Fetishes and the DSM: When Is a Kink a Mental Health Issue?
Sexual behavior is inextricably linked to cultural norms, and the latest version of the Diagnostic and Statistical Manual of Mental Disorders—psychiatry’s diagnostic bible—makes this readily apparent. Although sexual kinks are still a source of cultural controversy, their taboo status is steadily lifting, and the DSM-V treats unusual sexual behavior differently than previous versions of the manual.
Changing Sexual Norms
A little over a century ago, Sigmund Freud, modern psychiatry’s godfather, argued that clitoral orgasms were a sign of immature sexuality. For Freud, healthy adult sexuality meant nothing less than a vaginal orgasm. Contemporary sex researchers now emphasize the fact few women can reach orgasm with vaginal stimulation alone, and sex therapists frequently advise people having trouble with orgasm to focus on the clitoris. There have been other advances in thinking, of course, when it comes to sexuality. Until 1973, homosexuality was listed as a disorder in the DSM. Contemporary psychologists and psychiatrists now condemn conversion therapy, a treatment designed to “cure” homosexuality.
Contemporary sexual fetishes run the gamut. Many people have engaged in or acted on some form of sexual fetish at one time or another, and groups dedicated to advocating for the rights of those with unusual sexual interests have sprung up all over the Internet. More and more sex researchers recognize these behaviors as part of a sexual continuum and not necessarily indicative of a mental health issue.
The DSM-V’s Stance
Like their predecessors, contemporary mental health professionals frequently wrestle with the intersection of cultural norms and mental health, and the new DSM reflects this ongoing dialogue. Previous editions of the manual listed atypical sexual behaviors as diagnoses. For example, the DSM-IV listed the behavior of sexual masochism as a disorder. The new version, however, is largely silent on behavior, and defines fetishes as problematic only when they cause significant distress. Thus, masochistic behavior is now termed sexual masochism disorder only when the behavior causes problems for the individual.
When Is a Kink a Problem?
So when does a sexual kink cross the line into a disorder diagnosis? Some sexual behavior is inherently disordered, according to the new manual. For example, pedophilia remains a diagnosis because it’s impossible to act on a sexual attraction to children without breaking the law or causing harm to others. But for those who are blissfully dedicated to feet, bondage, or garter belts, the manual no longer defines the behavior itself as a problem. Instead, the so-called disorder is partially in the eye of the beholder. If your sexual fetish causes serious problems in your romantic relationships or significant personal distress, it may be time to consult a professional. Otherwise, the creators of the DSM-V are content to allow people to engage in whatever sexual behavior they want to without finding issue.
Not everyone is happy with the changes to the manual. Sex-positive writers and researchers point to the fact the new book still provides a list of sexual fetishes, which serves to label some sexual behaviors as inherently deviant even when they don’t cause problems. And the fact the DSM has changed its approach to diagnosis doesn’t mean every mental health professional has followed suit. The American Association of Sexuality Educators, Counselors, and Therapists publishes a list of therapists who adopt a nonjudgmental stance toward kinks. People who engage in non-normative sexual practices such as swinging, polyamory, and sexual fetishism report that they often struggle to find professionals who don’t view their behavior as deviant.
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