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Shouting, Voting and Not Much Science: How Sexuality Becomes Mental Illness

DARK NET: From BDSM to homosexuality, psychiatry's bible of mental illnesses is changing its view on sex

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(Photo: Dreamstime, Photo Illustration: R. A. Di Ieso/Vocativ)
Jan 12, 2016 at 11:30 AM ET

There were angry chants and picket lines. In one infamous incident, a man co-opted a microphone during a scientific conference to shout, “Psychiatry is the enemy incarnate!” For years, this is how gay activists fought against the fact that homosexuality was deemed a psychological disorder by the psychiatric organization that defines them. And then, forty-two years ago last month, homosexuality was finally no longer classified as a mental illness.

It happened in December of 1973, against the backdrop of the post-Stonewall era. The American Psychiatric Association voted in favor of removing homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, a hefty text that contains names and symptoms for all accepted psychological disorders. For more than two decades, since the first DSM, same-sex attraction had been considered pathological-first as “sociopathic personality disturbance” and then a “sexual deviation” — but, suddenly, newspaper headlines were trumpeting, “Doctors Rule Homosexuals Not Abnormal.” Robert Spitzer, a member of the APA, admitted that for all those years psychiatry’s diagnostic bible had been incorrect. “I would have to say we were wrong,” he told The Advocate in the wake of the decision.

That historic moment is often credited with paving the way for the gay rights advances that have followed-from decriminalization to same-sex marriage-but its significance goes beyond that. It shows just how subject to changing scientific understandings and, sometimes, even political influence the DSM can be-perhaps especially when it comes to sexuality.

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After all, it wasn’t the emerging body of scientific research around homosexuality that sparked the declassification. As psychiatrist Jack Drescher put it late last year in a retrospective journal article on the topic, gay activism was “the most significant catalyst for diagnostic change.”

And even still, homosexuality technically remained in the DSM in some capacity until just three years ago. In 1973, the wholesale psychological indictment of homosexuality was replaced by a limited diagnosis: “sexual orientation disturbance,” which applied to those with same-sex attraction who were “either disturbed by, in conflict with, or wish[ed] to change their sexual orientation.” This general concept lived on in later editions as “ego-dystonic homosexuality” and, under the category “sexual disorder not otherwise specified,” “persistent and marked distress about one’s sexual orientation.” It was only in 2013 that internal conflict about one’s same-sex desires was declassified as a mental illness.

These periodic revisions are made by a changing cast of committees devoted to various sections of the text. “They vote on it, they discuss it, they yell at each other, they write papers and they try the best they can to make a decision-and there’s precious little science to go on,” said Gary Greenberg, author of “The Book of Woe: The DSM and the Unmaking of Psychiatry.” “It’s subject more than other forms of medicine … to wherever the political, social, cultural winds are blowing.”

“In the more micro picture,” he says, “what is the normative sexual experience? Well, that changes.”

Susan Wright, founder of the National Coalition for Sexual Freedom, agrees. “As far as sexuality goes, it has always reflected the cultural norms of the time,” she says of the DSM. She says that is in part because the science of sexuality is both complicated and understudied. “We’re a long ways from having a good body of scientific research on sexuality,” she said. “When they were making these pronouncements that something was a mental illness, they were speaking from the cultural side of things.”
Another example of this is the DSM’s treatment of BDSM, an acronym for bondage, dominance, sadism and masochism.

In the very first edition, published in 1952, nearly 60 years before “Fifty Shades of Grey” became an international bestseller, sadism was considered a “sexual deviation.” Some 16 years later, masochism was tossed in, too. A dozen years after that, the DSM-III made it clear that someone could be diagnosed as a “sexual sadist” even if their partners were consenting. Say someone liked tying up only the most enthusiastic of participants — it didn’t matter.

Then, in 1994, in a seemingly progressive move, the entries were tweaked so that a diagnosis of sexual sadism or masochism required that a person’s desires or behaviors “cause clinically significant distress or impairment in social, occupational or other important areas of functioning.” However, Wright notes that a person could easily be distressed by their kinks for external reasons. Here again we see the interplay between cultural norms and the DSM’s conception healthy sexuality. “The problem is, it interferes with your day-to-day life because of the stigma,” she said.

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In fact, the diagnoses themselves interfered with the daily lives of many kinky people. “Under the earlier editions of the DSM, family court judges regularly removed children or restricted custody for parents if there was evidence of their BDSM activities, such as membership with an educational group or participation on an email list or website,” Wright wrote in a commentary in the scientific journal Archives of Sexual Behavior. For years, activists, including Wright, lobbied the DSM’s committee on paraphilias, meaning “abnormal” sexual behaviors or urges, as it considered revisions for the next edition.

Then a monumental change came in 2013 when the DSM distinguished between paraphilias and paraphilic disorders. This might seem like academic hair-splitting, but as Ray Blanchard, a member of the DSM-5 committee charged with overseeing changes to sexual and gender identity disorders, put it, the change “means that it’s possible to say that somebody has a paraphilia” — like sexual masochism — “without simultaneously saying that they have a mental disorder.” This is a big deal: In order to be considered “disordered,” a person has to “feel personal distress about their interest, not merely distress resulting from society’s disapproval,” or “have a sexual desire or behavior that involves another person’s psychological distress, injury, or death or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent.”

So you could be into flogging or humiliation and be considered mentally healthy, as long as you felt OK about your kinks and were only interested in enjoying them consensually.

This decision had a real-world impact. “We would get 100 people a year coming to us with child custody issues,” said Wright of the years before the DSM-5. But she says those numbers dropped as soon as the APA introduced its new edition. “We instantly were able to start introducing that into court,” she said. “Judges were looking at that and realizing, ‘Oh, there’s a change in the science.'”

This is why activists like Wright continue to try to lobby the DSM committees: They can have a real influence. Sometimes it’s by highlighting new research, sometimes it’s sharing the lived experiences of people who are impacted by the DSM and sometimes it’s making political arguments that can change the way existing research is viewed.

Wright has her sights set on getting virtually all kinks removed from the text. “Realistically, the next step would be transvestism-what is that in there for? Crossdressing, there is nothing wrong with crossdressing,” she said. “Talk about stigma, that should not be anywhere near the DSM.” Fetishism, which is defined as “sexual arousal from either the use of non-living objects or a highly specific focus on non-genital body part(s),” is another one. “Gone. Are you kidding me? Everybody has something that turns them on! It’s really no different from being a ‘leg man’ or being into breasts or long blonde hair.”

“It’s a constant fight,” she said. “There’s still work to be done.”

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