The APA Paraphilias Subworkgroup Agrees:
Kinky is NOT a Diagnosis
In the new proposals for the DSM-V, alternative sexual behavior has been depathologized. The American Psychiatric Association's Paraphilias Subworkgroup's DSM revisions acknowledge that you can be a fetishist, transvestite, sexual sadist or sexual masochist without having a mental disorder.
NCSF has worked very hard with its DSM Revision Project to make sure these changes take place, and will continue to strongly advocate for clear language of what exactly constitutes a mental disorder. Susan Wright liaisoned with the work group and supplied data that NCSF has gathered about the real-world discrimination and persecution that takes place against BDSM-fetish practitioners because of the DSM-IV-TR. The DSM Revision Petition was also extremely useful in generating comment from community members and mental health professionals urging that the current diagnoses be changed.
Read the "Rationale" section under each diagnosis to see their thinking on the paraphilias. The work group makes it clear that "non-normative" sexual behavior is practiced by healthy people:
"The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder."
"These revisions will affect everything-child custody, job discrimination battles, and even help change the way society views us," says Leigha Fleming, Chairperson and Director of Incident Response. "I think of all the people over the years who have had the DSM used as a tool of discrimination and punishment, and I'm proud of NCSF for continuing the fight to change it. This is the first step towards decriminalization of BDSM, which NCSF is pursuing with our Consent Counts project."
The Paraphilias Subworkgroup is now reconsidering what constitutes "clinically significant distress or impairment in social, occupational, or other important areas of functioning" when determining a mental disorder. The DSM must make it clear that people do suffer distress and impairment because of the societal stigma against alternative sex, but that doesn't mean they are suffering distress that is generated internally.
As part of the development process, the preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses are now available for public review and comment until April. Personal comments about discrimination and persecution are welcome additions to this commentary to continue to urge the work group to differentiate between sexual minorities and sex offenders.
Just as Norway recently joined Sweden and Denmark in removing consensual paraphilias entirely, NCSF continues to urge the complete removal of these paraphilias from the DSM. However like the incremental removal of homosexuality (to egodystonic homosexuality and then finally taken out in 1987) this is an important step for the BDSM-leather-fetish community.
NCSF needs your support to continue important projects like the DSM Revision Project that directly impact peoples' lives. Please join NCSF to show solidarity! We do so much for very little money, and we need your help.
February 16, 2010
The National Coalition for Sexual Freedom is committed to creating a political, legal, and social environment in the United States that advances the equal rights of consenting adults who practice forms of alternative sexual and relationship expression. NCSF advances the rights and advocates for consenting adults in the SM-Leather-Fetish, swing, and polyamory communities. We pursue our vision through direct services, education, advocacy, and outreach in conjunction with our partner organizations to directly benefit these communities.
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NCSF was asked by thge DSM Paraphilias subworkgroup to respond to their proposed changes to the DSM's consensual paraphilias. This is our letter to the editor of the Archives of Sexual Behavior that was published on July 15, 2010.
Archives of Sexual Behavior
National Coalition for Sexual Freedom
410 Guilford Ave, #127
Baltimore, MD 21202
Depathologizing Consensual Sexual Sadism, Sexual Masochism, Transvestic Fetishism, and Fetishism
[Letter to the Editor]
The DSM-V Paraphilias Subworkgroup's suggested revision to differentiate between paraphilias and Paraphilic Disorders appears to be a step forward in depathologizing unusual sexual interests. Paraphilia diagnoses are regularly misused in criminal and civil proceedings as an indication that individuals cannot control their behavior; these individuals turn for assistance to the National Coalition for Sexual Freedom (NCSF), a national advocacy organization that advances the rights of, and advocates for consenting adults in the BDSM-leather-fetish, swing, and polyamory communities.
One recent child custody case referred to NCSF illustrates the common misunderstanding that legal and social service professionals have with the DSM-IV-TR, and is the first documented reaction to the proposal to differentiate between paraphilias and Paraphilic Disorders. The children were removed in July 2009 while psychological evaluations were performed on the mother and the children, which concluded there was no mental illness.[1} However the case worker with the Department of Social Services Children's Division in the Midwestern state where this case occurred sent the following January 21, 2010 letter to the mother’s court appointed psychologist: (DSS, 2010):
"With regards to [mother's] alternative lifestyle; can she separate this from her parenting? There has been some questions arise from other team members regarding her sexual sadism. These are as follows:
"We were made aware at the last FST meeting that while all parties involved have seen the information provided regarding [mother's] blog and website, no action has been taken to determine how it affects the children or is factored into the stated case goal of reunification with [mother]. The following information is relevant:
A. Sexual Sadism is considered a form of paraphilia in accordance with the DSM-IV-TR.
B. [Mother] admitted in court on March 9, 2009 that she was a "domme" – slang for a female sexual sadist.
C. Sexual Sadism involves inflicting pain and suffering on another individual in order to achieve sexual arousal." …
"Sexual sadism on the web has the following information: 'The essential feature of sexual sadism is a feeling of sexual excitement resulting from administering pain, suffering or humiliation on another person. In extreme cases, sexual sadism can lead to serious injury or death for the other person. According to the DSM these catastrophic results are more likely when the paraphilia is diagnosed as severe, and when it is associated with antisocial personality disorder. They may experience distressed or impaired functioning because of the sadistic behaviors or fantasies. This distress and impairment may be due to the fact that the partner is not consenting. The diagnosis of sexual sadism is complicated by several factors, beginning with the fact that most persons with the disorder do not voluntarily enter therapy.'"
"[Mother] indicated she gave up this lifestyle in March. However the blog and stories that were found were posted to her website in May. There are concerns that she is still a moderator of the [BDSM] yahoo group. I have attached pages from her website in hopes that you can explore with [mother] her current involvement with this alternative lifestyle."
The CPS letter concludes with the recommendation that: "Even though [mother] is complying with attendance in therapy, we feel the above issues need to be explored and addressed."
At the final permanency hearing in February, 2010 the mother's lawyer submitted to the judge the proposed revisions for the DSM-V to separate the paraphilias from Paraphilic Disorders, resulting in a court determination to re-evaluate her entire case. The judge specifically chastised the Department of Social Services for not being aware of the proposed changes for the DSM-V. Based on the proposed revisions, in March the mother was awarded custody of three of the children, with the father retaining custody of one child in order to take advantage of his health care coverage.
As this example shows, when individuals who practice BDSM are brought to the attention of authorities, they are regularly misdiagnosed with a mental disorder. In 2009, NCSF was asked for help by 132 people regarding child custody/divorce issues directly involving their alternative sexual practices (NCSF, 2009). The year before, a total of 157 individuals contacted NCSF for help with child custody/divorce issues (NCSF, 2008). In total, almost 500 people each year request help from NCSF because of discrimination or persecution due to their alternative sexual practices.
Therefore the implications of "ascertaining a paraphilia" and "diagnosing a paraphilic disorder" are critical to depathologizing consensual paraphilias. I am concerned that if sexual sadism receives its own diagnosis code separate from Sexual Sadism Disorder, social services and legal professions will continue to think that anyone who practices consensual sexual sadism (or sexual masochism, fetishism and transvestic fetishism) therefore has a mental disorder.
The consensual paraphilias should be mentioned as the healthy comparison to a Paraphilic Disorder, much like various sexual behaviors are referred to in the proposed Hypersexual Disorder. Cybersex and masturbation don't have separate diagnosis codes in the DSM, and it is equally erroneous to assign separate codes for the paraphilias when they are not mental disorders or of clinical concern. For the same reason, the consensual paraphilias shouldn't be listed among the V-Codes.
Separating sexual behaviors (paraphilias) from the mental disorders (Paraphilic Disorders) is the first step in depathologizing consensual alternative sex. The second step is defining what exactly constitutes clinically significant distress. NCSF often consults with individuals who suffer distress and impairment in their social and occupational lives (ie. interpersonal difficulties) because their desires conflict with current societal standards. These standards stem in a large part from the DSM itself: pathologizing unusual sexual interests has led to increased discrimination and discouraged individuals from seeking treatment for physical and mental health problems (Wright, 2008).
A distinction must be made in the DSM-V between distress imposed by societal stigma, and distress that is generated internally. As seen in the above referenced child custody case, mental health professionals are not the only ones who consult the DSM. When attorneys, judges, and social workers read the diagnoses in the DSM, they see "distressed or impaired" as the determiner of mental illness. Without a comprehensible definition, they look at the individual who is on trial or in a child custody battle, and that individual certainly appears distressed. They even speculate that if the individual gave up their BDSM practices, then their life wouldn't be in disarray, so clearly they must be suffering a mental disorder because their sexual behaviors are obligatory or "obsessive" (DSS, 2010).
Therefore the current list by which distress and impairment are diagnosed must be rejected: 1) are obligatory, 2) result in sexual dysfunction, 3) require participation of nonconsenting individuals, 4) lead to legal complications, or 5) interfere in social relationships. Legal complications and interpersonal difficulties are common consequences of the stigma and discrimination against BDSM practices. In the Second National Survey of Violence & Discrimination Against Sexual Minorities, a total of 1,146 (37.5%) of the respondents indicated that they had either been discriminated against or had experienced some form of harassment or violence (Wright, 2008). As a result, 60% of the 3,000 respondents are not "out" about their BDSM interests; the stress of being closeted and/or coming out promotes distress and impairment in these individuals, similar to that experienced by homosexuals.
In addition, once a Paraphilic Disorder is diagnosed, can it ever be in remission? If so, what are the mechanisms for determining that? If the distress and impairment are resolved, does the individual go back to the ascertainment category? As of now, once a mental disorder is diagnosed, it appears to apply for the lifetime of the individual.
Finally, it must be made clear that Paraphilic Disorders are extremely rare. In particular, the descriptive text for Sexual Sadism Disorder needs to clearly state that it is limited to forensic populations, and, as Krueger (2009) states, "virtually all of the published papers using DSM criteria for Sexual Sadism have been done on studies of forensic populations." This will help prevent the conflation of those who practice consensual paraphilias with those who have a Paraphilic Disorder.
 All names and locations have been removed to protect the identity of those involved.
 Bolded in original letter despite there being no evidence the mother has antisocial personality disorder.
Krueger, R.B. (2009). The DSM Diagnostic Criteria for Sexual Sadism. Archives of Sexual
Behavior, published online 08 December, 2009.
Department of Social Services, Children's Division. January 21, 2010 letter.
National Coalition for Sexual Freedom (2009) (retrieved 5/7/10). 2009 Incident Response Report
National Coalition for Sexual Freedom (2008) (retrieved 5/6/10). 2008 Incident Response Report
Wright, S. (2008) (retrieved 5/6/10). Second National Survey of Violence & Discrimination
Against Sexual Minorities
The DSM-5 Says Kink is OK!
The American Psychiatric Association has depathologized kinky sex – including cross-dressing, fetishes, and BDSM – in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Now the paraphilias are considered to be “unusual sexual interests,” while those who have sex with children or people who haven’t consented, or who deliberately cause harm to themselves or others, may be diagnosed with a Paraphilic Disorder.
“The APA has made it clear that being kinky is not a mental disorder,” says Susan Wright, Spokesperson for NCSF. “That means people no longer have to fear being diagnosed as mentally ill just because they belong to a BDSM group. We’ve already seen the impact – NCSF immediately saw a sharp rise in the success rate of child custody cases for kinky parents after the proposed DSM-5 criteria was released three years ago.”
NCSF would like to thank everyone who participated in signing our DSM Revision Petition and for telling the APA about their own stories of discrimination and persecution. NCSF also thanks every member of the APA Paraphilias Subworkgroup for responding to our concerns, and drawing a hard line between consensual adult kinky sex and those who willfully engage in nonconsensual or harmful activities.
NCSF is proud to build on the work of kink-aware professionals who have come before us, including Race Bannon and Guy Baldwin, who helped make seminal changes in the DSM-IV in 1994.
The following are some statements about the various paraphilias in the DSM-5. Although highly clinical in language, they show the APA’s intent to not demand treatment for healthy consenting adult sexual expression:
“A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.” p. 686
“In contrast, if they declare no distress, exemplified by anxiety, obsessions, guilt or shame, about these paraphilic impulses, and are not hampered by them in pursuing other personal goals, they could be ascertained as having masochistic sexual interest but should not be diagnosed with a sexual masochism disorder.” p. 694
“Many individuals who self-identify as fetishist practitioners do not necessarily report clinical impairment in association with their fetish-associated behaviors. Such individuals could be considered as having a fetish but not fetishistic disorder.” p. 701
“Clinical assessment of distress or impairment, like clinical assessment of transvestic sexual arousal, is usually dependent on the individual’s self-report.” p. 703
To support NCSF, go to www.ncsfreedom.org. NCSF relies entirely on your donations to advance the rights of consenting adults and to do advocacy like our DSM Revision Project. Please donate now!
Normal or Not? A Sexual Attraction to Objects
The DSM-5 marks this transition by attaching the term "disorder" when an unusual sexual interest crosses these boundaries. So, hypothetically, someone who simply uses shoes to masturbate or whose partner accepts his unusual interest in shoes could be diagnosed with fetishism, but not a fetishistic disorder — unless the fetish crosses the threshold in one of the ways described above.
Along the same lines, Wismeijer also suggested that accepting one's unusual sexual preferences and choosing to live in a societal niche like the BDSM community might involve huge amounts of psychological work, which could translate into positive mental health.
Kinky is NOT a Diagnosis
Help make history by signing the DSM Revision Petition now! The diagnoses in the DSM-IV-TR still subject people who practice BDSM, fetishes and cross-dressing to bias, discrimination and social sanctions without any scientific basis.
We need 3,000 signatures, but we only have 2,200 now. If you don't speak up and call on the American Psychiatric Association to adhere to empirical research when revising the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM V), then the Sexual and Gender Identity Disorders Work Group won't make a meaningful change.
To sign, go to: www.thepetitionsite.com/1/DSMrevisionpetition
You can make your signature anonymous on this secure petition site so it doesn't appear on the Internet or when the petition is delivered to the APA.
"We, the undersigned, support the American Psychiatric Association's (APA) own goal of making its Diagnostic and Statistical Manual (DSM) a scientific document, based on empirical research and devoid of cultural bias. A diagnosis of a mental disorder can have a severe adverse impact on employment opportunities, child custody determinations, an individual's well-being, and other areas of functioning. Therefore we urge the APA to remove all diagnoses that are not based upon peer-reviewed, empirical research, demonstrating distress or dysfunction, from the DSM. The APA specifically should not promote current social norms or values as a basis for clinical judgments."
To find out more about the DSM and the Paraphilias section, read the NCSF & ITCR: The Foundation for www.thepetitionsite.com/1/DSMrevisionpetition's "White Paper on the DSM Revision" at www.ncsfreedom.org
October 15, 2009
The American Psychiatric Association has formed working committees to revise by 2011 its Diagnostic and Statistic Manual (DSM), the definitive resource on the Diagnostic Criteria for all mental disorders. Statements currently within the DSM Paraphilias criteria are contradicted by scientific evidence, therefore NCSF must conclude that the interpretation of the Paraphilias criteria has been politically – not scientifically – based. This politically motivated interpretation subjects BDSM practitioners, fetishists and cross-dressers to bias, discrimination and social sanctions without any scientific basis. We call on the American Psychiatric Association to remove or drastically restructure the Paraphilias section in the DSM.
The American Psychiatric Association's Paraphilias Subworkgroup Agrees: Kinky is NOT a Diagnosis!
In the proposals for the Diagnostic and Statistic Manual (DSM-V), alternative sexual behavior has been depathologized. NCSF applauds the American Psychiatric Association's Paraphilias Subworkgroup's revisions which state that you can be a fetishist, transvestite, sadist or masochist without having a mental disorder. More work needs to be done but this is an important first step!
Read more about the project. Included is relevant PR responses from the revision committee members as well as our responses to them.
Sweden takes sexual behaviors off their disease list
November 25, 2008 -
The Swedish National Board of Health and Welfare is declassifying sexual behaviors as mental illnesses to avoid strengthening prejudice against the behaviors, the Swedish news service Tidningarnas Telegrambyra reported last week. The diagnoses which will soon disappear from the disease registry include sadomasochism, fetishism, fetishistic transvestitism, transvestitism, gender identity disorder in youth, and multiple disorders of sexual preferences. NCSF applauds Lars-Erik Holm, the head of the National Board of Health and Welfare (Socialstyrelsen), who made the decision to declassify the behaviors because they are not illnesses in and of themselves, nor are they something perverse. "These diagnoses are rooted in a time when everything other than the heterosexual missionary position were seen as sexual perversions," Holm said.
"The NCSF's DSM Revision Project has the same goal to change or remove these harmful diagnoses," says Susan Wright. "We know from the hundreds of requests for help that NCSF gets every year through our Incident Response program that Sexual Sadism, Sexual Masochism, Fetishism and Transvestic Fetishism diagnoses in the American Psychiatric Association's Diagnostic and Statistic Manual (DSM) reinforce the negative stereotypes and stigma against alternative sexual behaviors."
To support NCSF's DSM Revision Project, please sign the petition (www.ncsfreedom.org) that will be sent to the APA urging them to adhere to scientific research when revising the diagnoses in the DSM. To find out more about this project, read the NCSF and the ITCR: NCSF Foundation's White Paper posted on www.ncsfreedom.org
A joint Project of NCSF and ITCR: The Foundation of NCSF
FOR IMMEDIATE RELEASE
National Coalition for Sexual Freedom
Marching Forward: NCSF proactively advocates for sexual freedom
November 19, 2008 - NCSF is proud to be the only group in the country with a national mission committed to changing the political, legal and social environment for those involved with the BDSM, swing and polyamory communities. The new board of NCSF was voted in at the annual Coalition Partner meeting held in Atlanta in September: Leigha Fleming is the new Chairwoman of NCSF, and new board members Laura
Carlson (Secretary), Klawdya Rothschild, Tim Murray, and Ron Zimmerman have joined existing board members Vivienne Kramer (Treasurer), Jim Duvall, Jim Fleckenstein, and Howie Zusel.
NCSF has directly helped tens of thousands of practitioners, businesses and groups since its founding in 1997. NCSF's newest project is the DSM Revision Project: Kinky is NOT a Diagnosis! The DSM Revision Petition is gathering signatures from individuals and organizations calling on the American Psychiatric Association (APA) to adhere to empirical research when revising the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Susan Wright is working directly with the DSM revision committee to ensure that healthy BDSM practitioners and cross-dressers are not misdiagnosed under the DSM criteria.
Media Outreach Project
Kink Aware Professionals (KAP)
Education Outreach Program
The Education Outreach Program (EOP) is run under the Institute for 21st Century Relationships by The Foundation of NCSF. ITCR supports the freedom of consenting adults to discover and to practice the intimate relationship structure that best meets their emotional and human needs. The EOP educates law enforcement officials, and our constituents about the risks of selective enforcement and how to minimize the risk of becoming a target. NCSF has published a number of pieces of literature for this program and has trained a team of individuals from across the country to deliver 10 educational presentations from "Traveling With Toys" to "How to Protect Your Event."
For over a decade, NCSF has formed valuable alliances with other advocacy organizations to work on projects that defend sexual freedom rights: Free Speech Coalition, the ACLU, American Association of Sex Educators, Counselors and Therapists, the Society for the Scientific Study of Sexuality, National Gay and Lesbian Task Force, the Gay and Lesbian Alliance Against Defamation, and the Gay and Lesbian Activist Alliance, among others. Susan Wright is on the Advocacy Committee of the American Association of Sex Educators, Counselors and Therapists.
NCSF is a member of the organizing committee for the Sex Positive Journalism Awards, along with journalist Miriam Axel-Lute and activists from The Center for Sex & Culture. The first award ceremony for the Sexies was held in New York City on October 4, 2008 (www.sexies.org). NCSF also participates in
Consent Counts, a group formed at Creating Change 2007 to take on the work of decriminalizing Leather/kink/fetish/BDSM consensual adult behavior (www.consentcounts.org).
Currently NCSF has 56 Coalition Partners who elect the board and establish the yearly goals at the annual Coalition Partner meeting. Coalition Partners are groups and businesses that serve BDSM, swing and polyamory practitioners. NCSF also has nearly 100 Supporting Members - groups and businesses who actively support NCSF - totaling tens of thousands of members. You can also become an individual member for $25, which goes directly to supporting NCSF programs and projects.
In the past decade, alternative sexual expression has become much more visible to the general public, bringing about an increasing number of attacks. The success of this fight depends on your support. You can become an individual member of NCSF, volunteer to join the NCSF staff, make a donation to NCSF, initiate or help out at a fund-raiser for NCSF, and encourage your group to become a Coalition Partner of NCSF. Every step you take helps us further the sexual freedom movement!
Check out these exciting projects on the NCSF website at: www.ncsfreedom.org
A joint Project of NCSF and ITCR: The Foundation of NCSF
Because the scientific evidence contradicts the statements currently within the DSM, we must conclude that the interpretation of the Paraphilias criteria has been politically NOT scientifically based. This politically motivated interpretation subjects BDSM practitioners, fetishists and cross-dressers to bias, discrimination and social sanctions without any scientific basis. We call on the American Psychiatric Association to remove or drastically restructure the Paraphilias section in the DSM.
The American Psychiatric Association's Diagnostic and Statistic Manual (DSM) is the definitive resource on the Diagnostic Criteria for all mental disorders. It influences the International Statistical Classification of Diseases (ICD) and other entities throughout the world.
The DSM-IV-TR definition of a mental disorder is that it is "…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom… Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders…" (p. xxxi)
Yet the Paraphilias section categorizes distress and dysfunction according to certain sexual behaviors, not psychological syndromes or patterns. Behavior itself is not evidence of psychopathology; compulsive hand washing may be a symptom of obsessive-compulsive disorder, but it is not a hand-washing disorder.
A distinction must be made between the cause and the effect. There is no data to support the Paraphilias as the cause of the distress and dysfunction in individuals. In addition, discrimination and societal pressure cause significant distress for a great number of people, in which the societal stigma is the cause rather than the sexual behavior itself.
There are no clear guidelines in the DSM that distinguish a Paraphilia from "healthy" sexuality. Can paraphiliacs be distinguished from those with "healthy" sexuality, except by differences in their sexual behavior? If yes, how? Can someone prefer those exact same behaviors without meeting the diagnostic criteria? Yes, according to the DSM itself (p. 568). So why not just define the abnormal preference instead of the behavior? Diagnostic criteria that pathologize everyone and do not distinguish pathology from normal variants are useless as diagnostic tools.
"A Paraphilia must be distinguished from the non-pathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complications, interfere in social relationships). (DSM, p. 568)
Let's examine each of these "indicators" of psychopathology more carefully:
Heterosexual behavior is considered "obligatory" by heterosexuals, just as homosexual behaviors are considered "obligatory" by homosexuals. Neither is considered to be a psychopathology like Sexual Sadism, Sexual Masochism and Transvestic Fetishism.
2. Result in sexual dysfunction
43% of women and 31% of men report sexual dysfunction (Laumann, Paik, & Rosen, 1999). Yet the DSM does not contain a diagnosis for people having difficulty with heterosexual interests such as divorce, sexual harassment, not being able to maintain their erotic attraction to their partner, not having enough sex, or not being able to find a relationship. There is no causation data that finds that being heterosexual causes dysfunction, only correlation. There is also no data indicating if sexual dysfunction is more common among heterosexuals than others.
Any sex can be problematic. Masturbation, oral sex and anal sex were once considered to be mental disorders or symptoms of other mental disorders until these behaviors became an accepted form of sexuality. Nymphomania, Satyriasias, and Erotomania are also no longer considered to be mental disorders because these diagnoses impose a cultural value judgment on sexual behavior, rather than comprising a diagnosable entity.
3. Require participation of nonconsenting individuals
Sexual assault is a crime, not a psychiatric diagnosis. Rape is not listed in the DSM. Why do other nonconsensual sex interests have a diagnosis? For Exhibitionism, Frotteurism, and Voyeurism, the diagnosis can only be made if the partner or other person has not consented to the activity. Sadomasochism without consent is a crime; if the behavior is consensual, then it should be considered the same as any other consensual sex act. Pedophilia is a crime because it involves sexual relations between adults and minors.
4. Leads to legal complications
There are a number of legal complications that can arise from consensual sexual behaviors: child custody disputes, divorce settlements, arrest for obscenity and indecency, etc. Historically homosexuals have broken laws and suffered severe social consequences due to their sexual behavior. On this basis some states denied homosexuals the right to adopt because they were breaking the law in their sexual relations. It wasn't until the abolition of state sodomy laws in Lawrence v. Texas (2003) that homosexual activities became legal throughout the U.S. Yet the DSM removed homosexuality as a diagnosis over 30 years ago.
5. Interferes with social relationships
Discrimination and societal pressure over certain sexual behaviors can lead to a great deal of distress and dysfunction. The individual internalizes societal values, creating a conflict between themselves and society. They can encounter prejudice from friends, relatives, partners and co-workers because of their sexual behaviors. This doesn't mean that the individual has a mental disorder. In addition, therapists' beliefs, socialization, and theoretical perspectives will likely affect their judgments of sexual behaviors when they are asked to treat this distress. Thus the Paraphilias are a diagnosis of social/sexual control.
According to the APA, "The utility and credibility [of the DSM]… require that it… be supported by an extensive empirical foundation." (p. xxiii) The DSM-IV-TR's own revision standards are:
- "to correct any factual errors…"
- "to ensure that all of the information is up-to-date…"
- "to reflect new information available…"
- "changes had to be supported by empirical data." (p. xxix)
The data in the DSM Paraphilias section is not supported by scientific research:
According to the DSM: "The individual Paraphilias can be distinguished based on difference in the characteristic paraphilic focus. However, if the individual's sexual preferences meet criteria for more than one Paraphilia, all can be diagnosed." (p. 569)
“Unusual” sexual interests are commonly found in the general population (Renaud & Byers, 1999; Sue, 1979)
"There is no empirical research suggesting that even those 'appropriately' (according to the DSM criteria) diagnosed with Sexual Sadism or Sexual Masochism are likely to experience either a dangerous increase in the intensity of their SM interactions nor that Pedophilia is a likely outgrowth of these activities." (Klein & Moser, p. 238)
According to the DSM: "Many individuals with these disorders assert that the behavior causes them no distress and that their only problem is social dysfunction as a result of the reaction of others to their behavior. Others report extreme guilt, shame, and depression at having to engage in an unusual sexual activity that is socially unacceptable or that they regard as immoral." (p. 567)
"Four out of five are satisfied with their S/M orientation." (Levitt et al. p. 472)
According to the DSM: "The behaviors may increase in response to psychosocial stressors, in relation to other mental disorders, or with increased opportunity to engage in the Paraphilia." (p. 568)
"The non-clinical studies of individuals with unusual sexual interests demonstrate that these individuals are indistinguishable from those with 'normophilic' (i.e., conventional) sexual interests." (Moser & Kleinplatz, 2003, p. 96)
2. Sexual Sadism
According to the DSM: "Some individuals with this Paraphilia are bothered by their sadistic fantasies, which may be invoked during sexual activities but not otherwise acted on; in such cases the sadistic fantasies usually involve having complete control over the victim, who is terrified by anticipation of the impending sadistic act. Others act on the sadistic sexual urges with a consenting partner (who may have Sexual Masochism) who willingly suffers pain or humiliation. Still others with Sexual Sadism act on their sadistic sexual urges with nonconsenting victims." (p. 573)
"The data suggest that the majority of rapists are not motivated by sadism." (Groth & Hobson, 1983; Hucker, 1997).
According to the DSM: "Sadistic fantasies or acts may involve activities that indicate the dominance of the person over the victim (e.g., forcing the victim to crawl or keeping the victim in a cage). They may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation, or killing." (DSM, p. 573)
"The inclusion of nonconsent is especially problematic in the case of Sexual Sadism. Although it is clearly possible for an individual with the diagnosis of Sexual Sadism to engage in nonconsensual acts, most “sadists” do not seek non-consenting partners." (Moser, 1999; Weinberg, Williams, & Moser, 1984)
"Just as it is inappropriate to confuse rapists with those individuals interested in consensual sexual activities, the lumping of individuals interested in consensual sexual sadism with those who engage in non-consensual activities is similarly inappropriate." (McConaghy, 1999)
According to the DSM: "Sadistic or masochist behaviors may lead to injuries ranging in extent from minor to life threatening." (DSM, p. 567)
"Although any sexual activity can lead to injury, there is no data to suggest that the practitioners of “sadistic or masochistic behaviors” frequent emergency departments more often than practitioners of other sexual behaviors. A review of the sports medicine and emergency medicine literature reveals numerous studies of specific injuries related to various sports and other activities. If unusual sexual acts resulted in a significant number of injuries, presumably they, too, would appear prominently in the medical literature." (Moser & Kleinplatz, 2005)
3. Sexual Masochism
According to the DSM: "Except for Sexual Masochism, where the sex ratio is estimated to be 20 males for each female, the other Paraphilias are almost never diagnosed in females, although some cases have been reported." (p. 568)
No studies have been found to support the 20:1 statement. Several studies were found that reported a significant number of women in the SM subculture (Breslow, Evans, & Langley, 1985; Gosselin, Wilson, & Barrett, 1991; Levitt, Moser, & Jamison, 1994). By combining the data of Breslow et al. (1985) and Levitt et al. (1994), a ratio of four male masochists to each female masochist was found. Even if clinical samples are overwhelmingly male, no study supports the naming of a specific ratio.
According to the DSM: "One particularly dangerous form of Sexual Masochism, called "hypoxyphilia," involves sexual arousal by oxygen deprivation obtained by means of chest compression, noose, ligature, plastic bag, mask or chemical (often a volatile nitrite that produces a temporary decrease in brain oxygenation by peripheral vasodilation). (DSM, pp. 572-3)
“In contrast to transvestism, bondage during the fatal asphyxial episode was not differentially associated with any specific erotic object or interest that we examined, even bondage pornography.” (Blanchard and Hucker, 1991, p. 375).
4. Transvestic Fetishism
According to the DSM: "Usually the male with Transvestic Fetishism keeps a collection of female clothes that he intermittently uses to cross-dress. This disorder has been described only in heterosexual males... Although his basic preference is heterosexual, he tends to have few sexual partners and may have engaged in occasional homosexual acts. An associated feature may be the presence of Sexual Masochism." (DSM p. 574)
"Cross-dressers… are virtually indistinguishable from non-cross-dressers [on the Derogatis Sexual Functioning Inventory (DSFI)]." Brown, et al. (1996, p. 265).
Because the scientific evidence contradicts the statements currently within the DSM, we must conclude that the interpretation of the Paraphilias criteria has been politically – not scientifically – based. Because of this, BDSM practitioners, fetishists and cross-dressers are subject to bias, discrimination and social sanctions without any scientific basis. We call on the American Psychiatric Association to remove or drastically restructure the Paraphilias section in the DSM.