Salient points, all. I am not in disagreement with you on any of this. My point is essentially that the DSM is seen by many of us in the mental health field as a guideline but one that we depart from often and sometimes radically. It is often debated, and hotly, within the community. I received training in a place that didn’t use it as all; when sexual issues came up in supervision around certain clients, I often found myself in the position of educator regarding fetishism and BDSM, having plenty of experience in both communities. While I do believe that sexual behavior *ca*n be very problematic for a person, aside from rape or sexual abuse, I think it is for a client/patient to decide whether it’s a problem meriting attention. Sex is certainly an interesting part of human behavior, but as a clinician I have no interest in demonizing/labeling a person based on what kind of sex they like to have.

I also think that aside from sociopathic/injurious/nonconsensual sexual behavior, a disorder shouldn’t be based on the kind of sex a person has. Addiction is not any use of alcohol or drugs, but a certain set of conditions around that usage, and one that is also, often, hotly debated within the mental health community. The problem with the DSM as a whole is that is often VERY unspecific about a great many disorders. (It’s worth it to note that the DSM is an American invention and while not entirely useless, is seen as bizarre by other clinicians around the world, because people are so complex!). Honestly, because BDSM is usually such an underground lifestyle, I doubt the DSM is going to change its stripes on this anytime soon. Not enough is known about it, it’s still shrouded in mystery and a little scary (for your average Middle American) for all that. So some perv pride is probably a helpful thing, getting it out there so that people can see that there are plenty of successful, happy people merrily engaging in BDSM.

There are a significant range of issues with the DSM and the paraphilias (as I think you agree), but I’ll touch on only a few. One of the most troubling is the reality that a patient with unusual sexual tastes categorized as a paraphilia will typically have those tastes seen as a symptom, regardless of the relevance or clinical history.

My favorite illustration of the problem lies in the fact that, say, compulsive hand-washing may be a symptom of OCD, but it isn’t a “hand-washing disorder”. By creating the imprecise taxonomy of the paraphilias, the DSM tries to assert that, because a behavior is sexual, it is somehow more significant than a non-sexual behavior that may be every bit as problematic to the patient.

Most troubling to me, though, is that the DSM contains unsupported assertions in its descriptions of the paraphilias that are either questionably accurate or also applicable to “normophilic” acts. For instance, there’s the “no shit” statement that “Frequent, unprotected sex may result in infection with, or transmission of, a sexually transmitted disease” — true, but is that _really_ a psych issue? Well, OK, maybe it is, but whoever wrote that obviously missed the fact that a single instance of unprotected sex may result in really bad news.

Then there’s “Sadistic or masochistic behaviors may lead to injuries ranging in extent from minor to life threatening” — again, true, but there’s no statement about, say, skiing, riding or parascending may lead to injuries!

The sacred cow of the DSM’s paraphilias is probably pedophilia. BUT there’s a strong argument that the criminal and psych aspects of the issue should be distinct, and the psych condition may well be covered by a blanket “inappropriate sexual attraction” condition.

And that’s really the core problem: the DSM has tried to take a number of behaviors that are “socially abhorrent” and create medical diagnosis to categorize them. But who really would lump sexual masochism as being in any way a similar condition to pedophilia? And why do some acts get a pass (I believe bestiality is A-OK by the DSM)? Others used to be problematic, but at some stage were magically made healthy (homosexuality being the obvious one).

We would all be better served if the DSM would stick with defining conditions based on the problems experienced by the patient, rather than defining types of behaviors as problems, even if the patient is perfectly functioning despite those behaviors.

I mean: there are many, many Americans who’d agree that atheism is a psych disorder…

M

Well said. Thank you for compiling these.

P