As utilized in the harm criterion, “functional impairment” (or “functional disability”) refers to the negative consequences in social or occupational functioning or other important activities of life. For instance, heart failure is impairing as it restricts physical activity; agoraphobia can be impairing if one becomes unable to leave the house. Functional impairment is a product of the interaction between a deficit and the environment, and the presence of impairment and the degree of impairment may depend on the environmental context. For instance, attention deficits and hyperactivity in a child may be quite impairing in a highly structured modern classroom but may have had little to no impairment in pre-modern societies.
One important consideration is whether functional impairment is direct product of the biological processes in question or is a result of society’s stigmatization. For instance, red hair by itself leads to no functional impairment, but individuals with red hair may not be able to find employment because of social stigma.
Paraphilias can cause impairment in sexual life in the absence of appropriate stimulus. However, it is unclear if this is an impairment just because society considers the behaviors pathological. Voyeurism or sadomasochism can be highly impairing if one is unable to find consensual sexual partners with whom to engage. Similarly, the more stigmatized these conditions are in a society, the more difficult it will be to find consensual partners. If impairment disappears simply by society’s acceptance of that behavior as a non-pathological normal variant, it is likely a result of society’s discrimination and I will term it extrinsic impairment (in contrast to intrinsic impairment, which is a direct result of a specific biological or psychological process).
It is fairly obvious that distress occurs in cases of socially deviant behavior and conflicts between individual and society. The requirement for distress alone does not protect social deviance from being pathologized. Distress or impairment that results from social deviance and conflict is extrinsic. It is different from intrinsic distress and intrinsic impairment, which are a direct result of the biological or psychological processes in question. A harm criterion that restricts disorder designation only to cases of intrinsic distress and intrinsic functional impairment can, therefore, protect against disorder designations of extrinsic distress and extrinsic impairment. (Rashed and Bingham have made a similar argument, namely that "psychiatry’s ability to distinguish deviance from disorder rests on the ability to define, identify, and exclude socially constituted forms of distress. These should lie outside the purview of candidacy for mental disorder."3)
Based on the above discussion of harm, I posit the notion of ethical validity of disorder designation. Ethical validity arises from considerations of intrinsic harm as well as considerations of harm caused by disorder designation. Harm caused by disorder designation includes all the ways in which disorder designation prevents individuals from flourishing in a manner that those without a disorder designation can flourish. This includes imposition of sick role, social discrimination and stigmatization, production of self-guilt and self-doubt in the individuals, unnecessary—possibly coercive—treatment, and barriers to progressive social change. Disorder designation lacks ethical validity in the case of conditions without intrinsic harm.
It is easy to see why it is ethically wrong to classify homosexuality or red hair as a disorder. Both conditions lack intrinsic distress and intrinsic impairment. In both cases, there is harm caused by disorder designation. A person whose sexual orientation is considered a disorder and a person whose red hair is considered a disorder cannot flourish in the same manner as a person whose differences are seen as normal variants.
The biggest practical challenge in implementing harm validity as a tool to limit disorder designation is that it may not always be possible to make the distinction between intrinsic distress and internalized distress, as both may be present simultaneously. In the case of ego-dystonic homosexuality, it is clear in hindsight that the distress was internalized. However, consider the distress associated with paraphilic disorders—how much of it is intrinsic and how much of it is extrinsic? It may also vary depending on the specific paraphilia. The degree of intrinsic distress may be different in pedophilic disorder compared to fetishistic disorder. It may very well be the case that all of distress with paraphilias is extrinsic, but it is difficult to determine conclusively. Another example would be hypoactive sexual desire disorder. How much of distress associated with low sexual desire is a direct result of the low sexual desire, and how much of it is due to our contemporary social norms that place a high emphasis on the need for an active sexual life?4
I suggest that even when these distinctions are not easily sorted, an emphasis on determining the presence of intrinsic harm would serve to stimulate social and psychiatric discourse on the nature of associated distress, particularly if it allows individuals with the conditions to talk about their subjective experience of distress. Perhaps, over time, stimulation of such discourse will lead to greater diagnostic clarification.
1. Wakefield JC. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 2007;6:149-156.
2. Bingham R, Banner N. The definition of mental disorder: evolving but dysfunctional? J Med Ethics. 2014;40:537-542.
3. Rashed AM, Bingham R. Can psychiatry distinguish social deviance from mental disorder? Philosophy, Psychiatry, & Psychology. 2014;21:243-255.
4. Aftab A, Chen C, McBride J. Flibanserin and its discontents. Arch Womens Ment Health. 2017;20:243-247.