious candidate for the meaning of “mental disorder” , that includes homosexuality. Obviously this a verbal dispute and nothing FORCES us to give “mental disorder” this meaning, but it seems like a fairly natural category we’d probably want a name for anyway.
Now, for me, it’s not that classifying homosexuality as a mental disorder is necessarily “stigmatizing”, more that it may come with the presumption that it is somehow irrational not to mind being homosexual, or that if it were possible I would be mistaken in not becoming heterosexual. This is simply mistaken. There is a very wide range of rationally permissible preferences. As long as I don’t have to deal with annoying paternalists who think they know better than me how I should want my mind to be, I don’t really care if people call homosexuality a disorder.
PART 1 of 2
I largely like and agree with this post. I think the post’s comparison of pedophilia and homosexuality is debatable, but plausible, and certainly not unreasonable, and I won’t comment further on it. But I am bothered by the comments—not because many of them advocate ideas that are false, unreasonable, and harmful (though many of them *do*), but rather because they are mostly repeating debates that have already happened at a MUCH higher quality elsewhere, and it sure looks like nobody has mentioned this fact in over 1,000 comments.
VERY well-developed versions of these same debates have already been taking place for DECADES—in fields such as philosophy of medicine, philosophy of psychiatry, and sociology. I’ve skimmed hundreds of comments in this thread, and only a few people have mentioned any of the relevant literature. A few people have mentioned Szasz (though not so much his critics, who are possibly even more important!), and a grand total of one (1) person (singular!) has mentioned Jerome Wakefield, and not much else has been brought up.
I hate people who dismiss everyone else’s ideas by saying “Read the literature!” because this sort of comment is generally condescending and unhelpful. But I’m going to do it. Please read the literature. At least a little bit of it. Or at least become aware that it exists. For starters, I recommend glancing over the following SEP articles—
Mental Disorder (Illness): https://plato.stanford.edu/entries/mental-disorder/
Philosophy of Psychiatry: https://plato.stanford.edu/entries/psychiatry/
These articles provide decent overviews of, and extensive sources for, many of the debates being brought up again and again in the comments here. For one thing, look at the section 8 “Values and Mental Disorder” in the “Mental Disorder (Illness)” article. And for more generic discussion that I think can help reduce diseased thinking about disease, there’s also the following—
Concepts of Health and Disease: https://plato.stanford.edu/entries/health-disease/
I don’t mean to endorse all the literature cited in these articles, or the articles themselves, in their entirety. They’re summary overviews with their own biases in what they cover and how they cover it. My point is more that they illustrate how these topics have been discussed extensively and for a long time, and at a high level of complexity—covering a great many topics discussed here, and doing so in a thoughtful and well-developed way. There’s no need to reinvent the wheel alone here. There is a cumulative tradition and set of communities and epistemic practices—resources of arguments, paradigms, theories, and criticisms, for copious object-level and meta-level issues here! There are specialist discourses on these topics that are worth engaging with, replete with useful conceptual distinctions and theoretical arguments which can be examined, adopted, rejected, criticized, and modified, for purposes of enriching the inquiry.
There is also, of course, a lot of meta-level debate over whether physical disorders are basically the same kind of thing as mental disorders, and/or whether we should engage in classification similarly or differently in these two areas.
The most notorious philosopher of mental illness might be Thomas Szasz, who advocates an extreme skepticism about mental disorders altogether. I’m pretty sure Scott is very much an anti-Szaszian. Szasz’s arguments probably don’t successfully apply to some more recent theories of mental disorders, so a lot of his ideas have been superseded. Hanna Pickard (a philosopher and psychotherapist) has defended a neo-Szaszian view in her book-chapter “Mental Illness is Indeed a Myth,” but she still shows that Szasz’s particular arguments and version of his theory were incorrect.
In the rest of this comment, I’ll discuss two anti-Szaszian theories of mental disorder (or disease more broadly, which is related) which I’ll discuss because I’m familiar with them and consider them fruitful to explore to improve the discourse. The first is a unified theory (Jerome Wakefield) which is realist and attempts to track the commonsense concept of disease or disorder. The second is a pluralist and pragmatist theory (Quill Kukla)—which I actually think closely resembles Scott’s revisionary pragmatist account given in “Diseased Thinking: Dissolving Questions about Disease.”
One major theorist is Jerome Wakefield (no relation to the anti-vax guy), known for his “Harmful Dysfunction” Analysis of mental disorder (HDA). (I’m pretty sure Wakefield also thinks the HDA is true of physical disorder, but he focuses mainly on mental disorder.) The HDA attempts to combine the need for a “biological” component (“dysfunction,” here a neutral term for, roughly, a failure of some bodily or mental element to perform its adapted evolutionary function) and a “normative” component (“harm”).
The HDA is supposed to apply to both physical and mental disorders. Wakefield has also compellingly argued that not all mental disorders are identical to, nor caused by, physical disorders. There can be mental disorder without (say) brain disorder. Nevertheless, this does not commit him to any kind of mind-body dualism. It is rather similar to how there can be software malfunctions even in the absence of hardware malfunctions, yet without any metaphysically dubious dualism that would say the software is a soul or anything like that. On this, see Wakefield’s article “Addiction and the Concept of Disorder, Part 2: Is every Mental Disorder a Brain Disorder?”
Not all harmful conditions are medical disorders at all, so something like a “dysfunction” component seems needed. But not all failures to perform evolutionary functions are bad, and (arguably!) it is misleading to call something a mental disorder if it is not at all bad—so something like a “harm” component seems needed. These statements are, of course, controversial.
Still, the HDA, or some variant of it, clearly has the ability to clarify a lot of the confusions that are messing up people’s thinking in some of the comments below Scott’s post—at the very least, by providing a body of empirically informed & logically rigorous argumentation and theory that can provide the basis for further discourse and debate! I think it should also disillusion some people of some beliefs they are highly confident in.
For example, some people in the thread have claimed it is “obvious” that homosexuality is a mental disorder, and that sheer political correctness is the only thing that prevents experts from admitting this fact. But really it is far from obvious that homosexuality is (or isn’t) a mental disorder—insofar as [1] it is far from obvious whether Wakefield’s harmful dysfunction account is correct or incorrect, and [2] it is unclear whether the HDA would imply that homosexuality is a disorder, because [2A] it is unclear whether homosexuality is a “dysfunction” in the right kind of evolutionary way; and [2B] the harm associated with homosexuality is caused by homophobia rather than homosexuality itself, and it is not entirely clear whether Wakefield’s analysis allows or disallows such extrinsically-caused harm to count as the right kind of harm to make a “dysfunction” qualify as a “disorder”.
Of course, the HDA has problems, and there is a lot of debate over it, and many theorists disagree with it. For an extensive recent anthology of chapters by Wakefield and fellow scholars who disagree with various aspects of his theory, see “Defining Mental Disorder: Wakefield and His Critics.” I haven't read much of it yet, beyond the intro chapter, but it looks fantastic and seems to be entirely open-access.
Defining Mental Disorder: Wakefield and His Critics: https://direct.mit.edu/books/book/5015/Defining-Mental-DisorderJerome-Wakefield-and-His
Interesting read! I’ve never thought about this topic before so thanks for writing about it.
I understand how most of the N'd sentences would sound bad without context, but one stood out to me.
"... it’s N important N for N your N sexual N partners N to N be N able N to N consent." At the very least, this particular clause seems quite safe to quote without context, and overall the whole N'd section prior also seems far more safe than all the other N'd sentences.
Good point on the general principle, but wrong on the specifics. Just as with homosexuality back in the day (pre-Hooker), most research on pedophilia uses hopelessly biased clinical and forensic samples, while statistical analysis of what good data exist shows that in the absence of coercion, negative outcomes are associated with social stigma and condemnation rather than with the contacts/relationships themselves.