Gloria Brame, Ph.D.

Why I don't trust the DSM about sex

Filed By Gloria Brame, Ph.D. | February 16, 2010 4:00 PM | comments

Filed in: Living
Tags: American Psychiatric Association, DSM IV, DSM V, sex quacks

I usually stick with visuals here but queries from various people asking my take on the the new DSM revisions, both as a sexologist and a BDSMer myself, prompts me to indulge in a bit of textualization.

I have long opposed the APA's framework for human sexuality, which, as I see it, is still fettered to a long-outdated Judeo-Christian, Victorian, reproductive model of sex (i.e., anything that isn't regular intercourse is suspect, and the further away from man-on-top vaginal penetration, the more suspect it is and the more likely to be viewed as a "disorder"). In other words, I don't believe that consensual adult sex, enjoyed for PLEASURE (and not reproduction) should be listed in the DSM in the first place.

I was much more excited by the news two weeks ago that Norway was removing BDSM from its version of the DSM, now joining Denmark and Sweden as the third progressive nation to base its diagnostics on FACTS rather than the very profitable fictions that have been fed to the American public about so-called sexual normalcy. Yay for the facts about sexuality. Boo to the people who still think sexual diversity is wrong, immoral, symptomatic of a mental disorder or -- as the APA has repeatedly insisted throughout the history of the DSM -- that falling outside the reproductive model is in itself a mental disorder.

To my mind, the DSM is so intellectually and scientifically outdated on matters of sex that it's almost irrelevant to sex therapists. In my private practice, I've seen way too many patients who visited psychiatrists, received bad, even insulting diagnoses or a fistful of scripts, and show up in my office feeling far worse than if they'd muddled through their sexual conflicts on their own. This "Bible" of psychiatric diagnoses has always been flawed, sometimes to dangerous, unscientific and harmful levels (such as keeping masturbation listed as a pathological behavior until 1961, and thus offering quack cures throughout the 1950s, including the medical torture and involuntary institutionalization of hundreds if not thousands of trusting patients; and continuing to do the same to homosexuals into the 1980s).

Whether or not the APA believes that BDSM/fetish sex is a pathology, as someone who has researched and written on the subject in the past (most notably in Different Loving, where I include a brief critique of the DSM), and as a practicing sex therapist, my view to the DSM is that it's an institutional, political document whose biases are not always based on the science but routinely based on the prejudices of the people charged with its revisions. This new revision will not change how I diagnose or work with my clients.

I respect the work of radical psychiatrist Thomas Szasz, who made it his life's mission to illustrate the cynicism, greed, and poor critical thinking that often goes into the APA's official views of psychiatric diagnoses and treatment. I am not opposed to psychiatry for the treatment of severe mental disorders; I support the use of drugs to mediate depression and mental illness. But I am opposed to psychiatry for the treatment of sexual disorders, if only because of their shameful history of quack sexual treatments.

Perhaps when they finally apologize for the harm they've caused, I'll review my long-standing animosity towards their diagnostic criteria. Perhaps then I would be a lot more impressed that their goal is to help people through a truly scientific, humanistic approach to human sexuality. Meanwhile, whatever they may put in the DSM, BDSM or fetishes are not symptomatic of anything but the normal range of sexual diversity in human beings.

I highly recommend another critique of the DSM in Psychology Today on the APA's new (and profitable) view towards Internet addiction.

If you aren't familiar with Thomas Szasz, his classic work, "The Medicalization of Everyday Life' is a must read.


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You and I have *so* got to sit down and compare notes one day ;)

As an outside observer on this subject since I am not a psychologist, psychiatrist, or therapist, I am not sure my take on this is worth a great deal. The main problem I see with this entire DSM revision issue is that they do not really revise the thing often enough. It seems to me they go ten to twenty years between those revisions and thousands upon thousands of people are "treated" by many in the Psychiatric community based on what is in that book. Rather like some might have said the military prepares to re-fight the last war they fought, so too does the DSM seem to lag a generation or so behind what reality seems to be. Sadly it seems far too many in the Psychiatric/Psychology profession seem to be content to keep someone coming back to ring up another hour of billing instead of actually helping someone. Which might also be a part of the reason the authors of the DSM seem to be content to leave it a generation behind. Many including myself have been "through" dozens of these professionals in order to find one that is worth talking to.

Absolutely. Absolutely. In the past (and with some potential in the future), it has been helpful to some to have a recognized medical process stream for transsexuals (GID/GI), because it could help obtain hormones, surgery, identification changes and such. Outside that, sex and gender minorities are done an outstanding disservice by inclusion in the DSM.

It's not just BDSM, either. I've had a bit of correspondence going a few months back with someone local (er, meaning somewhere in Alberta) who identifies as asexual, and has been pushed to get treatment for sexual aversion disorder (may have the terminology wrong offhand). At one point, both the sexual dysfunctions workgroup and paraphilias workgroup had both proposed removing distress as a requirement for diagnosis and treatment -- fortunately, this has been withdrawn for dysfunctions, but the proposed changes are really halfway muddled on this point for "paraphilias," proposing that consensual acts "are but aren't" -- i.e. are "paraphilias" but don't require treatment (I don't know if I'm supposed to link to this here, but: http://bit.ly/awvw7N ).

I tend to see "fetish" as one of those compromised words now that becomes a dumping ground for anything a person doesn't understand and doesn't care to figure out, with an assumption that it's all always illusory. Which is a disservice to many, because I've known people with BDSM-related identities that seem plausibly (to me) as intrinsic to who they are as transsexual identities are. Our society just doesn't adequately understand "fetish" just yet (I get into that a bit in "Rocky Horror" and "Risky Thinking" at the same link).

Mercedes, I think (though I may be wrong) that the trend with DSM has been to require the client express significant distress or difficulty in functioning before a sexual diagnosis is assigned.

Certainly it is a requirement for a diagnosis of Sexual Aversion Disorder, and it is also a requirement for sexual orientation to be considered a disorder as well.

I truly hope this trend continues with DSM V. Psychological treatment should be a source of help for those who want it, not a tool to oppress individuals into conformity.

oops... I messed up the link. Here it is:
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=195#

You need to click on the tab for DSM IV to see the current wording.

Yes, distress is a requirement in the current and proposed models. My comment was in reference to two presentations last year, one by Ray Blanchard and one by the Sexual Dysfunctions work group, both of which initially proposed removing this requirement (and in the case of paraphilias, what they're proposing now is a muddled compromise).

WRT the person who identifies as asexual, they weren't diagnosed with SAD, but regularly pushed by their family to seek treatment for it.

Gloria; I'm gonna play devil's advocate here for a minute? I have an intensely personal relationship with the DSM. In 1974, and as a boy of 19, I came out to my parents and they put me into a mental instition for being gay. But guess what? "Uh-oh", the newest DSM had just come out and it declared that my homosexuality was not a mental illness (or a crime!). The prevailing shrinks knocked their heads together and kicked me out! That flawed, not perfect DSM freed me; so that I could progress to a life of love and mental well-being.
I think all of your arguments are sound. I hope you'll always prick, prick, prick them to do better. We all know that 'the Bible' is a terribly flawed document. And that's the way I view the DSM. Flawed; but a backbone of it's own; and because nothing else better has emerged.
I trust you'll always fly your own kite; and not let a piddling thing like 'the Bible' float too long or too high over you or your clients? :)

I think you're missing Gloria's point, Jim. Homosexuality should never have been included - which would mean your parents wouldn't have thought to have you institutionalized since it wouldn't have been pathological.

It's like how the right says that homosexuality was only removed from the DSM because of political pressure. They're right - part of the reason it was delisted was political pressure. Then again, the only reason it was there in the first place was politics.