That being said, DSM-based diagnoses do have real-life consequences for all sexual minorities. They have influenced employment decisions, child custody proceedings, security clearances, and health insurance coverage. Social stigma is no joke, either. A 2006 study found that of 1,017 self-identified BDSM practitioners, 36 percent had experienced violence or harassment because of their sexuality, and 30 percent had been the victim of job discrimination. (William Saletan’s recent Slate story, which incorrectly argued that “everything we condemn outside the world of kink is celebrated within it,” doesn’t help.)
The DSM has a profound impact on societal attitudes toward kinksters, which can in turn influence how we are perceived by our friends, sexual partners, and—most significantly for mental health—by ourselves.
It’s a bizarre cycle. According to the APA’s paraphilias fact sheet for the forthcoming DSM, I can be diagnosed with “sexual masochism disorder” if I feel “personal distress” about my sexuality. Usually, I don’t. But the moments when I do feel distressed (when I wonder if, perhaps, there might really be something wrong with me) occur when I receive unsolicited emails from psychiatrists who have read my public disclosures about my sexuality and reach out to offer their services.
Of course, some people are genuinely, consistently distressed by their atypical sexual urges and fantasies. A few psychiatrists have argued that by including the paraphilic disorders in the DSM, the door remains open for those individuals to seek treatment. I’m not convinced. In fact, I have nothing but faith that if someone genuinely wants psychiatric care, the mental health community will find a way to provide it.
A person who feels persistent personal distress about the shape of her nose, for example, can access psychiatric treatment despite the fact that “nose perception disorder” is not listed in the DSM—she can be treated for body dysmorphic disorder, depression, or a whole host of other broadly defined issues. Along the same lines, someone who is deeply dismayed by his masochistic sexual urges, for example, doesn’t need to be diagnosed with “sexual masochism disorder.” He could be treated for “sexual disorder not otherwise specified,” identity problems, or adjustment disorder—all of which are already listed in the DSM. Isolating specific paraphilias as potential “disorders” is redundant. Worse, that specificity suggests that there is something unique to people with certain atypical sexual urges that makes us more likely to be mentally disordered than anyone else.
Despite its best efforts, the DSM still allows existing sexual stigmas and social norms to define whether a sexual practice is “healthy.” (After all, 20 years ago, it would have been very easy for bigots to describe homosexuality as an unhealthy urge akin to alcoholism.) That’s why social conventions can’t dictate “health”—that must be determined by clear and compelling medical evidence. Alcohol dependence, for example, is medically harmful. Homosexuality is not. Neither is a consensual expression of atypical sexuality. Even the more colorful aspects of BDSM aren't necessarily riskier than skiing, football, or even ballet. (Saletan’s examples of long-term harm come from the porn industry, which isn’t exactly known for protecting actors specializing in any genre. And as Dan Savage points out, the kinkster community has an ethic of safety and communication.)
The fundamental tenet of medicine is, “First, do no harm.” But every day, I receive emails from kinky men and women around the world who tell me about their incredible loneliness and shame. Many of them cite the psychiatric understanding of paraphilias—a de facto endorsement of social stigma—as a partial source of their isolation. The continued presence of the paraphilias (despite their superficial name change) in the forthcoming DSM V is redundant, unscientific, unnecessary, and harmful to millions of kinksters. The paraphilic disorders are also harmful to the field of psychiatry itself. Psychiatry is a noble profession, and I have no doubt that the members of the DSM paraphilias subworkgroup have nothing but the best and kindest intentions. I’m sure they just want to help. But continuing to pathologize noncriminal atypical sexualities only hurts all of us. (And not in the fun way.)