In this three-part essay I have dealt with the thorny question of what conceptual defenses are available to restrict the ability of a society to arbitrarily designate negatively valued behavioral states as mental disorders. Ego-dystonic homosexuality presents a way to stress test candidate defense strategies; ego-dystonic homosexuality is ideal for this purpose since there is widespread consensus in contemporary psychiatry regarding its non-pathological status. Plus, any definition of mental disorder that simply requires the presence of distress in the individual without an analysis of the nature of distress will fail to exclude ego-dystonic homosexuality and other similar conditions where distress is generated because of social conflict. Notions of dysfunction, including objectivist notions by Boorse and Wakefield, offer limited defense, since the presence of dysfunction is already inferential in the vast majority of behavioral disorders and, even in cases like homosexuality, the question of whether dysfunction is present has proven remarkably elusive. Evaluative criteria of harm provide similarly weak defenses, either because they are highly relativistic or because they are unable to exclude distress resulting from social conflict. Instead, the only way to reliably exclude ego-dystonic homosexuality from the realm of mental disorders is to require intrinsic harm to be a necessary criterion for a mental disorder definition. There is no a priori reason for this requirement based on conceptual analysis of mental disorder, but there is a strong ethical argument in support. There are practical challenges in distinguishing between intrinsic distress and internalized distress but requiring intrinsic harm as a criterion would serve to stimulate social and psychiatric discourse on the nature of associated distress and lead to greater diagnostic clarification.
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