AMA Journal of Ethics^®

On the face of it, psychiatry is a clinical discipline grounded, like the rest of medicine, in science. Yet cultural values play a greater role in psychiatry than they do in the rest of medicine when it comes to deciding what constitutes a “disorder.” Nowhere is this more apparent than in psychiatry’s treatment of putative sexual disorders, or “paraphilias.” These passages in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the first edition of which appeared in 1952 [1], are reflections of US culture as it existed when the values of many of the first DSM’s drafters were formed. The DSM’s treatment of sex certainly does not reflect the values of today. Sexual practices have changed, and the prevailing mores surrounding how we label and discuss sexual behavior have changed as well.

Psychiatry’s meddlesomeness in sexual behavior has a long history. There was a time when medicine, an inherently conservative field, opposed many kinds of sexual expression on the grounds that they induced “hysteria” in women or “neurasthenia” in men. Masturbation, for example, was seen as deeply pathological. Foremost in the assault upon sexual expression was Vienna psychiatry professor Richard von Krafft-Ebing, who, in Psychopathia Sexualis (1886), not only opposed homosexuality and fetishism but linked them to genetic “degeneration”: those who took part in unapproved sexual activities were said to be born “degenerate” and to pass the bad seed on to their children [2]. Sigmund Freud, the founder of psychoanalysis, had a similar horror of many kinds of sexuality; he believed that masturbation caused neurasthenia [3] and that paranoia arose as a result of sexual developments in early childhood [4].

It was against this background of European hostility to certain forms of sexual expression that US psychiatry took over global leadership of the field after the Second World War. In psychiatry, the major American leadership instrument was the abovementioned Diagnostic and Statistical Manual of Mental Disorders [1]. American psychiatry has notably failed to make a distinction between atypical sexual interests and harmful treatment of other people (whether that be a violation like rape or merely subtle coercion), grouping together such disparate ideas as sexual assault and attraction to people of the same sex under the general banner of mental disorders.

The DSM-I quickly dispatched what it called “sexual deviation”: “The diagnosis will specify the type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism” [5]. Thus from the get-go two major areas of human sexuality were declared off-limits: attraction to people of the same sex and what is today called non-vanilla sexuality, or kink. The DSM-I also declared “rape, sexual assault, and mutilation” to be part of “sexual sadism,” thus completely conflating the innocuous—for example, the people who like to dress up on Saturday afternoon and play domination-submission in bed—with the terrible [5].

The DSM-II in 1968 expanded the range of “sexual deviations” to include “exhibitionism” and “voyeurism,” alongside fetishism and homosexuality. The second-edition manual helpfully explained that it considered sexually deviant those “individuals whose sexual interests are directed primarily towards objects other than people of the opposite sex” or towards “bizarre” sex, such as “sexual sadism and fetishism” [6].

Meanwhile, a veritable sexual revolution was sweeping American and West European society in the 1960s [7]. The taboos against sex outside of marriage were weakening. Likewise, sexual interests and behaviors that previously had been seen as hideous perversions had become widespread: by the end of the century, oral sex came to be practiced by the vast majority of people and some kind of anal sex by almost half. (According to US government statistics, in 2002, 90 percent of men and 88 percent of women aged 25-44 practiced oral sex; the respective figures for practice of anal sex were 40 percent and 35 percent [8].) What, in general, had been “pornography” was now becoming adult entertainment—one scholar speaks of the “mainstreaming” of adult content [9]. Leather became part of the sexual repertoire of straights, gays, and lesbians alike [7]. The 1960s marked the beginning of the ascent of sadomasochism, now commonly known as BDSM (bondage/domination/sadism/masochism) or roleplaying, onto the spectrum of normal.

The Stonewall riots in New York in 1969 gave gays and lesbians the stimulus to “come out of the closet,” and many did so. Acting under political pressure, in 1973 the American Psychiatric Association decided to remove homosexuality from its list of sexual disorders [10]. By the end of the 1970s, the US sexual scene looked quite different from its appearance in 1950 [7].

Few of these changes in sexual practices and mores were reflected in the DSM that appeared in 1980 (DSM-III), a volume that in other respects brought dramatic changes to psychiatric diagnosis with the creation of such illnesses as “major depression,” “bipolar disorder,” and “attention deficit disorder.” Under the leadership of Robert Spitzer at the New York State Psychiatric Institute, the subcommittee that drafted the chapter on “psychosexual disorders” went into great detail about what it disliked, which is to say, what it found “pathological.”

First of all, the transsexuals came under the gun when the DSM-III endorsed a “gender identity disorder” called “transsexualism,” which, happily, turned out to be “rare.” It was defined as “a persistent sense of discomfort and inappropriateness about one’s anatomic sex and a persistent wish to be rid of one’s genitals and to live as a member of the other sex” [11]. In the liberal community today, a substantial consensus exists that to be transgender is not pathological but a variant of normal.

Then the DSM-III revived Viennese psychoanalyst Wilhelm Stekel’s old term “paraphilias” for fetishes and BDSM-type interests, which it described as “unusual or bizarre imagery or acts…necessary for sexual excitement.” To be sure, the manual conceded, “the imagery…such as simulated bondage, may be playful and harmless and acted out with a mutually consenting partner,” but it speculated this would be true only in a minority of cases: “More likely it is not reciprocated by the partner” or, even worse, the partner would be “nonconsenting” [12].

The manual thus continued the American psychiatric tradition of conflating crime with consensual pleasure. The section on “sexual sadism” reeked of this conflation, lumping “nonconsenting partners” and partners who suffer “extensive, permanent, or possibly mortal” bodily injuries together with the Saturday-afternoon-in-the bedroom set. BDSM was, in the DSM-III, right up there with zoophilia (bestiality) and pedophilia [13]. Only a complete divorce from the realities of American sexual life in these years could have led to this kind of thinking.

It also turned out that, with “ego-dystonic homosexuality,” the DSM-III had not entirely given up on pathologizing homosexuality after all. “Generally individuals with this disorder have had homosexual relationships, but often the physical satisfaction is accompanied by emotional upset because of strong negative feelings regarding homosexuality” [14]. Psychiatry was still unwilling to give up its stigmatization of homosexuality: the “ego-dystonic” angle—oddly treating negative feelings about one’s sexual orientation as somehow diagnostically different than negative feelings about other aspects of one’s self—was merely a subtler way of suggesting that homosexuality was probably a bad idea. It was gone in the next edition of the DSM.

The DSM-III take on “psychosexual disorders” became dominant not just in the United States but in much of the world, as this edition of the manual was translated into many languages and became the global gold standard of diagnosis. The DSM-III thus dragged not just US psychiatry but much of the western world into Sexual Sunday School.

Further editions of the DSM changed little of this picture. The whole approach to sexuality remained naïve, censorious, and puritanical. Yet some of the refinements in these later editions show what can happen in ethical terms when one gives nosologists who apparently have little real-world experience absolute free rein.

The DSM-III-R in 1987 introduced “frotteurism” as a disorder (subway groping, which, however distasteful, qualifies more as assault than a psychiatric disorder). “Transvestic fetishism,” too, was discovered as the field became increasingly alarmed about growing transexuality. The fetish section became more explicit, explaining that “among the more common fetish objects are bras, women’s underpants, stockings, [and] shoes” [15]. The DSM contributors appear shocked that “the person with Fetishism…may ask his sexual partner to wear the object during their sexual encounters” [15]. Leather, which according to my research had become by far the commonest fetish in the world, was not even mentioned. (Today, latex has almost overtaken leather: a Google search in August 2014 yielded for “leather fetish” 1.49 million hits and for “latex fetish” 1.07 million).

To the credit of the disease-designers of the DSM-IV in 1994, the section on disorders of performance (hyposexuality) was amped up considerably [16]. These can cause considerable disruption in a person’s sexual and romantic life. This at least shows some concern for a person’s experience of sex

All this brings us to the current edition, the DSM-5, published in 2013 and the catechism of what psychiatry today considers to be pathological in bed. Once again, the sexual landscape has undergone something of an earthquake, almost comparable to the sexual revolution of the 1960s. Fetish/BDSM is currently rushing onto center stage. Things previously considered taboo are now practiced with pleasure by millions of people. Numbers are hard to come by, but, for example, according to a 2014 survey of 2,000 people in the UK, 66 percent of university graduates and 37 percent of non-graduates had tried bondage [17]. The Fifty Shades trilogy, too, has had an epochal impact. In 2011 the novel Fifty Shades of Grey was published [18], and the sales, which by 2014 amounted to more than a hundred million copies worldwide [19], rocketed the trilogy to the most popular literary composition of modern times. Fifty Shades, of course, is about sadomasochism [20]. It has made roleplaying socially more acceptable and greatly accelerated the demand for sexual “toys” and roleplaying-themed adult entertainment [21].

Now, one would think that a real-world tremor of this kind would somehow shake the sheltered studios of the disease-designers. Not a bit of it. The DSM-5 left the list of “paraphilia” categories almost entirely untouched. (Oh, not entirely: they added the qualifier “asphyxophilia” to the discussion of “sexual masochism disorder” to take account of a subset of adventurous types who practice “breath control” [22]. Dangerous? Possibly, but so is motorcycle racing. A psychiatric disorder? Probably not.) The new DSMmakes a distinction between “paraphilias” and “paraphilic disorders” that is essentially without a difference. When this purported distinction was first proposed, JP Fedoroff commented, “Once a person is ascertained [i.e., labeled by a clinician as having a paraphilia], it is hard to imagine that he will not be regarded as having been diagnosed” [23]. The point is that, as long as these categories are retained in the DSM, it will not have relinquished the idea of pathologizing atypical sexual interests.

The history of psychiatry’s encounter with sexual diagnoses calls into question the role of psychiatrists as society’s moral gatekeepers, one for which the study of histiocytes in medical school poorly qualifies them. The history of the DSM’s otherworldly, judgmental, and completely unscientific approach to sex would be risible if the consequences in the real world of making behavior into medical diagnoses were not so serious: for example, partners in divorce cases risk losing access to their children on the grounds that their sexual behavior qualifies them as “perverts” [24]. It’s time for psychiatry to bow out of the bedroom.