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THE MEDICAL MODEL OF SEXUAL DEVIANCE
As we have mentioned before, whenever a society becomes seriously concerned with achieving or maintaining sexual conformity, it ceases to treat its sexual deviants as harmless individualists, but instead regards them as sinful, criminal, or sick. In other words, where deviant sexual behavior appears as a social issue, it tends to be discussed in either religious, legal, or medical terms.
We have already described in two earlier chapters how the religious and legal frames of reference shape the perceptions of those who use them. (See "Natural—Unnatural" and "Legal—Illegal.") We have also seen that in modern times these traditional approaches to the problem have increasingly been amended or even replaced by a medical or psychiatric approach. The following pages may further clarify this development and point out some of its implications,
The Function of Models
When people are confronted with the unknown or unexpected, they usually try to gain at least some understanding of it by likening it to something familiar. For example, a man who is puzzled by the workings of the brain may liken it to a computer in order to explain them. Needless to say, by making this analogy, the man does not imply that the brain is, in fact, a computer consisting of electronic circuitry, tapedeck, typewriter, etc. Instead, he merely uses the computer as a model or means of comparison. He decides to regard the brain as if it were a computer and thereby comes a little closer to finding out how it works.
Similarly, a man who encounters some bizarre human behavior may try to understand it by constructing for himself a certain conceptual model or frame of reference in which his bewildering observations somehow "fall into place". For example, he may ascribe "mad" behavior to demonic possession or see it as God's punishment for a life of sin. That is to say, he decides to regard madness as if it had a supernatural cause. He then finds that, in view of this assumption, the hitherto incomprehensible actions of madmen suddenly begin to make sense and can be explained. In short, he arrives at his otherwise unobtainable insight by using a religious model of madness.
However, another observer may not believe in God or demons and thus may choose to assume that madmen are simply victims of unfortunate persona! experiences and that they were "driven mad" by what happened to them in the course of their lives. Such an observer decides to regard madness as if it were learned behavior. He uses a learning model of madness.
A third observer may reject both of these models and prefer to believe that mad behavior is caused by a lack or loss of health. Thus, he decides to regard madness as if it were a disease. This means that he uses a medical model of madness.
There are, of course, many other possible models of madness, and we will discuss some of them later on. Even the three models listed here can be divided into various submodels according to differences in detail. For instance, Christians, Hindus, Buddhists and polytheistic "primitives" may subscribe to different religious models of madness, even if they agree on its supernatural origin. By the same token, different modern scientists may use very different learning models of madness, from psychoanalytic theory to operant conditioning. Finally, in the course of history doctors have used at least two major medical models of madness, depending on whether they traced it to physical or psychological causes. Accordingly, at times they ascribed madness to a diseased body, at other times to a diseased mind.
People choose a particular model to fit their own preconceptions, needs, and purposes, and they usually stick to it as long as it helps to provide them with workable explanations. However, it is not unusual that, upon closer study, a certain phenomenon raises so many new questions that a formerly useful model becomes inadequate and has to be replaced. Thus, for example, when people ceased to believe in supernatural forces and discovered that some forms of rnad behavior were caused by physical damage to the brain, they abandoned the religious model of madness in favor of the medical model.
It should be noted, however, that the replacement of one model by another does not defeat its original purpose, but rather confirms the basic principle of all model-making. Models are indispensable, but, by definition, they are never more than temporary structures. A model is supposed to make the strange look familiar, to "make sense" out of what appears to be senseless. As soon as it fails to fulfill this function, it has outlived its usefulness and thereby frees us to look for another, more comprehensive or more precise model which might produce better results. Therefore, it can very well be said that models are made only in order to be tested.
Models are also made in order to be compared to other models. A model always arranges certain concepts, ideas, theories, or points of view in such a way that they invite comparison with other concepts, ideas, theories, and points of view. For example, both the religious and medical models of madness spell out how mad behavior is caused, what should be done about it, and by whom, and to what extent a madman is responsible for his condition:
• According to the religious model, mad behavior is caused by evil spirits, it should be fought with exorcism, and this exorcism should be performed by a priest or other religious authority. The madman is likely to be responsible for his condition by having offended God. However, once he has repented, and the evil spirit has left him, he is saved.
• According to the medical model, mad behavior is caused by a disease, it should be fought with medical treatment, and this treatment should be administered by a doctor. The madman is almost never responsible for his condition, only unlucky. However, once he has successfully responded to drugs, electroshock, psychosurgery, etc., he is cured.
Naturally, if one so desires, one can carry this comparison a great deal further, because both models correspond in many additional details. Thus, where the advocates of the religious model speak of demons, the human soul, divine commandments, temptation, sin, penance, forgiveness, faith, and redemption, the proponents of the medical model speak of germs, viruses, parasites, the human body or the human mind, rules of hygiene, infection, injury, trauma, pathology, therapy, health, and rehabilitation.
The fact that we can make such point-by-point comparisons does not, of course, imply that all models are equal or that we are justified in choosing any model we like as long as we remain consistent. On the contrary, it is precisely when we compare different models with each other that we discover their relative merits. We also have to remember that history records many cases in which a certain model proved to be the only "correct" one and thus rendered all others obsolete. For instance, with regard to certain forms of madness a formerly tentative medical model was later so strongly confirmed by scientific discoveries that it actually lost the character of a model and became the accepted factual truth. (The best known of these cases is perhaps the insanity caused by syphilis.) On the other hand, there have also been cases where a medical model of madness was not only not confirmed, but positively disproved by science. (The best known of these cases is perhaps the insanity allegedly caused by masturbation.)
A detailed comparison of models can also help us to recognize each model as a separate entity and to keep it free from adulteration. That is to say, by clarifying the distinctions between different models, we can protect ourselves from conceptual confusion or what some scientists have called a "model muddle". Models must not be mixed. They cannot possibly work if their parts do not fit together logically. A hodgepodge of unrelated assumptions or an amalgamation of heterogenous models can never produce any meaningful insight.
Unfortunately, simple and self-evident as this truth seems to be, it is not always appreciated in practice. Again, the case of "masturbatory insanity" offers perhaps the best illustration: In the 18th and 19th centuries many European and American physicians declared that masturbation softened the brain and led to a mental breakdown. Some also asserted that the harmful habit itself was produced by an inherited abnormal physical or mental constitution. Thus, masturbation was considered to be both the cause and the effect of madness. In any case, masturbators were ill, and their illness required strong therapeutic measures, such as infibulation, clitoridectomy; and castration.
Obviously, those who advanced this view believed that they had thereby created a modern "enlightened" medical model. However, a closer analysis shows that this model still contained a number of traditional "unenlightened" religious elements. For example, the very terms in which doctors spoke of the alleged medical problem ("onanism", "self-abuse", or "solitary vice") were either directly derived from the Bible or otherwise openly judgmental. Furthermore, the useless and cruel "medical treatment" was clearly better designed to punish than to heal. Finally, unlike true medical patients, masturbators were still morally condemned and held responsible for their condition. Therefore, the supposedly medical model of "masturbatory insanity" was, in fact, a religious or moral model in medical disguise.
It should be remembered, however, that such "model muddling" is by no means a thing of the past. It remains a powerful (and usually unrecognized) temptation at all times. This is apparent to any observer of the contemporary psychiatric scene. Today even in one and the same "mental hospital" different psychiatrists may proceed from very different assumptions. Consequently, they may fight the same "disease" with very different types of "treatment" from surgery, drug therapy, and electroshock to behavior modification, group discussion, encounter sessions, and psychoanalysis. Furthermore, it is quite common for psychiatrists to differ in their diagnosis of a particular patient, not only with regard to the kind of illness he may have, but even with regard to the question whether he is ill at all. Naturally, all of this often leads to confusion, not only among the general public, but also within the psychiatric profession itself. As a result, some exasperated psychiatrists have, in the meantime, already begun to demand a radical break with tradition and to proclaim "the death of psychiatry".
Indeed, while the news of its death may be somewhat exaggerated, it seems clear enough that modern psychiatry is in serious trouble. Or to use an appropriate metaphor, it is suffering from an ever deepening "identity crisis". There is even the possibility that, in the long run, it may not survive as a medical discipline, and the reason for this can again be found in the continued indiscriminate mixing of models. The basic problem is easil y stated: Psychiatrists, when dealing with abnormal behavior, are supposedly practicing some form of medicine. However, it is becoming increasingly obvious that many of their professional activities do not really fit into a medical model. Instead, they are much more meaningful in the context of other models. For example, the behavior modification techniques, group encounters, and individual "talking sessions" mentioned above are not medical treatments in the strict sense of the term, and there is no logical reason why people who want them should have to visit a doctor. As a matter of fact today many such people go to psychologists, lay analysts, and all sorts of family, marriage, sex, drug, or youth counselors. Many of these "experts" have no medical training and do not pursue any medical objectives. By the same token, those who seek their help are not considered sick and therefore are not called patients, but clients. Their difficulties are not defined as symptoms of a disease, but as "adjustment problems", "emotional disturbances", "underdeveloped social skills", "faulty learning", or simply "problems in living".
At the present time the best known and most important nonmedical psychiatric technique is, of course, psychoanalysis. It is true that its founder, Sigmund Freud, was a physician and that he developed his theories in the course of treating his patients. However, over the years he realized that these theories had much wider implications and could not be tied to the practice of medicine. Instead, he saw ever more clearly that he had created a whole new critical education and research system. Therefore, he came to the conclusion that it was unnecessary for psychoanalysts to attend medical school. On the contrary, he hoped that they would take up interdisciplinary studies combining elements of biology, psychology, sociology, the history of civilization, mythology, literature, and other subjects in the humanities. In further recognition of its nonmedical importance, he also recommended psychoanalysis for various people who were not sick, such as artists, writers, and analysts-in-training. Unfortunately, because of certain historical circumstances, Freud's intentions were not carried out by his successors. After his death, psychoanalysis was reconfirmed as a medical specialty, and as such it became part of the vast modern psychiatric enterprise. This development, in turn, could not but add to the growing general confusion. (For a further discussion of the nonmedical character of psychoanalysis see "New Models.")
Naturally, what has been said here about "madness" or "mental illness" in general also applies to sexual deviance when it is defined as a psychiatric problem. Modern psychiatrists may subscribe to very different models of sexual deviance and therefore may also differ greatly in their professional practice. Some may regard every sexual deviant as a sick person and offer him various traditional medical therapies. Others may consider most sexual deviants to be perfectly healthy and refuse to treat them at all. Still others may assume a third position and try to correct even deviants who are not ill using any method that seems to produce results. In short, the apparently medical character of psychiatry is no guarantee that psychiatrists will behave like "regular" doctors and deal with sexual deviants in the same way as with "regular" medical patients.
In view of these circumstances it is perhaps advisable to take a closer look at the medical model and its implications.
Implications of the Medical Model
The medical model of sexual deviance is based on the assumption that it can best be explained as a disease. Or rather, the various forms of deviant sexual behavior are like so many different diseases which have their own causes and symptoms, and which can be medically treated. The assumption further implies that sexual deviants are medical patients, that the classification of their behavior is a medical diagnosis, that this behavior should be corrected by a doctor, and that his attempts to do so constitute therapy. Finally, it is assumed that sexual conformity equals health and that the return to conformity amounts to a cure.
People who make these assumptions do not necessarily mean that a sexual deviant is "mentally ill" or even that there is such a thing as "mental illness". Indeed, they may believe, to the contrary, that all sexual deviants are physically ill and that every illness in the world is physical. In short, the medical model of deviant behavior does not, in itself, suggest a need for "mindhealing" or psychiatry. A few, brief examples may clarify this point:
Physical diseases have traditionally been divided into three major categories according to their causes:
1. Infectious Diseases, i.e., diseases caused by some germ or virus, as for instance gonorrhea, syphilis, tuberculosis, or the common cold.
2. Systemic Diseases, i.e., diseases caused by some bodily breakdown or malfunction, as for instance a hardening of the arteries, an enlargement of the prostate, or diabetes.
3. Traumatic Diseases, i.e., diseases caused by some external agent or influence on the body, as for instance food poisoning, a broken limb, a cut, or a burn.
All three of these categories have, at one time or another, also been used to classify and explain deviant behavior. For example:
• When people discovered that a syphilitic infection can ultimately reach the brain and thus cause bizarre conduct, they began to suspect that perhaps all abnormal behaviors might have similar causes. (In this view, deviance indicated an infectious disease.)
• When people believed in "degeneracy", deviant behavior was ascribed to an inherited weakness, a progressive deterioration of genetic material which manifested itself in "bad nerves" and an overstimulated and misdirected sexual appetite. (In this view, deviance indicated a systemic disease.)
• When people believed in "masturbatory insanity", deviant behavior was traced to the injurious habit of "self-abuse" which overheated the brain and deprived the body of certain essential fluids. (In this view, deviance indicated a traumatic disease.)
It is very important to note that in all three of these examples deviant behavior was ascribed only to physical causes. In other words, a person's behavior was "wrong", because his body was sick. If the body had been healthy, the behavior would have been "right", and it became "right" again as soon as the body was cured. (On the other hand, the behavior remained "wrong", if the body proved incurable.) There was no suggestion of a "mind" or "psyche", "mental illness", or "psychiatry". The entire problem was seen strictly in terms of physical illness and physical treatment. The patient simply needed an ordinary physician.
However, it will be recalled from our earlier historical sketch that in modern times deviant behavior has increasingly been attributed not to physical, but to purely mental diseases. In this view, there is nothing wrong with the deviant's body, but there is something wrong with his mind. It follows that no ordinary physician can cure him, and that he needs instead the help of a "mindhealer" or psychiatrist. Nevertheless, since all psychiatrists are medically trained, they share certain basic assumptions with the physician and thus may also distinguish between infectious, systemic, and traumatic mental diseases.
Unfortunately, in actual practice this approach has not proved to be very useful. Especially with regard to sexual deviance the traditional medical categories have often led to confusing and contradictory propositions. For example, over the years the single mental disease "homosexuality" has been traced to each or all of three different kinds of causes. Specifically, the following theories have been proposed:
• People are homosexual because they were seduced by other, mostly older homosexuals. Therefore, homosexuals must be kept away from young people. (In this view, homosexuality is an infectious disease.)
• People are homosexual because they were born with a certain "weak personality", because they have become senile, or because their "character has disintegrated". (In this view, homosexuality is a systemic disease.)
• People are homosexual because neurotic parents or traumatic early sexual encounters have prevented their normal sexual development. (In this view, homosexuality is a traumatic disease.)
Of course, the psychiatrists who proposed these theories did not always make their underlying assumptions explicit and, in many cases, even remained unaware of them. Indeed, some psychiatrists were clearly embarrassed when these assumptions were spelled out by critical observers. After all, there is something coarse and clumsy about any direct equation of mental and physical diseases. It seems simpleminded to imply that the mind is a thing, a concrete, tangible object or organism which can be infected, break down, or sustain injuries. If such implications are found in psychiatric pronouncements, they are not to be taken literally, but figuratively. The concepts of infection, systemic malfunction, and trauma can be applied to mental diseases only in a poetic or parabolic sense. There are no "mental germs" or vulnerable "mental organs". Therefore, if one wants to classify mental diseases along the same lines as physical diseases one has to take refuge in metaphors.
Actually, as a closer examination reveals, the term "mental disease" itself is metaphoric. That is to say, strictly speaking, a mind cannot be diseased any more than an intellect can be obese or an instinct can be cancerous. One can talk about a "sick mind" only in the sense in which one talks about a "sick joke" or a "sick economy". In fact, just like the words "joke" and "economy", the word "mind" also refers to an abstraction. The mind is a concept, a notion, or an idea which summarizes the activity and function of the human brain. It is obviously not the brain itself. (A brain disease is a physical disease.) Therefore, when we say that somebody's mind is sick, we are actually saying that "the function of his brain" is sick. As a matter of fact, depending on the case, we may be saying that the function of his brain is sick while his brain itself is healthy.
One does not have to be a professor of logic to see that, taken at face value, such a statement is nonsense. It is like saying that the performance of an automobile engine has broken down while the engine itself is in perfect working order—a hopeless contradiction. Yet this kind of contradiction is unavoidable as long as one insists on ascribing a concrete condition to an abstract concept or, in other words, as long as one seriously claims that "the mind can be sick in the same way the body can be sick" and that "mental disease is like any other disease". This claim would make sense only if the mind were indeed a thing and thus could be put in the same logical category as the body. However, as we have seen, no modern scientist makes this assumption.
The situation was different in ancient times when people believed that not only the body, but also the mind was concrete. For example, the ancient Greek word for mind, "psyche", (which forms part of the modern word "psychiatry") originally meant "breath" and then "soul", and this soul was assumed to be located in a certain specific part of the body (the heart, the diaphragm, the liver, or the brain). It was also assumed that the soul was some sort of ethereal creature or spirit and that it could therefore be influenced and even possessed by other spirits. Today no doctor, not even a psychiatrist, believes in spirits or souls. The word "psyche" has now become an abstract, purely technical term and no longer refers to a living and breathing invisible being. In short, when modern psychiatrists talk about a "disease of the mind" they are not talking about an actual disease of an actual organism, but about a metaphorical disease of a theoretical proposition.
It seems necessary to emphasize and reemphasize this simple point because, as experience shows, it is all too easily forgotten. Furthermore, the professional language used by psychiatrists is often "neo-archaic", imprecise, and misleading. For instance, we constantly hear not only about psychiatry (healing of the mind), "psychotherapy" (cure of the mind), and "psychopathology" (sickness of the mind), but even about "psychoactive drugs (drugs that act upon the mind) and "psychosurgery" (surgery performed on the mind). However, these and similar terms do not really mean what they seem to say, and anyone who fails to recognize their metaphorical character is bound to misunderstand them. In other words, since the mind cannot be sick except in a metaphorical sense, it can also only be healed or cured in a metaphorical sense. Psychoactive drugs do not really act upon the mind, but upon the brain and perhaps other parts of the body, and psychosurgery is in fact always brain surgery.
One may, of course, wonder why this kind of loose terminology continues to be employed by professionals who are supposed to know better. Thus, one may well ask: "If a psychosurgeon in fact operates on the brain, why does he not say so? Why does he not refer to his work simply as brain surgery? The answer is that he is not directly concerned with the brain itself, but operates on it only in order to gain indirect influence on something else. His aim is not so much to alter the brain as the behavior which is determined by the brain. Indeed, he may regard the brain itself as healthy and only the behavior as sick. In a sense, then, it is only the behavior on which he is actually operating. Therefore he thinks of himself more as a "behavior surgeon" than a brain surgeon. Brain surgeons operate only on diseased brains and would never consider operating on a healthy brain. Surgery on a healthy brain must therefore be justified by calling it "psychosurgery", i.e., surgery on the mind. It then becomes, so to speak, surgery by proxy. Once this rationale is accepted, the whole procedure suddenly begins to make sense: A healthy brain may be surgically injured, because this injury results in healing a sick mind.
It is an ironic coincidence that at a time when "psychosurgery" is becoming popular in the Western world there are also reports of Western patients with various bodily diseases traveling to certain backward countries in order to undergo an operation called "psychic surgery". In this type of operation, which is illegal in Europe and America, a "psychic healer" performs imaginary surgery as part of some magic ritual. No surgical instruments are used, no incision is made, and yet in the end the healer claims to have cut out the diseased organ by force of his mental powers alone just as surely as if he had used a knife. In fact, as proof of his accomplishment he usually shows the patient some bloody intestines which supposedly have been left over.
Needless to say, modern Western doctors consider any such magic ritual to be nothing but criminal quackery and an outrageous, cynical fraud. Nevertheless, if only for theoretical reasons, the ideology behind this "fraud" deserves to be taken into consideration when one discusses the concepts of physical and mental disease. It also casts a dramatic and very welcome light on the difference between physical and mental forms of therapy. As a matter of fact, in view of this newly illuminated perspective, we can now clarify our teminological problems in the following manner:
The surgical alteration of behavior which is being advocated in our culture is, in fact, always brain surgery, i.e., ordinary surgery performed on a real organ. The term "psychosurgery" for such an operation is misleading, because it suggests that one can perform surgery on the mind, a wholly imaginary organ or organism. The term "psychic surgery", on the other hand, refers to imaginary surgery on a real organ, such as the brain, the stomach, the liver, or the heart. Finally, as a fourth logical possibility, one can conceive of imaginary surgery being performed on an imaginary organ like the mind. This would perhaps best be described as "psychic psychosurgery".
Perhaps the entire issue can be summarized this way: If one believes in the proposition that both a real organ (like the brain) and an imaginary organ (like the mind) can be subject to operable diseases, one might as well also propose real and imaginary forms of surgery. Thus, one would arrive quite logically at four different possible combinations:
1. Ordinary surgery, i.e., real surgery performed on a real organ (like the brain).
2. Psychosurgery, i.e., real surgery performed on an imaginary organ (like the mind).
3. Psychic surgery, i.e., imaginary surgery performed on a real organ (like the brain).
4. "Psychic psychosurgery" i.e., imaginary surgery performed on an imaginary organ (like the mind).
The first and last of these therapies are "pure", i.e., they are based on matching concepts of theory and practice and thus are logically consistent. "Psychic psychosurgery" is, of course, nothing more than a ceremony, a purely magic ritual, and as such it is out of place in a scientific civilization. It may well have existed in one form or another among ancient or "primitive" peoples, but it is of no practical significance today. Ordinary surgery, which dates back thousands of years, is still recognized and has, in the meantime, been brought up to nearly miraculous standards. It is familiar to everyone and poses no conceptual problems. Truly problematical are only the second and third of the above categories, because they are logically "impure". Fortunately, in our present culture "psychic surgery" is easily dismissed as fraudulent and illegal, but "psychosurgery" is another matter. We know, for example, about the Stone Age custom of trepanning, i.e., the practice of cutting holes in someone's skull and thereby allowing evil spirits to escape from the brain. Thus, we know that, as soon as even the most primitive tools (sharpened stones) had become available to man, he used real surgery in the hope of influencing imaginary forces. This ancient hope has persisted and is, in fact, being strengthened today by the continued refinement of surgical tools and techniques. The belief in spirits may have waned, but some modern surgeons remain convinced that the right knife or electrode inserted in the right place inside their patient's skull will control his "psyche".
Indeed, the results of "psychosurgery" are often dramatic enough: Formerly violent patients became docile, sexually aggressive patients lose all interest in sex, etc. However, this is sometimes also true of other forms of physical mutilation, such as castration, which no one has yet dared to call psychosurgery. Many critical observers are therefore unimpressed and demand more "honesty in advertising" and better theoretical justifications. The most serious objections to the practice, however, are based on the fact that it has often been used on unwilling and defenseless patients, such as prisoners and inmates of mental hospitals, some of whom should never have been found guilty or sick in the first place. Especially in the last few years the public outcry against "psychosurgery" has grown so strong that its practitioners have become more cautious, and the number of operations has drastically declined, at least in the United States.
Another important reason for this change has been the development of new "psychoactive" drugs which are now increasingly being used to treat violent, restless, depressed, and schizophrenic patients. People with sexual problems can also be "chemically castrated" by drugs which lower the body's production of testosterone and thus may reduce a person's sexual desire. Unlike a surgical castration, however, this chemical castration is not permanent, but is easily reversed by giving up the drug. In short, today various human behaviors can be provoked, stopped, changed, or revived by pills and injections alone. However, as in the case of "psychosurgery", it is not scientifically correct to say that these interventions act upon the mind, since they clearly act upon the body. The resulting bodily changes then produce a change in behavior. As a matter of fact, both the so-called psychoactive drugs and psychosurgery have led many psychiatrists away from their preoccupation with the "psyche" and refocused their attention on the body. After all, if a disease can be cured by physical treatments, such as surgery and drug ingestion, it may very well be nothing more than a physical disease. Why drag such an elusive concept as "mind" into it? Thus, the old belief in the purely physical causes of all "mental" illness has surfaced again and may well be confirmed in the future. In any case, some of the most critical modern psychiatrists advocate a new emphasis on strictly medical, or rather biological research. At the same time, they have also become very humble about what they can do in regard to moral problems and social issues.
This new-found humility is further reflected in the more recent general concept of illness itself. It is no longer assumed that there is such a thing as a definite, fixed state of health which is sometimes replaced with an equally definite state of illness. Instead, it is now being realized that human beings have to adapt and change throughout their lives and that, by definition, these adaptations and changes give no cause for concern as long as they do not impair normal (i.e., the usual) functioning. By the same token, to the degree that physical and psychological functions do become impaired, i.e., to the degree that the normal continued changes become maladaptive, they might become subject to medical intervention. In this view, health and illness are not clear-cut alternatives or irreconcilable opposites, but rather parts of the life process, and they lie on a continuum.
All of this means that in medicine, just as in any other scientifically based enterprise, there is no room for dogmatism. Especially in the psychological realm the decision of what is or is not maladaptive depends on a great number of individual and social factors which have to be considered in their totality. Furthermore, those who endeavor to offer someone their diagnosis and treatment must not forget to take their own value assumptions into account. Finally, past medical and psychiatric abuses have made it clear even to the average layman that he cannot simply suspend his own judgment when he enters therapy. He also knows that, in spite of certain exaggerated earlier claims, not all of his problems have a medical solution.
Critique of the Medical Model
As we have seen, the development of a concept of "mental illness" enabled medical science to arrive at four different possible kinds of diagnosis: A person could turn out to be
1. healthy in body and healthy in mind,
2. sick in body and healthy in mind,
3. sick in body and sick in mind, and
4. healthy in body and sick in mind.
In the first instance no medical treatment was needed. In the second instance a "body doctor" was required. In the third instance this "body doctor" had to be helped by a "mind doctor", and in the last instance only a "mind doctor" could possibly do any good.
This situation was reflected in the increasing specialization of medicine. Psychiatry or "mindhealing" emerged as a separate branch, although its practitioners still received a regular medical training. Thus, they learned to treat not only physical, but also mental illness and became, in fact, "super-doctors" with more skills and more authority than their traditional colleagues. On the other hand, eventually there also appeared various nonmedical "psychotherapists" who were unqualified to treat the body and who treated only the mind. Something of a middle position came to be occupied by the followers of "psychosomatic medicine" (from Greek psyche: soul or mind and soma: body) which considered illness in both its mental and physical aspects. .
A corresponding division also appears in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. Originally based on Kraepelin's system of mental disorders, it has been modernized several times, but it still carries the old implications. The 1968 edition (DSM II), for example, listed six major categories of abnormal behavior. The first two of these ("Mental Retardation" and "Organic Brain Syndromes") referred to physical problems. The following three categories ("Psychoses Not Attributed to Physical Conditions", "Neuroses", and "Personality Disorders") described purely mental problems. The final category ("Psychophysiological Disorders" ) contained "mixed" conditions that had both mental and physical aspects.
It should be pointed out, however, that this classification system was often criticized even by psychiatrists themselves as arbitrary, heterogenous, unreliable, and invalid. For instance, "psychoses" constituted not only a major category of their own, but also appeared as a subcategory of "organic brain syndromes". Disorders such as "neuroses" were defined largely on the basis of psychoanalytic assumptions and thus belong to a different theoretical framework from the other categories. Finally, the category "personality disorders" listed such peculiar subcategories as "sexual deviation", alcoholism", and "drug dependence". Leaving aside the question of whether alcoholism is not itself a form of drug dependence, one had to ask oneself what scientific information any of these terms really contained. Even if one assumes that sexual deviation and drug dependence indicate some illness (and this is a highly questionable assumption) the classifications themselves did not tell us very much about it. It was rather as if ordinary doctors decided to use diagnoses such as "weakness", "fatigue", "fever", "cough", or "headache". All of these complaints can have a thousand different causes, and so can each of the so-called personality disorders. Furthermore, it is hard to see how they are different from the neuroses.
The most serious criticism of the diagnostic manual, however, asserted that some of its categories were pseudo-scientific, i.e., that they were nothing more than moral prejudices in "objective" disguise. This suspicion was nourished by the history of psychiatry which, in earlier times, had claimed the existence of such diseases as "masturbatory insanity", "pathological mendacity", and "vagabondage". Indeed, until 1973 American psychiatrists officially also regarded homosexuality as a disease. They finally dropped this label only under increasing pressure from gay liberation groups. Thus, as some of them humorously observed, a simple stroke of the pen instantly and miraculously cured hundreds of millions of "patients" all over the world—the greatest mass cure in medical history.
In response to the various criticisms, the Diagnostic and Statistical Manual was once again overhauled in 1980. The new edition, known as DSM III, tries to be simply descriptive and therefore ignores the previous large categories. Instead, it lists many heterogenous "disorders", one after another, from "substance use disorders" to "anxiety disorders", "adjustment disorders", and "personality disorders". Again, these classifications are somewhat arbitrary and do not really explain anything, but they also seem to be more cautious and modest than before. Unfortunately, the new class of "psycho-sexual disorders" remains a questionable hodgepodge of medically disguised value judgments. "Homosexuality" as such has been dropped from the list, but such poorly conceived categories as "inhibited sexual desire", the unjustified equation of male orgasm with ejaculation in "inhibited male orgasm", and the clearly ideological notion of "paraphilias" continue to mar the whole enterprise. Serious sexologists will therefore have to wait for DSM IV to find out whether psychiatry can deal with sex in a truly scientific manner. (For a more detailed critique, see "Basic Issues in Sex Therapy.")
Experience has shown that a psychiatric diagnosis can be more than a "neutral" medical statement. It often has immediate, and sometimes far-reaching social consequences. People who have been labeled "mentally ill" may be subject to forced commitment to an institution, forced treatment, and all sorts of other drastic interventions. This is particularly true of those who have been so labeled because of their sexual behavior. Their "illness" may well be used as a pretext for isolating, restraining, denigrating, and punishing them. The question of whether they are really ill or not is therefore beside the point. The only important question is what social or moral significance we attach to their "symptoms". A limping, asthmatic, cross-eyed, or near sighted man is certainly abnormal and sick, yet we leave him alone and respect his rights as a person. Even if he should become fatally ill, we would never cure him against his wishes. In contrast, a harmless "sexual deviate" may or may not be sick, yet we insist that he change his behavior and treat him as an inferior human being. It seems, therefore, that sexual deviation as well as some other examples of "mental illness" are essentially moral rather than medical problems.
At least this is the position taken by some recent critics of the medical model of abnormal behavior. In America the most articulate of these critics have been the sociologists Erving Goffman and Thomas J. Scheff and the psychiatrist Thomas S. Szasz.
Goffman, in 1959, wrote an influential essay on "The Moral Career of the Mental Patient" (later reprinted in his book Asylums) which examined the human experience of being hospitalized and treated for "mental illness". This experience turned out to be one of humiliation and betrayal. The so-called therapeutic measures revealed themselves as part of a moral ritual by which society stigmatized some of its members.
The same view was elaborated a few years later by Scheff in his book Being Mentally III (1966). He described chronic mental illness as a social role, the result of scapegoating and victimization. It was, in fact, nothing more than a special label applied to certain deviants and mainly used to ostracize them or to deny them their civil rights. The whole exercise served only the purpose of controlling "residual rule-breakers". The medical jargon and paraphernalia of psychiatry were means of deception which helped to ease the conscience of the community.
However, perhaps the most scathing attack on the medical model of deviance came from inside the psychiatric profession itself. Szasz, in his books The Myth of Mental Illness (1961) and The Manufacture of Madness (1970), called mental illness a myth and likened the treatment of mental patients by institutional psychiatry to that of witches by the Inquisition. For him, the belief in mental illness is just as false and dangerous as the belief in witchcraft and leads to the same excesses. Psychiatrists do not deal with mental illness and its treatment, but with "personal, social, and ethical problems in living". By mistaking these problems for diseases, and thus assigning the blame for antisocial behavior to some external force, we undermine the principle of personal responsibility and foster the illusion that social conflicts can be solved by medical science.
These and other calls for a critical reassessment have, in the meantime, found a remarkable echo not only among the general public, but also in the therapeutic and helping professions. Even many conservative psychiatrists who rejected the main thrust of the criticism had to admit that it contained enough truth to make them uncomfortable. They were forced to enlarge their field of vision and to recognize, perhaps for the first time, the social dimensions of their professional activity. Instead of concentrating only on the "patient" and his "illness", they had to examine their own role as agents of social control. Consequently, they became more cautious in their pronouncements and more tolerant of deviant behavior.
Especially deviant sexual behavior is now treated much more leniently in psychiatric circles than only a few decades ago. After all, as Kinsey's statistics and numerous other recent surveys have shown, such behavior is far more common than had previously been suspected. Indeed, many forms of alleged sexual deviance have been shown to be "normal" and not deviant at all. If our criminal laws do not yet always reflect this insight it is no longer the fault of psychiatrists who today are often among the most ardent advocates of reform.
Summing up, we can say that those who still use the medical model of deviance now do so with much more sophistication. However, some others (including some certified psychiatrists) have turned to new, nonmedical models in their own practice.
New Models
Earlier in this chapter, we discussed the nonmedical character of psychoanalysis, and we have mentioned Sigmund Freud's hope that it would not be tied exclusively to medical practice. Indeed, any neutral description of the psychoanalytic process reveals that it rests on a learning model of behavior. The analysand (i.e., the person to be analyzed) tries to recall long-forgotten experiences with the help of free association and the recollection of current dreams. His verbal reports are scrutinized by the analyst who looks for certain clues, recurrent themes, or patterns which might give a hint at some repressed early traumatic experience. As soon as this experience or series of experiences have been identified and made conscious, the analysand has regained his chance to deal with them in a rational and appropriate fashion. In short, the psychoanalytic method is essentially a historical or, more specifically, an autobiographical method. The troubled person learns from his own life history that he once learned a "wrong" lesson. This insight then sets him free to profit from future lessons that life might have in store for him.
Psychoanalysis has long been popular in the United States and Europe and has won many prominent followers, some of whom, like Marie Bonaparte and Erik Erikson, for example, have even employed its techniques to study famous historical personalities, such as Edgar Allan Poe and Martin Luther. (Freud himself had written a study of Leonardo da Vinci.) Thus, the nonmedical use of psychoanalysis is well recognized. By the same token, however, many men and women who once might have asked for the services of a psychoanalyst now seek still other nonmedical treatments, such as yoga, meditation, biofeedback, etc. In spite of their differences, all of these treatments have one thing in common: They do not make an assumption of illness and, while they may help some suffering people, they are also applicable to those who merely want to "grow" or increase their personal potential.
Another increasingly popular treatment is known as "behavior modification". It is also based on a learning model of human behavior and employs various techniques of reward and punishment to reinforce behavior which is acceptable while decreasing that which is unacceptable. Again, no assumption of illness is made. Instead, the procedure is entirely pragmatic: "Faulty learning" is corrected without any far-reaching metaphysical speculations. Not surprisingly, however, this uncritical approach has upset many libertarians who have found the techniques of punishment used in the process to be rather repulsive. Moreover, in its early years, "behavior modification" was sometimes used to modify behavior that would better have been left alone. Thus, homosexuals, for example, were subjected to some very bizarre and revolting treatments designed to turn them into heterosexuals. (So far, the reverse has not been tried.) Such abuses have, in the meantime led to justified public outrage and to greater professional caution. There is no doubt, however, that under strict guidelines and in the hands of sensible practitioners, behavior modification can still do a great deal of good.
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MODELS OF SEXUAL DEVIANCE*
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RELIGIOUS MODEL
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LEGAL MODEL
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MEDICAL MODEL
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PSYCHOANALYTIC MODEL
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LABELING MODEL
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CAUSE OF DEVIANCE
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Demonic possession or lempiation by the devil. Sinfulness
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The deviant's "criminal character"
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Not always known, but some natural cause (illness) assumed
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Individual, largely unconscious life experiences. Arrested or impaired psychosexual development
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Labeling by those who cannot tolerate differences
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MEANING OF DEVIANT BEHAVIOR
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Sin, heresy.
Deviant is possessed or evil
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Crime
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Symptomatic of illness
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Symbolic acting-out of unconscious and unresolved childhood conflicts
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Determined by those who label the deviant.
Today mostly seen as criminal or sick
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FORM OF INTERVENTION
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Exorcism, repentance, confession
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Punishment, sometimes also "rehabilitation"
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Medical treatment. Drugs, electroshock, psychosurgery, etc.
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Psychoanalysis. Deviant becomes conscious of hidden conflict by means of free association, interpretation of dreams, etc.
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Criminal punishment or psychiatric treatment, often involuntary
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INTERVENING AUTHORITY
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Priest or other religious authority.
Sometimes chosen by deviant, sometimes by society
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Police, judge, correctional officer.
Always chosen by society
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Physician or psychiatrist. Sometimes chosen by deviant, usually by society
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Analyst.
Always chosen by deviant
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Today usually a judge or psychiatrist.
Chosen by those who label the deviant.
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RIGHTS AND DUTIES OF DEVIANT
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Right to receive exorcism. Duty to atone for sins
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Right to be presumed innocent until proven guilty.
Duty to accept punishment and to "pay his debt to society"
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Right to be considered sick, not evil.
Duty to try to get well and to cooperate with doctors
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Right to have his behavior interpreted as symbolic, not judged morally.
Duty to cooperate with analyst
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No rights.
No duties
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RIGHTS AND DUTIES OF SOCIETY
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Right to condemn and isolate sinners.
Duty to help them if they repent
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Right to protect itself against criminals.
Duty to punish them
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Right to be protected from sick people who are dangerous.
Duty to provide medical treatment for them
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No rights.
Duty to see deviant behavior as indicatio of emotional disturbance
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Right to control socially harmful deviants.
Duty to leave all other deviants alone
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GOAL OF MODEL
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To save the soul from eternal damnation
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To control crime
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To cure illness.
To help deviant avoid blame by treating him as a medical patient
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To resolve deviant's unconscious conflicts
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For the intolerant:
To maintain the status quo by labeling and "correcting" deviants.
For the tolerant:
To liberate the oppressed
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1 This chart is adapted from a similar one used by M. Siegler and H. Osmond in Models of Madness, Models of Medicine, N.Y.,N.Y., 1974, pp. 16-18
Still other nonmedical models of deviance have been proposed in recent years. Thomas S. Szasz, for example, who declared mental illness to be a myth, has suggested a "rule-following model" or "game model" of human behavior and misbehavior. According to this suggestion, people slowly learn the rules of the many different games of life, and they also learn to understand which games have priority in which situations. Conflicts arise when people disagree about certain rules, change the rules in the middle of the game, or refuse to learn new rules for new games. Some of these conflicts are external and manifest themselves in social disputes, struggles, or revolutions; others are internal and distort the "normal" individual behavior. These distortions are then often mistaken for "mental illness" when, in fact, they are simply problems in living—a failure to cope successfully with a difficult situation. In other cases, people are called mentally ill in order to remove them from a social game in which they have become obnoxious to others.
Needless to say, Szasz's model is easily reconciled with the "labeling model" used by such writers as Goffman and Scheff. As we have repeatedly mentioned, deviance of any kind is best understood as a label attached to rule breakers by a conforming majority. Any study or treatment of deviance therefore has to take the whole social context into account. Those who mistake deviance (including "mental illness") for an individual problem are shortsighted. Certainly, according to this model, it is not a medical problem.
Fortunately for our discussion, most currently popular models of deviance have been examined in depth by two defenders of psychiatry, Miriam Siegler and Humphry Osmond, in a very illuminating study entitled Models of Madness, Models of Medicine (1974). By comparing different models of madness, drug addiction, and alcoholism, they were able to demonstrate the relative advantages, limits, and implications of each model and thus to end some of the present professional confusion. However, the importance of their study does not end there. While they themselves made no attempt in this direction, their method can also easily be applied to the problem of sexual deviance. It seems appropriate, therefore, to include a simplified adaptation of one of their charts in the present text. Since it is self-explanatory, it does not require any additional comment. (See chart on preceding page.)
As already mentioned, however, Siegler and Osmond are far from abandoning the medical model. On the contrary, they believe it to have unique advantages and, indeed, great potential for the future. Of course, they demand a heightened critical consciousness on the part of their colleagues as well as some therapeutic restraint. Psychiatrists must realize that not everyone who seeks their help or is referred to them is mentally ill. Indeed, "screening out" such alleged patients is one of their professional duties. In many such cases, certain nonmedical treatments offer the best hope and should be suggested. Nevertheless, there remains a sufficient number of individual and social problems which can be solved with the help of a medically oriented psychiatry. As a matter of fact, it seems that in the past many psychiatrists have failed because they did not have enough faith in the medical model and did not adhere to it strictly enough. Again, sexual deviance is an interesting case in point.
We had seen earlier that, in Victorian times, alleged mental patients suffering from "masturbatory insanity", "nymphomania", or "homosexuality" had often been treated as both sick and immoral even by their own doctors. However, in the medical model, properly understood, there is no room for moral blame. Quite the opposite: It is the unique authority of a doctor to declare someone sick and thus to absolve him from all responsibility for his condition. In the strict sense, therefore, and by definition, a patient is not a deviant. He may deviate from accepted standards, but he does so with official permission, because as a sick person, he "cannot help it". This means that a psychiatrist, as a doctor, has the power to free sexual nonconformists from their morally negative deviant role and to assign them to the morally neutral sick role. This decision alone can save them from harassment and persecution. By the same token, a psychiatrist who fails to arrive at a clear decision undermines the very foundations of his profession. Any ambivalence, any mixing of medical with moral approaches is detrimental not only to the patients, but also to the practice of psychiatry itself. Indeed, the fact that for so long "mental patients" could be perceived and treated as deviants points to this historical failure of psychiatrists.
On the other hand, it is understandable why people should find it difficult to suspend their moral judgment in the face of "abnormal" sexual behavior. First of all, in our culture morality and sexual conformity have become nearly synonymous. Furthermore, and most importantly, the general public well realizes that a psychiatric diagnosis is often a "cop-out," i.e., a professional stratagem which helps both doctor and "patient" to avoid facing certain moral issues. Finally, we must remember that many sexual nonconformists are justified in refusing the sick role that is being thrust upon them by well-meaning, but sexually prejudiced doctors. Thus, to return to our examples, masturbators, "nymphomaniacs", and "homosexuals" have successfully fought not only against the pernicious labels of sin and crime, but also against the more benign label of sickness.
Observations such as these tend to support the critics of the medical model who insist on seeing the problem in moral terms, although their morality may well be quite different from the traditional one. Ultimately, therefore, we must hope for the open-rninded further study of human sexuality, a continued thorough discussion between all concerned parties, and cooperation on all sides. Difficult as it is, a general commitment to reason still offers the best hope for dealing with nonconformity.
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