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Validity

It is quite possible for a diagnosis to be completely reliable, but still not be valid. For example, we might suggest that there exists a disorder called 'Kinderman Syndrome'. Kinderman Syndrome might be diagnosed if someone possesses all of the following 'symptoms': having thinning brown hair, a south-east English accent and protruding ears. This diagnosis would probably be quite reliable. Although some interviewers might be poor at discerning a 'south-east English' accent, and some might be uncertain as to the exact definition of 'thinning' hair, I suspect a rigorous investigation would establish that any panel of suitably selected and trained clinicians would be able to agree at least 75% of the time as to whether these criteria are met. We might have to develop the criteria carefully - we might have to define 'protruding' in relation to ears, and even define the exact shade of 'brown' we meant. So there might be some work needed to refine the definitions, and we might need to train our clinicians. But I suspect we could get high reliability.

But is it valid? Is there in any real sense a syndrome, a disorder, a mental illness that - validly - exists merely because we can define it? Of course not. I am sure many of the people I have encountered in my professional life would leap at the idea of 'Kinderman Syndrome'. But we cannot accept that 'mental illnesses' exist merely because we can name them. We can't accept that reliability alone makes a 'disorder' a valid concept.

This is not just a theoretical argument. I mentioned the tragic and scandalous case of Alan Turing earlier in this chapter. Leaving aside the fact that it is immensely difficult reliably to define either heterosexual or homosexual sex (many men who have sex with other men do not regard themselves as gay, and many men who regard themselves as heterosexual have had sexual experiences with other men) the point is that to define somebody as having a 'disorder' because they have sexual preferences that a particular community chooses to repudiate does not make it a valid diagnosis. Incidentally (because I mentioned sexual preference), modern diagnostic manuals do not tend to label sexual preferences as 'disorders'. But they certainly do label distress associated with sexual issues as 'disorders'. So we have 'gender identity disorder'; rather than simply saying that someone has experienced a great deal of distress living in a discriminatory and heterosexist world, we label this distress as a 'disorder'.

There have been plenty of invalid diagnoses - diagnoses that psychiatrists have unhesitatingly rejected. In the 19th century, an American doctor called Samuel Cartwright seriously suggested that slaves who attempted to escape from their captors were suffering from the illness of 'drapetomania'10 (the Greek word drapetes means a runaway slave). According to Cartwright, men and women with a desire for freedom were merely exhibiting the symptom of an illness. In a frightening reflection of the behaviour of academics and clinicians, Cartwright wrote a scientific paper (the 'diseases and peculiarities of the negro race') in which he hypothesised that the aetiology of his newly identified 'illness' involved slave-owners treating their possessions as if they were human beings. Unsurprisingly, Cartwright suggested that the 'treatment' for 'drapeto- mania' was whipping.

Of course, not only is this nonsense, it was recognised as such by the psychiatrists of the day. But ... those psychiatrists did not suggest that it was equally nonsensical to medicalise a person's sexual preference. In my professional opinion, we need to question the validity of all mental health diagnoses. As colleagues and I said in a recent paper - we should 'drop the language of disorder'.11

 
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