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Guest Blog: Charles A Moser, MD, PhD and the DSM

By Russell J. Stambaugh, PhD

At the end of the 1980’s, the nascent world of open, above ground BDSM was facing very hard times.  Pansexual BDSM groups had come aboveground shortly after the 1969 Stonewall Riots, and local groups had burgeoned in major cities during the early 1970s.  The Leathersex communities’ titleholder events had become national conventions in the 1980s, and in 1983, david stein’s iconic “Safe, Sane and Consensual” campaign had gone viral among the gay and pansexual BDSM communities.

But as the decade drew to a close, Safe Sane and Consensual looked like a PR campaign, not reality.  The HIV/AIDS pandemic ravaged the Gay and Altsex communities, putting an end to the illusion of ‘Safe Sex”.  The American Psychiatric Association came out with the Diagnostic and Statistical Manual (DSM-IV).  Although it had completed the delisting of homosexuality begun in 1974, no such revision included consensual altsex behaviors, all of which were psychopathology in the new manual.  Kink was officially not ‘sane.’  And across the Atlantic Ocean in The United Kingdom, Scotland Yard arrested several dozen Leathermen in a sting operation and charged them with assaulting their submissives.  When the Leathermen protested that the assaults were consensual behaviors, the submissives were charged as accessories in their own ‘victimization;’ English law provided no right to consent to assault.  All would eventually serve three years in prison.  American activists held their breath that judicial conservatives appointed by Ronald Regan might import this thinking to the US.  You might consent to kink behavior, but that carried no guarantee you would be protected under the law!

This article details how the contribution of one man; Charles A Moser, MD, PhD, challenged the clinical assumptions that had pathologized consensual kinky behavior for over a century before he started working to overturn them.   It is a story of the struggle to make psychiatric diagnosis abandon conventional and uncritical thinking and garden variety politics, for diagnosis based upon scientific evidence, logic, and thorough observation.  Today, the most recent revision of the psychiatric manual regards a much wider variety of sexual expression as potentially healthy than in the 1980s because of Dr Moser’s work, which first saw fruition in the Diagnostic and Statistical Manuals 5th major revision in 2013, but continues as consensual kinks are delisted from the World Health Organization’s International Classification of Diseases (ICD-11) as it is individually modified and adopted by the United Nations 193 member nations.  Charles Moser, PhD, MD is not recognized for this contribution by the American Psychiatric Association, but his work established the intellectual foundation for the DSM changes and inspired and international movement that is manifesting in the ICD-11 revisions.

The Context of Challenging the DSM:

“Here we must beware the game of name-calling hidden in otherwise decent but indemonstrable concepts favored by psychoanalysis, concepts such as narcissism, deneutralized libido, and prepsychotic masquerading as normal.  None of these terms has been defined clearly enough so that observers can agree when evaluating a live person.  So I avoid them.  I can only say that, within the highly selective sample that my informants present, there is no one who is psychotic, prepsychotic, or latently psychotic by the standards that clinicians accept, for example having hallucinations, delusions, inexplicable or bizarre behavior, or major pathology of mood.  And these people, were one to try to apply character diagnosis to them, are as varied as I expect are the readers of this book.  Most of my informants are stable in employment; most are college graduates or beyond, lively in conversation, with a good sense of humor, up-to-date on politics and world events, and not more or less depressed than my social acquaintances.”  — Robert J Stoller, MD, in Pain & Passion: A Psychoanalyst Explores the World of S&M (1991) pp 19.  (The emphasis is mine, the italics, Stoller’s)

Social change is very rarely the product of any single individual.  Not Frederick Douglas, Mohandas Gandhi, nor Martin Luther, great though their individual contributions may be, accomplished their social changes in a vacuum.  So it is with de-pathologizing kinky behavior.  Robert Stoller sums up the problems of destigmatizing kink in his first chapter of his book.  Having called sadomasochism a perversion, he must claw back the impression that his study is about a bunch of crazies.  At the time of its writing, his study of the world of commercial sadomasochism was three years ahead of the first representative sample study of American sexual behavior, The National Sex and Social Life Survey, which,  to get funding through Congress during the George Herbert Walker Bush administration, pointedly declined to ask a single question about kink.  Stoller’s conclusion above presages the first such sample that did ask about kink in any Western country by 17 years.   This is the magnitude of the challenge that Charles A Moser took on when he conducted the first self-selected sample of American sadomasochists, and eventually decided to undertake a thorough criticism of the psychiatric diagnostic system as it related to consensual kink.

Charles A Moser, MD, PhD, did the research and academic writing that made diagnostic change possible.  His research on kink and his contribution of over 100 scholarly articles over 45 years, most on alternative sexualities, created an evidence-based conversation in psychiatry that coincided with the social changes that have made de-pathologizing kink an intellectually credible effort.  His bibliography can be found here: https://docx2.com/charles-moser-phd-md/  The links all avoid paywalls and I have employed them where possible so that you can read what Charles wrote.

To understand Charles intellectual contribution, it is necessary to describe the state of psychiatric thinking that prevailed at the end of the twentieth century as he began publishing his criticism.  That entails looking at the American Psychiatric Association’s thinking and practice in revising their diagnostic manuals.  In the late 1970s as psychoanalysis began to loosen its influence over American psychiatry, the American Psychiatric Association undertook its first major revision of the DSM.  Before 1980, the manual was a plagued by disagreements over construct validity and there was poor agreement among clinicians about the diagnoses as Stoller emphasized in the above quote.  The previous diagnoses might not be wrong, but neither were they agreed upon nor testable. The strength of the changes in the 1980 DSM revision is that diagnoses had greatly improved inter-rater reliability and were described in clearer symptomatic terms, albeit at somewhat decreased emphasis upon their underlying meaning and contexts.  To destigmatize them somewhat, ‘Sexual Deviations’ were re-labeled ‘paraphilias’, a Latin/Greek chimera meaning ‘unusual loves.’  In 1980, no one was complaining that consensual paraphilias such as sexual sadism, sexual masochism, transvestism, and fetishism were stigmatized but the DSM-III did respond to intense pressure mounting since the late 1950’s to stop including homosexuality as a sexual deviation because that was so highly stigmatizing and not well grounded in the best science.  That story is told in more detail here: https://elephantinthehottub.com/2017/06.  Since 1980, the American Psychiatric Association had delisted homosexuality but asserted it could feel confident in their classifications of the on the grounds that they were clearly described symptoms that could be reliably coded.  

All that was about to change in the wake of Stonewall, as kink practitioners started to come above ground.  In 1972, Pat Bond and Terry Kolb took the Till Eulenspiegel Society (TES) out of Bond’s small apartment into the basement of the first openly gay friendly church in the country, publicizing their meetings in Screw and The East Village Other, although to do so, he had to change his original name, The Masochists Liberation Front to the name of an obscure figure from German folklore in order for even the underground press to run his meeting announcements.  On the West Coast in 1974, Cynthia Slater founded the Society of Janus (SOJ) in San Francisco.  These pioneers were testing the theory that kinky folk would have enough in common regardless of their specific sexual interests that they would get together for social meetings and durable clubs could be formed.   This set the stage for Charles Moser to gather data on people practicing sadomasochism and make evidence-informed arguments about them.

Charles graduated from the University of Washington School of Social Work in 1975, just as these social kink organizations started to form.  He was aware of them because of the sexual diversity of his initial social work placement and later private practice, and he enrolled in the Institute for Advanced Study of Human Sexuality (IASHS) because it was a unique and convenient place to pursue additional training in human sexuality, a much-neglected topic in post-graduate mental health training.  In 1979, Charles completed his doctoral dissertation on a sample of self-described sadomasochists for his PhD at the IASHS, in San Fransisco.  The sample for Charles study was drawn from contact magazines and from volunteers from TES and SOJ.  In 1984, with the famous sociologist of sexual communities M S Wienberg and with C J Williams, he published his first academic paper on kink in the journal Social Problems in which they noted that their sample of sadomasochists did not conform well to the medical definitions of sexual sadists and masochists.  Instead, they argued that sadomasochism consisted of dominance and submission, role play, consensuality, a sexual context, and mutual agreement by participants to call what they were doing ‘S&M’.  That paper can be found here: https://docx2.com/wp-content/uploads/The-Social-Constituents-of-Sadomasochism.pdf.  This paper was published very shortly after the gay submissive david stein coined the slogan “Safe, Sane and Consensual’ for New York City’s Gay Male S/M Activists (GMSMA) in 1983 to address widespread public concerns that kink was dangerous behavior performed by crazy people, a very legitimate reading of the prevailing psychiatric definitions.  At that time, scarcely any data had been collected about kink practitioners and there was little basis for scientifically disputing negative public perceptions or psychiatric diagnoses.

Charles went on to publish the conclusions of the first self-selected sample studies of American kink practitioners.  Prior to his work, there was only one sociological study of members of a kinky community, by Andreas Spengler, in Germany https://link.springer.com/article/10.1007/BF01541150 .  Charles challenged prevailing notions from Spengler’s German data that the only women who participated in kink lifestyles were sex workers, and that most of the men were gay.  And Moser’s data mirrored those of his urban sexology practice in the Bay Area in the midst of the developing HIV crisis.  Under these pressures, Charles left social work to take medical training to amplify his ability to serve a much more diverse sexual community than anyone had anticipated when he had completed grad school 8 years previously.  Having already established a practice as a sex therapist, Charles correctly foresaw that he would need all the legitimacy he could get to best serve his outsider clientele, even though he claims not to have foreseen the approaching tsunami of financial services colonization of mental health.  In 1991 Charles took the plunge into medical training.  Since his completion of his medical residency in 1994, Charles has maintained a medical practice as an internist and primary care physician in San Francisco.

As of 1997, about when I first met Charles at AASECT Charles had yet to publish on the weaknesses of the DSMs and the weaknesses in the American Psychiatric Associations case for pathologizing consensual kinks.  In his essay for a collection of the personal journeys of professional Sexologists, How I got Into Sex https://www.amazon.com/How-Got-into-Sex-Criminologists/dp/1573921157,   Charles described becoming a leading expert on sadomasochism, the Director of Research at IASHS, and had a thriving practice as an internist serving a sexually diverse community without having decided to commit his knowledge to challenging Krafft-Ebing’s orthodoxy of 115 years earlier.  Several changes mobilized him.

In 1997, NCSF was founded conjointly by the TES, SOJ, GMSMA, and the National Leather Association.  Two years later, Charles served as a consultant to NCSF.  Among its missions, NCSF sought to destigmatize consensual kink.  Charles was a natural fit with NCSF’s desire to do that using scientific argument and evidence.

In 2000, The American Psychiatric Association issued an update of their DSM-IV, the DSM -IVTR, which left most of their diagnostic categories unchanged, including those covering the paraphilias, thus dispelling hopes they would make these diagnoses less pathologizing without increased pressure from outside advocacy.

In 2001, the first representative sample studies began to emerge suggesting that many psychiatric assumptions about sexual variance were overly pathologizing kink.   Charles’ study found most kinksters were happy with their sexual interests, a finding inconsistent with the American Psychiatric Association’s stance.  Although those he studied were not sick or depraved, they constituted a sample of kinky volunteers.   Like Stoller’s informants, it was not possible to know if they were representative of the larger population of Americans engaged in kinky behaviors.   Following J Richters et al (2008) https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1743-6109.2008.00795.x as series of studies explicitly evaluated the mental health of kinky subjects using the Neuroticism Scale of The Big Five Personality scale.  Other studies were critical of the models pathologizing kink (Cross and Matheson (2006) to be found in https://www.amazon.com/Sadomasochism-Powerful-Pleasures-Peggy-Kleinplatz-ebook/dp/B00HRU95X4.  The first representative sample study of diverse sexual behaviors in the United States was published in 2017, but did not examine personality or mental health.

Taking over from the initial efforts of Guy Baldwin and Race Bannon, The National Coalition for Sexual Freedom had relaunched the DSM project in the late 2000s to influence the DSM review process, and in the years close to the 2013 release of DSM – 5, NCSF had talked directly with the Paraphilias Committee members about the accumulating data that the mental health of kink communities, in so far as it could be known through social surveys, looked pretty similar to that of the general population.  The Paraphilias Committee had done a thorough review of the academic literature and was well aware of these data even as the advocacy community presented them.  But so too were the Paraphilia Committee members aware of the many other social actors who presented alternate points of view that the public hoped APA would accommodate.  For all the disclosure, there is an irreducible opacity in just how much the volume of these efforts influenced the final product.  You will just have to take my word when I suggest that the tremendous body of work the Charles Moser published played a critical role in altering the context for these discussions.  But here is the evidence from Charles own writings.  Don’t take my word for it, take his!

Charles and the DSM:

The summary that follows highlights Charles Moser’s arguments against the paraphilia sections of the DSM.  In the period between the release of DSM-IVTR in 2000, and the May 2013 release of DSM – 5 publishing date, Charles wrote 16 articles on other topics, about half of which targeted problems with other sections of the manual, including those covering sexual disorders, the proposed diagnoses of hypersexuality/compulsive sexual behavior and sex addiction which eventually were not included in DSM – 5, and on gender diagnoses.     This essay focuses of the paraphilia category itself because of its centrality to the experience of all kinky people, but these other diagnostic criticisms are important to many kinksters because communities overlap, and much BDSM involves gender play.

In 2001, Charles began his direct attack on the DSM in Paraphilia: A Critique of a Confused Concept. http://tempik.webzdarma.cz/literatura/parmoser/.  In it he thoroughly deconstructed the assumptions behind the concept of paraphilia as represented in the DSM.  The core of his argument was that medicine and sexology knew so little about the etiology of heterosexual, homosexual, or variant sexual interests that there was no basis for handling these sexual interests differently in the manual.  Sexual interests were some more frequent than others, but extremely variable throughout the contemporary human population and throughout history, with no intrinsic basis for declaring some troublesome and others benign even though some more directly led to reproductive consequences. This was tacitly acknowledged by the APA when the DSM stopped pathologizing homosexuality, which had originally been classified with the perversions by Krafft-Ebing precisely because of its inevitable consequences on reproduction.  If homosexuality was no longer a disease, why then were less common or less popular sexual interests still pathologized?

Charles answered his own question by analyzing the process and dynamics of how clinicians define variant sexual interests as mental disorders.  This process relies on the subjective opinions of clinicians.  No matter how ‘scientific’ the procedure for comparing the agreement between diagnosticians might be, calling for them to make a subjective estimate of pathology that was lacking a solid basis in scientific evidence was faulty science. The current nosology reflected heterosexual bias and privileged social assumptions of normality on a conventionalist basis.

When it came to science, the paraphilia category had no clothes.  Although back in 1980, John Money had appropriated Wilhem Stekel’s language ‘paraphilia’ or ‘strange love’, in the chimerical contraction of Latin and Greek, to rescue the diagnoses from the obvious stigma of the previous term; “sexual deviation” — the language in DSM’s I and II — the paraphilia language had become stigmatizing due to the inherent unscientific assumptions of the psychiatric profession itself! There was no good science linking the paraphilias together such that they inevitably co-occurred or profited from the same treatment, and it was unclear, when such interests were presented as ‘ego-dystonic’ or unwanted that the reasons were intrinsic to the preferences, rather than real or imagined discrimination based upon social stigma.  In fact, Moser argued, it was unclear that the sexual variations were diseases at all.  By showing that the diagnostic manual reserved to the clinicians’ subjective opinions the critical diagnostic question of whether a sexual interest was a problem, Charles had APA in a trap.  With the recognition that all such decisions were subjective in their application, they lacked a scientific basis. Yet what is the purpose of a diagnostic category if it does not reserve to the clinician the basis for conferring a diagnosis on the basis of their expert knowledge as professionals?

To keep reading, go to: https://elephantinthehottub.com/2021/09/charles-a-moser-md-phd-and-the-dsm