The American Psychiatric Association has decided that people with kinky sexual interests (which—let’s just get this out of the way—includes me) don’t necessarily have mental disorders. That seems like good news, right? If we look up sexual masochism, fetishism, transvestism, or sadism in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, they won’t be there! In their place, we’ll find a new list of “paraphilic disorders”: sexual masochism disorder, fetishistic disorder, transvestic disorder, and so on. The difference? To be diagnosed with one of these noncriminal sexual disorders, the person must “feel personal distress about their interest.”
Simply put, the DSM V will say that happy kinksters don’t have a mental disorder. But unhappy kinksters do.
Some sexual minorities have applauded this diagnostic compromise as a step forward. It isn’t. This is just the same routine that the psychiatric community dragged homosexuality through decades ago, and adult, consensual (in other words, noncriminal) expressions of atypical sexuality should be removed from the DSM entirely for many of the same reasons that homosexuality was.
In 1952, the DSM I officially categorized homosexuality as a mental disorder. As the gay rights movement gathered momentum in the 1960s, however, the psychiatric community introduced a diagnostic compromise by saying that people who were comfortable with their sexual orientation did not have a mental disorder. The APA triumphantly removed general homosexuality from the DSM in 1973. But for people who were "in conflict with" their homosexuality, they introduced a new condition instead: “sexual orientation disturbance” (SOD). The 1980 DSM III replaced SOD with "ego-dystonic homosexuality," but the basic principle remained the same: Happy homosexuals did not have a mental disorder, while unhappy ones did.
The term paraphilia—which sexologist John Money defined as unusual sexual interests—first appeared in the DSM III. (Before that, the DSM II listed homosexuality, masochism, sadism, transvestism, fetishism, and other consensual minority sexualities alongside criminal pedophilia and frotteurism in the category of “sexual deviations.”) Although there were minor wording changes to the subsequent DSM IV and DSM IV-TR, psychiatric consensus continued to lump noncriminal paraphilias together with criminal paraphilias as mental disorders.
Thankfully, all forms of homosexuality (including ego-dystonic homosexuality) were finally removed from the DSM in 1987, after a long struggle and far too late. Noncriminal sexual paraphilias should also be removed for many of the same reasons that homosexuality was: People who are stigmatized and misunderstood, such as sexual minorities, might be unhappy—but the unhappiness itself is the problem that should be treated, not the person’s sexual identity or practice.
To be clear, I’m not comparing the experience of being kinky to the experience of being gay, lesbian, bisexual, or transgender. No one is trying to stop kinky people from getting married or, with a few exceptions, threaten our physical safety. The LGBTQ community has serious human rights violations to contend with; most kinksters face nothing more serious than internal turmoil, awkward conversations with new partners, and cultural mockery.
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.)