CONTENT NOTE: This essay contains sentences that would look bad taken out of context. In the past, I’ve said “PLEASE DON’T TAKE THIS OUT OF CONTEXT” before or after these, but in the New York Times’ 2021 article on me, they just quoted the individual sentence out of context without quoting the “PLEASE DON’T TAKE THIS OUT OF CONTEXT” statement following it. To avoid that, I will be replacing spaces with the letter “N”, standing for “NOT TO BE TAKEN OUT OF CONTEXT”. 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.

Here’s a post about HiTOP, a scientifically-grounded taxonomy of mental disorders meant to compete with the DSM. It has many good features (see further discussion here about advantages and disadvantages) and deserves more attention. But one claim stood out. The author of the post writes:

Some critics have argued that healthy behaviours are sometimes labelled as ‘disordered’ simply because they don’t fit our culture-bound vision of normal behaviour. The most famous example of this, of course, is homosexuality. As late as DSM-III, homosexuality was classed as a ‘sexual deviation’, and could be treated by psychiatrists as a form of psychological dysfunction. It was removed from later editions in response to mounting pressure, but the problem arguably still remains in other areas [. . .]

DSM alternatives say this all the time. “The DSM pathologized homosexuality! That means it reflects our biases and stereotypes! Let’s replace it with our purely biological, apolitical taxonomy of mental disorders!”

But HiTOP and its relatives won’t solve the problem of political bias in mental disorder classification. Nothing will ever solve that problem, because it comes from people wanting an incoherent thing.

For example: does the DSM classify transgender as a mental disorder? Hard to say. It includes 302.85: Gender Dysphoria, defined as “a marked incongruence between one's experienced/expressed gender and assigned gender”. It also includes approximately one million caveats saying that transgender definitely isn’t a mental disorder. Why the contradiction? Because regardless of the philosophical definition of mental disorder, the practical definition is:

• 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.

The DSM writers are trans-friendly and want to make sure trans people can get the care they need (for example, in most states, people need a psych evaluation before they can get gender affirmation surgery), so they want to force insurance companies to cover transgender, so they have to include it. But they also don’t want to stigmatize trans people, so they also include a lot of paragraphs about how even though they just listed it as a mental disorder, it definitely isn’t a mental disorder.

(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 - yes, you’re the wrong gender, but you’re crazy for being unhappy about it? - and also, I can’t find support for this distinction in a literal reading of the DSM criteria themselves)

When the DSM is political, it’s not (just) because the authors are ideologues and want to go around stigmatizing people they don’t like. It’s because “is X a mental disorder or not?” is scientifically meaningless but politically very important.

I’ll give an even worse example: from N a N biological N point N of N view N, homosexuality N and N pedophilia N are probably N pretty N similar. Both are “sexual targeting errors”: from an evolutionary point of view, our genes get passed down through couplings with sexually mature opposite-sex partners, and our instincts probably evolved to promote this. But instincts are hard - ducks sometimes decide humans are their mother and imprint on them - so sexual targeting errors are pretty common. I’m just speculating here - nobody has a strong evidence-based theory of either condition - but I think my speculations fit the small amount of evidence there is (for example, both are only weakly linked to genetics, suggesting they involve unconscious learning in some way).

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.

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?

We have to classify pedophilia as a mental illness, because we want insurance to pay for treatment. If someone shows up at a psychiatrist saying “Help, I feel an urge to molest children, is there anything you can do to get rid of that urge or prevent me from acting on it?”, I definitely want insurance to pay for this person’s treatment. Therefore, pedophilia “is” “a” “mental” “illness”, and no sophisticated categorization algorithm will ever convince me otherwise.

That N means N that N a N purely N biological N apolitical N taxonomy N of N mental N disorders N which N classifies N all N things N with N similar N biological N causes N in N the N same N way N would N also N probably N classify N homosexuality N as N a N mental N disorder. But the whole point of these purely biological apolitical taxonomies of mental illness was to make sure we would never again repeat the DSM’s error of calling homosexuality a mental disorder!

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.

Or if “political correctness” sounds too dismissive, we can rephrase it as: “they want something that doesn’t think about ethics and practicality at all, but which is simultaneously more ethically correct and pragmatically correct than other taxonomies”. 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:

• Hitting kittens is worse than hitting punching bags, even though the biology of the muscle movements is exactly the same in both cases.

• 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.

• Pedophilia N is N worse N than N homosexuality N, not N because N the N biology N necessarily N involves N different N processes N or N brain N regions, N but N because N it’s N important N for N your N sexual N partners N to N be N able N to N consent.

• Panic disorder should be a mental disorder, and meditative bliss states should not be a mental disorder, even if they involve similar mental feedback mechanisms.

So your purely biological, apolitical taxonomy of mental disorders will either:

• Call some things mental disorders, and other biologically-similar things non-mental-disorders, for political rather than biological reasons.

• Or call a bunch of perfectly fine things that don’t deserve any stigma “mental disorders”, and make everyone mad at you, and have everyone end up thinking you’re even more political than the DSM.

New taxonomies of mental disorders are still useful for other reasons. I’m not criticizing HiTOP - I like HiTOP - and the DSM is still silly for a lot of reasons. This post is not an attack on new taxonomies full stop. It’s just the claims to be able to avoid political bias in what is vs. isn’t a disorder that I find compelling.