BDSM & The DSM
From believing the mentally ill were possessed by the devil in the Middles Ages, to the criminilasation of homosexuality still present in today’s world, the stigmatization of mental illnesses and sexual proclivities remains an undercurrent of our world.
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) is one of the primary reasons that misunderstandings (and misdiagnoses) have continued in today’s society.
What is the DSM?
The Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM, is the official mental illness classification manual in the United States. The DSM was first published in 1952 and has gone through five revisions since then.
Prior to its publication, the United States had no standardized definitions for mental illnesses. In the first rendition of the DSM (DSM-I), the American Psychiatric Association created 128 categories of illness with the goal of making a manual that was acceptable to the psychiatric field as a whole, thereby standardizing diagnoses of patients.1
We’ve taken a look through the five editions of the DSM to provide you with a breakdown of what each says about kink, sexuality, and BDSM.
Whilst our summary is almost certainly not comprehensive, the evolution of language in the DSM when it comes to kink tends to coincide most succinctly with the societal changes that were taking place around the same time.
The language within the DSM matters for a number of reasons, not the least of which is that it continues to be the authoritative voice of psychiatry in the United States. As such, those who diagnose (or misdiagnose) illnesses directly affect the lives of their patients. Such diagnoses can have legal and professional repercussions for the patient. When an individual’s sexual proclivities or orientation are placed against the backdrop of this text, the only result is that kink is driven further underground and education/awareness is less likely to reach those who consider themselves insane or worse.
DSM-1: The Creation of “Sexual Deviations”
The first edition of the DSM was published in 1952 and brought with it the beginning of what would be a decades-long categorization of sexual activity that was considered outside of the norm.
This first edition does not provide much in the way of diagnoses of sexual deviations, only stating that it includes the majority of cases previously categorized in the United States as “psychopathic personality with pathologic sexuality.”
Let’s break that phrase down a bit.
Psychopathic means the patient suffers from an antisocial disorder that manifests in an inability to love or to establish meaningful relationships. Likewise, to be psychopathic means to be egocentric and/or incapable of regret.
Pathology is related to a disease or injury.
Combining these terms creates a fairly negative and dark assessment of what it means to be a kinkster.
DSM-1 highlights a number of kinks as sexual deviances: homosexuality, transvestism, pedophilia, fetishism, and sexual sadism. It goes on to include (within sexual sadism) acts of rape, sexual assault, and mutilation.
The definition of sexual deviations was not really expanded upon or explored until the third edition, almost 30 years later.
DSM-2: “Distasteful” Practices are Mental Illnesses
In 1968, DSM-2 was published and brought with it an expansion of what types of behavior fell under sexual deviations: exhibitionism, voyeurism, sadism, and “other sexual deviation” were added to the list.
DSM-2 also included additional guidance to psychiatrists in terms of diagnosing sexual deviance. It advised that the category only be applied to “individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and fetishism.”
The use of subjective terms such as “distasteful” and “bizarre” within a manual used to diagnose a person’s sanity is not only sobering, but is an indicator of the pervasiveness of a narrative that sexuality must be confined to the restraints of societal norms.
Even more tragic is that the LGBTQ+ community was essentially deemed loveless, egocentric, and lacking a sense of regret or remorse both within the context of medicine and outside of it for many, many years to follow, with trans and non-binary still classified in the most current version of the DSM.
DSM-3: Paraphilias and Psychosexual Dysfunctions Appear
In 1980, the third edition of the DSM was published, and with it came the removal of the term “sexual deviance” and the appearance of its replacement, “psychosexual dysfunctions”.
Thankfully, DSM-3 also dropped homosexuality from the list of such dysfunctions, though it does create a diagnosis called “ego-dystonic homosexuality,” which (broadly speaking) was intended for individuals experiencing emotional pain or distress related to their sexuality and a strong personal desire to be attracted to the opposite sex.
DSM-3 makes a point to create definitions and means for diagnosis for each of the kinks listed in this rendition. The term “paraphilia” also makes its debut in the DSM-3, with the following kinks falling under its purview: fetishism, transvestism, zoophilia, pedophilia, exhibitionism, voyeurism, sexual masochism, sexual sadism, atypical paraphilia.
Whilst the DSM-3 acknowledges that someone exhibiting a paraphilia may imagine scenes that are playful and harmless and acted out with a mutually consenting partner”, it goes on to say that “more likely it is not reciprocated,” and in its most extreme form, is acted out with a nonconsenting partner.
Hypothetically, the grouping of both consensual and non-consensual activities under the umbrella of paraphilia could have muddied the waters for those tasked with diagnosis. It’s also quite possible that the lack of clear direction led to the concept that an individual cannot consent to being hurt. DSM-4 would unfortunately carry the same implication.
DSM-4-TR: Diagnosing Paraphilia
Very little changed in the way of sexuality when it came to the 1994 edition of the DSM, which was subsequently tweaked to become DSM-4-TR in 2000.
One significant change in this version was the addition of the phrase “clinically significant distress or impairment” to the definition of a mental disorder. When it came to paraphilia, DSM-4-TR advised that two criteria would need to be met.
Criterion A was that the paraphilia involved "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one's partner, or children or other nonconsenting persons that occur over a period of six months." Criterion B included the distress/impairment qualifier within the context of “social, occupational, or other important areas of functioning.”
Eight specific paraphilic disorders were called out in DSM-4-TR: exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism.
Interestingly, Criterion B changes for four of these kinks. A patient could be diagnosed with exhibitionism, frotteurism, and pedophilia only if they acted upon the urges. For sexual sadism, Criterion B specified that the patient acted on the urges with a nonconsenting person.
DSM-5: The Difference Between Paraphilia and Paraphilic Disorder
Three years before the fifth edition of the DSM was released, the American Psychiatric Association announced the formation of a subcommittee whose purpose was “distinguishing between benign paraphilias versus paraphilic disorders that cause real anguish to the individual or predispose the individual to violate the rights of other people or harm them in serious ways.”
This was one of many important steps in the right direction for the fifth edition, thanks in no small part to the amazing efforts of the National Coalition for Sexual Freedom, formed in 1997.
DSM-5 addresses kink and BDSM in a number of refreshingly new and incredibly significant ways.
First, it assigned the term “disorder” to paraphilias. This move officially made a distinction between people who want to explore and express their sexuality in healthy ways (from whips to furry handcuffs) and those who wish to inflict harm (versus hurt) on others.
Making a distinction between healthy and unhealthy sexuality now allows medical professionals to recognize consensual kinks as outside of social norms and not clinically significant.
The following kinks were defined in DSM-5 as “anomalous activity preferences”:
courtship disorders
voyeuristic disorder
exhisbitionistic disorder
frotteuristic disorder
algolagnic disorders (sexual masochism disorder and sexual sadism disorder)
Again, the significance of adding “disorder” to these activities cannot be understated.
A few years after DSM-5 was published, The Atlantic wrote a fantastic article outlining how the DSM-5 came to address kinkiness and what it means for patients. Perhaps as the medical profession starts to slowly open up to the possibility that consensual kinks are not illnesses, so too will the stigma inflicted on kinksters begin to ease.
When a Kink Might Be a Legitimate Illness
We want to emphasize that healthy kink is about the ability to recognize concepts such as consent, negotiation, and limits.
If you truly feel personally distressed by your kinks, or if you have an overbearing desire to act in a way that you know is not ethical - or have acted on those desires before and are struggling with that reality - we encourage you to reach out to a medical professional in your area.
