Sexual Violence and Deviance in American Psychiatry, 1952-2013

This insightful article by Joanna Bourke delves into the complex and often fraught debates within American psychiatry from the 1950s to 2013 concerning whether individuals who commit sexual violence, particularly non-sadistic rape against adults, should be classified as mentally ill. Published in Women’s History Review, the article offers a crucial historical perspective on the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), often referred to as the ‘Bible’ of American psychiatry.

Bourke specifically focuses on the controversial proposal to introduce a diagnostic category called ‘Paraphilic Coercive Disorder’ (PCD), defined as a pathological state compelling sufferers (assumed male) to engage in sexually aggressive practices. The article highlights that while diagnoses like ‘Paedophilia’ and ‘Sexual Sadism’ have consistently been included in the DSM since its first edition in 1952, the APA steadfastly refused to pathologize non-sadistic sexual violence committed against adults. This refusal remained consistent despite various proposals, including ‘Sexual Assault Disorder’ in 1976 and ‘Paraphilic Rapism’.

The debates surrounding PCD, particularly animated in the lead-up to the DSM-III-R in 1987 and DSM-5 in 2013, were momentous due to the profound impact DSM diagnoses have on treatment options, access to insurance, eligibility for state benefits, and levels of stigmatization and sympathy. The manual’s influence extends globally, affecting diagnostic categories in the International Classification of Disease (ICD) used by the World Health Organization.

Bourke meticulously dissects four overlapping arguments that ultimately led to the failure to pathologize non-sadistic rapists:

• Uncertainty about ‘Normal’ Male Sexual Aggression: Research from the late 1970s onwards indicated that a significant proportion of “normal” male college students experienced sexual arousal from images and descriptions of sexual coercion, with some even admitting they would rape if guaranteed not to be caught. This raised concerns that classifying PCD could lead to the “pathologisation of young, middle-class, and predominantly white men”, implicitly defending male privilege.
• Feminist Worries about ‘Excusing’ Harmful Sexual Behaviors: Feminist opponents, like Paula Joan Caplan and Samantha Clavant, feared that a diagnosis like PCD would be misused in courts by defense lawyers to argue that rapists should receive psychiatric treatment instead of prison sentences, thereby lessening accountability for perpetrators.
• Concerns about the Misuse of Psychiatry in Courts: A major objection stemmed from the connection between proposed diagnoses and Sexually Violent Predator (SVP) laws, which emerged in the U.S. from 1990. These laws allowed for indefinite commitment to psychiatric institutions if offenders were deemed likely to reoffend and diagnosed with a mental disorder after serving their prison sentences. Psychiatrists were dismayed that these laws threatened to conflate ‘criminal behavior’ with ‘mental illness’, especially since the link between volitional impairment and sexual dangerousness was not clinically confirmed. Critics also highlighted the misuse of existing diagnoses like ‘Paraphilia NOS’ (Not Otherwise Specified) and ‘Sexual Sadism’ by evaluators in SVP proceedings, often based solely on criminal behavior rather than actual fantasies or distress.
• Defense of the Psychiatric Profession’s ‘Territory’ and Scientific Status: The APA aimed to protect its reputation amidst growing criticism from the anti-psychiatry movement and accusations of medicalizing everyday behaviors and engaging in social control. Many prominent psychiatrists, including Abraham Halpern and John Z. Sadler, argued that including ‘vice-laden diagnoses’ like PCD would “be an invitation to the anti-psychiatric movement to scorn and ridicule the American Psychiatric Association” and would make psychiatrists appear as “social control agents” rather than physicians. The APA itself officially sided against participating in SVP procedures, deeming them an “unacceptable misuse of psychiatry” that threatened the profession’s integrity.

Bourke argues that the APA’s decision not to include PCD was driven by a complex interplay of scientific difficulties in distinguishing ‘criminal’ from ‘mentally disordered’ rapists, the self-interest of the profession, and the influence of public opinion, feminists, and civil rights groups. This refusal, ironically, served to affirm psychiatry’s scientific credentials by insisting upon clear classificatory boundaries between criminal conduct and mental disorder, while also revealing an underlying unease about the nature of ‘normal’ male sexuality.

Article Reference:

Bourke, J. (2023). Sexual violence, deviance, and the paraphilias in American psychiatry, 1952–2013. Women’s History Review, 32(7), 960–976. https://doi.org/10.1080/09612025.2023.2197792.