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
Guide to Choosing a Kink-Aware Therapist, created by Keely Kolmes Psy.D. and Geri Weitzman Ph.D., will help people who engage in BDSM find a therapist who can accept them without judgement or prejudice. Some therapists cause more harm than good when they slap a label of mental illness on a client simply because they enjoy kinky sex.
"Over the years, I have received many calls from folks around the globe who wanted access to therapy that was respectful of their kink identity, but didn't know where to turn to find it," says coauthor Geri Weitzman, PhD. "We are excited to share this resource on finding kink-aware therapists with our community, in the belief that a warmly accepting therapeutic environment should be available to all."
"Therapy needs to be a place where you can feel safe to bring your whole self. I hope that our article is a helpful tool for kink-identified clients and the therapists who want to learn more about working competently with them," agrees coauthor Keely Kolmes, Psy.D.
The second publication has been years in the making: Therapists Guide to Polyamory was written by Geri Weitzman, Ph.D., Joy Davidson, Ph.D. and Robert A. Phillips, Jr., Ph.D., and edited by NCSF Foundation Chairman James R. Fleckenstein, B.A., and Carol Morotti-Meeker, M.S., M.L.S.P. This guide answers all of a therapist's questions about the purpose and practice of polyamory: everything from the motivations and benefits of polyamory, to emotional and social concerns such as discrimination and family disapproval are covered. Polyamorists can use this guide to explain their lifestyle to their therapist, and for therapists who understand that personal value systems may sabotage their goal of enabling their clients to explore options and life experience in a neutral or supportive way.
"For too long, polyamorous clients have consistently expressed concerns that their therapists completely failed to understand the clients' lifestyle choices at best; at worst, therapists immediately pathologized the clients' lifestyle and ascribed all of the clients' issues solely to the decision to have nonexclusive relationships," says NCSF Foundation Chairman Jim Fleckenstein. "This piece, written by three clinicians and thoroughly supported with three pages of references, should help put an end to this practice. I was deeply honored to have had the opportunity to co-edit this vital work."
NCSF is dedicated to ensuring that everyone can find a mental health professional who is understanding and supportive of alternative lifestyles, and believes these guides are an important addition to its Kink Aware Professionals referral list and the DSM Revision Project. A member of KAP recently wrote: "Thank you for operating this fantastic resource. All of my current clients have found me through the KAP database, which is helping me cultivate exactly the kind of practice I'd hoped for."
Also available on the NCSF website are the results of Second National Survey of Violence & Discrimination Against Sexual Minorities which found significant discrimination and persecution against BDSM practitioners. With over three thousand respondents, 37.5% indicated that they had either been discriminated against or experienced some form of harassment or violence. Over 500 comments were written by the respondents which have been gathered into "In Their Own Words" which documents the trauma experienced by those who have been persecuted.
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.