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A Brief History of Homosexuality and Sadomasochism in the DSM

or, You can't spell BDSM without DSM

Timeline

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook used by psychiatrists and other mental health professionals to diagnose and classify mental disorders. The DSM has gone through several revisions in its publishing history, and the way it has classified and diagnosed certain disorders has evolved. This article will focus on the history of the DSM with regards to the diagnosis of Homosexuality and Sadomasochism.

Precursors (1918-1951)

In 1918, the American Psychological Association (known at that time by the name "the American Medico-Psychological Association") published the first edition of Statistical Manual for Use of Institutions for the Insane.

The World Health Organization (WHO) issued the International Classification of Diseases-6 (ICD-6) in 1949. It contained a section on mental disorders.

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DSM-I (1952-1967)

In 1952, The APA published the first edition of the DSM (DSM-I.) It was based on the WHO's ICD-6 and the military system. The DSM became the first official manual and glossary of mental disorders with a focus on clinical use. The disorders included in the manual were based on theories of abnormal psychology and psychopathology. The manual classified Homosexualiy and “sexual sadism” (along with transvestism, pedophilia, fetishism) as “sexual deviations” within within the larger "sociopathic personality disturbance" category of personality disorders.

Critics challenged the DSMs reliability and validity. But it still gained acceptance.

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DSM-II (1968-1979)

The DSM-II, published in 1968, was even more stronger aligned to psychoanalysis than the first edition. It retained the classification of Homosexuality as "sexual deviation" but changed the label from "sociopathic personality disturbance" to "sexual orientation disturbance." In addition, it is officially listed as mental illness.

The DSM-II also added a new category called "sexual deviation," which included various sexual behaviors including homosexuality, fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism, masochism, and "other sexual deviation."

This category is for 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. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them.

With the advent of the Gay Liberation movement, the classification of Homosexuality became controversial and there were growing calls to remove it from the DSM. The National Gay Task Force and other homophile organizations protested outside the American Psychiatric Association (APA) meetings, demanding the removal of homosexuality from the DSM.

In the 1972 APA conference, a panel discussion on homosexuality (led by actual homosexuals) took place. Lesbian activist Barbara Gittings and gay activist Frank Kameny participated. John Fryer, a gay practitioner, testified anonymously as "Dr. Henry Anonymous," disguising his identity with a mask and voice distorter due to the risks of openly identifying as a gay psychiatrist.

The panel on homosexuality including Lesbian activist Barbara Gittings, gay activist Frank Kameny, and Dr. John Fryer disguised as "Dr. Henry Anonymous."
Image Source: New York Public Library Digital Collection.

In 1973, activists continued their efforts, disrupting panels and giving speeches. Ronald Gold, a notable gay activist, criticized the APA members for considering homosexuality an illness, saying, "Stop it, you're making me sick." Activists pointed out gaps in the APA's reasoning and emphasized their productivity as members of society. The APA responded by appointing a task force, and in 1973, the board of trustees voted to declassify homosexuality as a mental disorder.

So, in the seventh printing of DSM-II in 1974, the ADA removed Homosexuality as a disorder, but added “sexual orientation disturbance,” a new diagnostic code for individuals distressed by their Homosexuality.

This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.

This new code would remain the manual (under different names) until the release of the DSM-5 in 2013.

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DSM-III and DSM-III-R (1980-1993)

The ADA published the DSM–III in 1980. In this version, the APA changed the category of “sexual orientation disturbance” to “ego-dystonic Homosexuality.”

Ego-dystonic Homosexuality
the condition of being distressed about an inability to be aroused by the opposite sex. There is a sustained pattern of same-sex arousal that the person explicitly states is unwanted and persistently distressing. The condition is frequently accompanied by feelings of loneliness, shame, anxiety, and depression.

CITE: APA Dictionary of Psychology

DSM-III defines Masochistic Personality Disorder as a condition needing further study The disorder's diagnostic criteria were:

  1. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which they will suffer, and prevent others from helping them, as indicated by at least five of the following:
    1. Chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available
    2. Rejects or renders ineffective the attempts of others to help them
    3. Following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
    4. Incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provokes an angry retort then feels devastated)
    5. Rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themselves (despite having adequate social skills and the capacity for pleasure)
    6. Fails to accomplish tasks crucial to their personal objectives despite having demonstrated the ability to do so (e.g., helps fellow students write papers, but is unable to write their own)
    7. Is uninterested in or rejects people who consistently treat them well
    8. Engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
  2. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
  3. The behaviors in A do not occur only when the person is depressed.

In the DSM-III-R, published in 1987, sadomasochism was moved from the paraphilias category to the SDNOS category, reflecting a growing recognition that consensual sadomasochistic behavior did not necessarily constitute a mental disorder.

And while the "ego-dystonic Homosexuality" diagnostic category was removed, the category of "sexual disorder not otherwise specified" (including "persistent and marked distress about one’s sexual orientation”) remains.

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DSM-IV (1994-1999)

The DSM-IV, published in 1994, included a new category called "sexual and gender identity disorders," which included disorders related to sexual orientation and gender identity.

Furthermore, the APA completely removed Masochistic Personality Disorder from the DSM.

As explaind in the Leather History Timeline The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition is issued with considerably revised definitions of Masochism and Sadism, which in essence say that it they are not illnesses unless you are bothered by your interest in them and they interfere with your normal functioning in other aspects of your life.

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DSM-IV-TR (2000-2012)

In 2000, the APA releases the DSM-IV-TR, a revision of DSM-IV. It alters the diagnostic criteria for "Sexual Sadism" so that a diagnosis is now only allowed if the impulse or fantasies cause distress or they have been performed non consensually.

DSM-IV-TR Criteria

  • Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
  • The person has acted on these sexual urges with non consenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
  • Sexual Sadism is severe and is associated with Antisocial Personality Disorder. The sexually sadistic individual may either seriously injure or kill the victim or partner.

Associated features

  • The paraphilic focus of Sexual Sadism involves acts in which the individual derives sexual excitement from psychological or physical suffering (including humiliation) of the non-consenting victim. It is the suffering of the victim that is sexually arousing. Sadistic fantasies or acts may involve activities that indicate the dominance of the person, such as forcing the victim to crawl or keeping the victim confined. Such fantasies may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Some individuals with this Paraphilia feel empowered by their sadistic fantasies; this feeling may be invoked during sexual activity but not otherwise acted upon. Some individuals with SS may engage in sexual acts for many years without the need to increase the potential for inflicting serious physical damage; however, usually the severity of their sadistic acts increases over time. When SS is severe, or when it is associated with Antisocial Personality Disorder, the individual with SS may seriously injure or kill the victim.
  • The urges must have been recurrent for at least six months for a diagnosis to be made or attempted. Achieving sexual excitation or orgasm is dependent on the other individual’s being humiliated or receiving pain. Some individuals are bothered by these fantasies, which may occur during the sexual excitation and activity but are otherwise not carried out; thus, they remain fantasies. The partner (victim) may very well be terrified of the anticipated act, especially if the behavior involves total control or domination. In other instances, the sexual sadist will have a partner who willingly acts with him or her; she or he may suffer from sexual masochism. Some individuals with SS may act out their fantasies on unwilling partners or victims. Typical sadistic fantasies involve dominance over the partner/victim, and the fantasies were most likely present during the individual’s childhood.
  • The urges must have been recurrent for at least six months for a diagnosis to be made or attempted. Achieving sexual excitation or orgasm is dependent on the other individual’s being humiliated or receiving pain. Some individuals are bothered by these fantasies, which may occur during the sexual excitation and activity but are otherwise not carried out; thus, they remain fantasies. The partner (victim) may very well be terrified of the anticipated act, especially if the behavior involves total control or domination. In other instances, the sexual sadist will have a partner who willingly acts with him or her; she or he may suffer from sexual masochism. Some individuals with SS may act out their fantasies on unwilling partners or victims. Typical sadistic fantasies involve dominance over the partner/victim, and the fantasies were most likely present during the individual’s childhood.

Child vs. adult presentation

Sadistic sexual fantasies are likely to have been present during childhood and it is likely that individuals with SS were abused as children, both sexually and physically. Adult presentation is usually expressed in early adulthood about the time that the sexually sadistic activities appear, and the disorder is usually chronic in its course. Generally the sadistic acts increase in severity over the sufferer’s lifespan.

Gender and cultural differences in presentation

Sexual Sadism presents itself in males in over 95% of known cases researched worldwide. Sexual Sadism will present itself in much the same manner throughout different cultures. Although this disorder can be obtained by males or females, it is more common for males to behave with more non-consenting partners even if it is considered rare.

Epidemiology

  • Sexual Sadism is found in only 1 to 2% of the population in the United States.
  • Age of onset varies greatly, but it typically has developed by early adulthood.

Etiology

There is no universally accepted cause or theory explaining the origin of Sexual Sadism. Some researchers explain it as the result of biological factors. Evidence for this theory comes from abnormal findings from neuropsychological and neurological tests from offenders. Others believe it is caused from brain injury or mental disorders such as Schizophrenia.

Empirically supported treatments

  • Behavior therapy is often used to treat Sexual Sadism. This psychological treatment includes management and conditioning of arousal patterns and masturbation as well as cognitive restructuring and social skills training.
  • Medication is especially recommended for individuals with SS who exhibit behaviors dangerous to others. The medications that are used are female hormones, which speed up the clearance of testosterone from the bloodstream, and Antiandrogen medications, which block the body’s uptake of testosterone. SSRIs may also be used.

Prognosis

Because of the chronic course of sexual sadism and the uncertainty of its causes, treatment is often difficult. The fact that many sadistic fantasies are socially unacceptable or unusual leads many people who may have the disorder to avoid or drop out of treatment. Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual sadism should be referred to a specialized clinic for the treatment of sexual disorders or to professionals with experience in treating such cases.

In the same year the APA began work on the DSM-V.

In 2008, Susan Wright, MA of the National Coalition for Sexual Freedom (NCSF) started a petition calling on the American Psychiatric Association (APA) to require that all diagnoses in DSM be based on empirical research. 3,288 supporters signed the petition out of the 4,000 goal.

We, the undersigned, support the American Psychiatric Association's (APA) own goal of making its Diagnostic and Statistical Manual (DSM) a scientific document, based on empirical research and devoid of cultural bias. A diagnosis of a mental disorder can have a severe adverse impact on employment opportunities, child custody determinations, an individual's well-being, and other areas of functioning. Therefore we urge the APA to remove all diagnoses that are not based upon peer-reviewed, empirical research, demonstrating distress or dysfunction, from the DSM. The APA specifically should not promote current social norms or values as a basis for clinical judgments.

The petition is closed, but it is still possible to view the petition, the signatories, and comments made to it online.

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DSM-5 (2013-present)

The ADA publishes the DSM-5 in 2013. For the first time, the condition of experiencing "distress over one's sexual orientation" (under whatever name) does not appear.

Also, for whatever it might mean, the DSM-5 renames "sexual sadism" as "sexual sadism disorder."

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Works Cited

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Inside a huge gothic library, a handsome monk and a beautiful nun conduct research.