English Professional work

DSM – Diagnostic and Statistical Manual of Mental Disorders

About The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)

By Svein Skeid

The American Psychiatric Association, APA, considerably revised their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994. SM and Fetishism were considered to be healthy forms of sexual expression, as long as they do not impair the daily functioning of the subject.

According to DSM-IV, SM and Fetishism only become diagnosable dysfunctions when the urges, fantasies or behaviors “cause clinically significant distress or impairment in social, occupational or other important areas of functioning.”

In addition APA said that “a paraphilia must be distinguished from the non-pathological use of sexual fantasies, behaviors or objects as a stimulus for sexual excitement.”

The DSM-IV revision, in 1994, was seen as a step forward, but is far from satisfactory. Stigma knowledge shows that many psychological, physical and social problems are not caused by the individual afflicted, but by taboos, prejudices, and discrimination imposed by the environment.

According to Charles Moser, the diagnostic criteria changed yet again in 2000 for the worse introducing version DSM-IV-TR (2000).

According to The Differential Diagnosis of the Paraphilias “A Paraphilia must be distinguished from the non-pathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complications, interfere in social relationships). (DSM, p. 568)

“The way this diagnosis is interpreted, any reason that you are seen by a physician or therapist (including court order, as to assess who should get custody of your children in the event of a divorce), can bring about the diagnosis even if it has nothing to do with the issue being investigated.”  Charles Moser on the ReviseF65 discussion group January 22, 2006.

In a press release November 25, 2008, NCSF, National Coalition for Sexual Freedom says about DSM-IV TR:

“We know from the hundreds of requests for help that NCSF gets every year through our Incident Response program that the Sexual Sadism, Sexual Masochism, Fetishism and Transvestic Fetishism diagnoses in the DSM reinforce the negative stereotypes and stigma against alternative sexual behaviors.”

From the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders

The DSM-IV defines mental disorders. Previous editions of the DSM listed sadism and masochism as diagnosable disorders just for having such fantasies or urges over a period of time. The new edition adds modifying criteria: with both masochism and sadism, both A & B criteria must be met in order to make a diagnosis. That is, you must have the fantasies, urges, etc., and the fact that you have them must make you effectively dysfunctional in an important area of your life.

Diagnosic criteria for 302.83 Sexual Masochism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound or otherwise made to suffer.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic criteria for 302.84 Sexual Sadism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM Revision White Paper:

Charles Moser and Peggy J. Kleinplatz:
DSM-IV-TR and the Paraphilias:
An Argument for Removal

English Professional work

Psychological Surrender

Is Sadomasochism a mental pathology?
From Kraft-Ebing to Carl Jung, through years of research on the ground, Dorothy Hayden express her conclusion about masochism. The proposal for a new Psychological approach to BDSM.


By Dorothy C. Hayden, CSW

“Proud to be a perv”. Picture from SM Pride 2003 in London by Svein Skeid.62AkselProudPerv7

A number of years ago, in connection with my work with sexual addiction, a number of lifestyle submissives started coming to me for treatment. Some of these people were extremely hesitant to discuss their reasons for seeking therapy; they were so ashamed of their fantasies and behaviors that it took years of working with them until I knew their real names or their telephone numbers. Patients who able to be forthcoming about their masochistic behaviors and fantasies were as confused as I was. One of my patients, giving me a written masochistic fantasy after months of resistance, said, “Here it is. This is what I came to therapy for. It’s terrible. It’s sick. It’s wonderful. I hate it; it’s my favorite fantasy. I can’t stand it, I love it. It’s disgusting. I don’t want to stop it.”

Learning about the world of S&M has been an invaluable experience to me. I had to admit to myself that, viewed from the perspective of what I knew about the nature of the individual self, masochism puzzled me by flying in the face of everything that was rational about the nature of the human personality. People want to be happy and to avoid pain and suffering. They seek to maintain and increase their control over themselves and their surroundings. And they desire to maintain and increase their prestige, respect, and esteem. Viewed from the perspective of these three principles about the self, masochism is a startling paradox. The self is developed to avoid pain, but masochists seek pain. The self strives for control, but masochists seek to relinquish control. The self aims to maximize its esteem, but masochists deliberately seek out humiliation.


I heard stories of whips, canes, racks, cock-and-ball torture, dripping wax on naked skin, electronic devices designed to deliver just the right amount of pain, the difficulty of finding the right mistress, and the surprising number of “dungeons” that existed within a few block radius of my mid-town office. Time and again, men would talk of the frustration of being unable to entice their wives or partners, who found these sexual activities to be perverse, into engaging in the sexual behaviors that they most longed for. I suspected that there was a vast number of people who felt tremendous shame and isolation about masochistic submissive longings. I decided to check the clinical literature on masochism to better arm myself with some psychodynamic understanding of why these men, who so often felt shame-bound, were so keen to be dominated, hurt, tortured and humiliated by strong, dominate women.

This is what my research revealed: According to the Diagnostic and Statistical Manual of the American Psychiatric Association, (the shrink’s bible), anyone who engages regularly in masochistic sex is mentally ill by definition. There is a long tradition of regarding masochism as the activity of mentally ill sick individuals. Freud described masochism as a perversion. One of his followers linked masochism to cannibalism, criminality, necrophilia and vampirism. Another analyst said that all neurotics are masochistics. In short, clinical perspectives have regarded masochists as seriously disturbed.


Krafft-Ebing, the nineteenth-century psychiatrist who coined the term, subsumed masochism under the broad heading of “General Pathology” in this famous volume, Psychopath Sexualize, in 1876. Masochism became a pathological, sexual and psychopathic phenomenon all at once.

“By masochism I understand a particular perversion of the psychical sexual life in which the individual affected, in sexual feeling and thought, is controlled by the idea of being completely and unconditionally subject to the will of a person of the opposite sex; of being treated by this person as a master — humiliated and abused. This idea is colored by lustful feeling; the masochist lives in fantasies, in which he creates situations of this kind and often attempts to realize them. By this perversion his sexual instinct is often made more or less insensible to the normal charms of the opposite sex – incapable of a normal sexual life – psychically impotent.”

It has become practically a dogma of psychoanalytic thought that masochism is a sexual condition in which punishment is required before satisfaction can be reached. Freud understood the phenomenon as resulting from an “unconscious feeling of guilt” as “a need for punishment by some parental authority. Writing in 1919, Freud found the genesis and reference point for masochism in the Oedipus-complex. Masochism, he said, actually begins in infantile sexuality, when the wish for the incestuous connection with mother or father must be repressed. Guilt enters at this point, in connection with incestuous wishes. The parent figure then becomes the dispenser of punishment instead of love and appears in desires for beating, spanking, etc. The fantasy of being beaten becomes the meeting place between the sense of guilt and sexual love. Whether it involves literal pain or not, the punishment desired by the masochist is enjoyed in and of itself. Punishment and satisfaction both give pleasure – and humiliation. Freud, in referring to masochism as a “perversion”, cemented it forever in the ghetto of the aberrant and deviant.

My research, however, did not jibe with my clinical reality. The people who presented to me were not immature or inferior. In fact, the reverse seemed to be the case. Masochists are more likely to be successful by social standards: professionally, sexually, emotionally, culturally, in marriages or out. They are frequently individuals of inner strength of character, possessed of strong coping skills with an ethical sense of individual responsibility. A famous study of the “sexual profile of men in power” found to the researchers’ surprise, a high quantity of masochistic sexual activity among successful politicians, judges and other important and influential men.


It became obvious to me that psychology’s theories of masochism were obsolete. In the 1960’s, homosexuality was deleted from the DSMIV and was recognized not as a pathology, but as a lifestyle choice.

It is my contention that the same should be done with masochism and that, like homosexuality, it needs to be removed from the rubric of “psychopathology” and be seen for what it is: a sexual lifestyle choice. It is the intention of this paper to suggest ways of understanding masochism without invoking theories of mental illness.

The questions, however, remained. I puzzled as to why so many men, raised in a culture that valued masculine initiative, assertiveness, and dominance, want to be relieved of these qualities and surrender their will to a strong, dominant woman who might torture, control and humiliate them. What was the basis of this compelling urge to surrender and serve, to relinquish control, to accept physical pain and emotional humiliation?

As I listened to my patients over the years, I began to see masochism less as a sexual aberration and more as a metaphor through which psyche speaks of its suffering and passion.

There was a definite connection between suffering and pleasure the intrigued me.

Clients spoke of the rapturous delight in submission, the worship, in wild abandon and the deliverance from the confining bondage of “normalcy”.

Ritualized suffering seemed to be a way of giving meaning and value to human infirmities. After all, there is no paucity of suffering in human life. None of us need go looking for pain. The suffering of helplessness, disappointment, loss, powerlessness and limitation, is a part of the human condition. It is my hunch that there is something like a universal need, wish or longing for surrender completely to certain aspects of human life and that it assumes many forms. This passionate longing to surrender comes into play in at least some instances of masochism. Submission, losing oneself to the power of the other, becoming enslaved to the master is the ever-available lookalike to surrender.


Submissives speak of a quality of liberation, freedom and expansion of the self in a scene as a situation similar to the letting down of defensive barriers. They speak of the experience of complete vulnerability. I believe that buried or frozen, is a longing for something in the environment to make possible surrender, a sense of yielding of the false self. The false self is an idea developed by a famous psychoanalyst who posited that most parents need their children to behave in circumscribed ways in order for the child to receive their love. For a child, parental love is a matter of survival, and so the child forges a “self” that they think will ensure parental love and approval. The false self is usually a “caretaker” self. A Scene sometimes allows for years of defensive barriers that support the false self to be broken through. It carries with it a longing for the birth of the true self. Deep down we long to give up, to “come clean”, as part of a general longing to be known or recognized. The prospect of surrender may be accompanied by a feeling of dread and or relief or even ecstasy. It is an experience of being “in the moment”, totally in the present. Its ultimate direction is the discovery of one’s identity, one’s sense of self, of one’s sense of wholeness, even one’s sense of unity with other living beings. Joyous in spirit, it transcends the pain that evokes it. One’s exquisite pain is sometimes akin to mystical ecstasy. Within the context of that surrender, a self-negating submissive experience occurs in which the person is enthralled by the dominant partner. The intensity of the masochism is a living testimonial of the urgency with which some buried part of the personality is screaming to be released. The surrender is nothing less than a controlled dissolution of self-boundaries.

The deeper yearning is the longing to be reached, known and accepted in a safe environment which narcissistic, dysfunctional or preoccupied parents were unable to provide the child at a young age.

Fantasies of being raped, which are very common, can have all manners of meanings. Among them, one will almost always find, sometimes deeply buried, a yearning for deep surrender. The submissive longs for and wishes to be found, recognized, penetrated to the core, so as to become real, or, as one analyst says it “to come into being.”


In addition to the longing to surrender into a truer sense of self, masochistic behaviors have another meaning. People need and take delight in fantasy production. Ask the Disneyland folk who cater to adults as much as to children. Scenes have tremendous potential for potentiating fantasy. Costumes, rituals, scenarios, an endless variety of sex props, and elaborate sets reveal of the richness the creative inner life and speak to the very real human need for fantasy play. The fantasies are the carriers of a full spectrum of human feelings: to control, to be controlled, to tease, to be teased, to play, to please, and to achieve solace from the confines of the mundaness of ordinary life. They represent the suspension of normal reality that is an occasional necessity for all healthy people.

Probably the last thing masochism appears aimed at is balance. In keeping with its paradoxical nature, masochism provides not so much a state of weakness, but a sense of surrender, receptivity and sensitivity. Masochism is the condition of submitting fully to an experience, which counters lives that, in our Western society, are ego-centered, constrained, rational, and competitive. Strength can be a terrible burden. It is a constraint, which can be relieved in moments of abandonment, of letting down and letting go. So it is hardly surprising that the pull of masochistic experiences should be so strong in a culture the overvalues ego strength at the expense of a fuller experience of all dimensions of psychic life.

In conclusion, I believe that therapists need to radically alter their approach to doing psychotherapy with masochistic patients. My colleagues complain that masochists are difficult to “cure”. Perhaps because the paradigm from which these therapists operate are faulty. The recognition of value and meaning in the desire to suffer humiliation runs counter to the prevailing attitude in psychology. The main thrust of modern theory and practice has been toward ego psychology. The values of psychotherapy have been aimed, for the most part, at building strong, coping, rational problem-solving egos. Ego-values are certainly worthy ones, yet it costs something to gain strength, to cope, to be rational and to solve problems. This may account for the dissatisfaction many people feel after years of psychotherapy. Building a strong ego is only one side of the story; it neglects other, crucial parts of the human psyche. Modern psychology has been in large measure dominated by helping people develop independence, strength, achievement decisive action, coping and planning. What’s missing is attention to the more subtle dimensions of soul.


The psychoanalyst most in tuned with the missing element in psychotherapeutic work with masochism is Carl Jung. Masochism may be imagined as cultivation of what Jung called the “shadow” – the darker, mostly unconscious part of the psyche which he regarded not as a sickness, but as an essential part of the human psyche. The shadow is the tunnel, channel, or connector through which one reaches the deepest, most elemental layers of psyche. Going through the tunnel, or breaking the ego defenses down, one feels reduced and degraded. Usually, we try to bring the shadow under the ego’s domination. Embracing the shadow, on the other hand, provides a fuller sense of self-knowledge, self-acceptance and a fuller sense of being alive. Jung’s idea of the shadow involves force and passivity, horror and beauty, power and impotence, straightness and perversion, infantilism, wisdom and foolishness. The experience of the shadow is humiliating and occasionally frightening, but it is a reduction to life&Mac220;to essential life, which includes suffering, pain, powerlessness and humiliation. Submission to masochistic pain, loss of control and humiliation serves to embrace our shadow rather than deny it. The result is the achievement of an inner life that accepts and embraces all aspects of our selves and allows us to live with a deeper sense of our true selves.

In conclusion, the psychotherapeutic community needs to re-examine masochistic submissions to see it not as a pathology but as a healthy vehicle for surrendering fixed defense mechanisms, for relinquishing control to something or someone greater than themselves, for achieving freedom from the pervasive and relentless need to cultivate, promote and assert the self, for gaining some relief from having to make innumerable choices and decisions, for engaging in healthy fantasy enactments, and for the exploration, acknowledge and acceptance the “darker” or “shadow” side of their personalities. In addition, many patients speak of achieving a loss of self-awareness that they describe as ecstasy or bliss in which the individual transcends his normal limits and ceases to be aware of self in ordinary terms.

A travesty of our profession is that we continue to try to “cure” a systems of beliefs and behaviors that enrich and enlivens the lives of so many people. The continuing pathologizing of masochism by keeping it in the DSMIV as a psychopathology and by most therapists’ efforts to “cure” masochists is in part responsible for the continued , shame, isolation and low self-esteem of these creative, spontaneous and courage people who want to be afforded the dignity of choosing their own form of non-exploitative sexuality.


Dorothy Hayden, MBA, CSW, received her masters degree in clinical social work from New York University and has received advanced clinical training at the Post Graduate Center for Mental Health. She is a psychotherapist in private practice in New York City.

You can contact her with the E-mail:
Dorothy Hayden, CSW
209 East 10th Street #14
New York, NY

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