English Professional work

ICD Revision White Paper

Lack of homogeneity

Chapter F65 does not represent a homogeneous totality. Different diagnoses without any logical connection are combined in an unclear and non scientific way only because they are “unusual” phenomena.

The diagnoses are superfluous

Any psychiatric condition that members of the group may suffer from is as for the rest of the population covered by the other, non paraphilic, diagnoses as for example depression, OCD, anxiety disorders, personality disorders or psychoses.

If for example a person is preoccupied with her fetish to the extent that it becomes a problem in her daily life, she could for example become diagnosed with an obsessive compulsive disorder.

When homosexuality was removed as a diagnosis in 1977, the Norwegian Psychiatric Association stated that they were “doubtful towards the application of psychiatric diagnoses on isolated aspects of behavior”. A person showing a particular behavior is not diagnosed according to that behavior, but on the basis of a set of symptoms. “Ideally speaking, psychiatric diagnoses should be related to causal connections in a wider perspective, a broader aspect of suffering, reduced social functioning and/or a desire for treatment”, they stated.

Sleeping diagnoses

As for the former homosexuality diagnosis, the fetish and SM diagnoses are virtually not being used by the medical profession today, at least not in Norway. They are not being used to treat people’s illnesses.

  • “The main objective of diagnosis is patient care”. (IGDA workgroup WPA 2003; The WPA International Guidelines for Diagnostic Assessment by the World Psychiatric Association 2003). 
  • In a letter to the SM organization Smil-Norway of Desember 19, 2008 the health authorities inform that “None of the diagnostic codes in question were reported to the Norwegian Patient Register in 2007 or 2008. This gives a strong indication that the codes are not in use”. 
  • The Norwegian Directorate of Health informs the medical publication “Dagens Medisin” that according  to the Norwegian Patient Register the diagnostic codes in question were not used last year, i.e. in 2007 (24). 
  • Senior counselor, Arild Johan Myrberg at the Norwegian Directorate of Health, reported that it was difficult to find any health care professional in Norway that was willing to defend the diagnoses (25).

The only function of the diagnoses, in our opinion, is to stigmatize a subpopulation and to make discrimination legitimate. That contradicts the hippocratic ethics of the medical profession not to harm (26).

Science and prejudice

Psychiatry otherwise usually regards people as healthy as long as there is no evidence of psychopathology. International research shows the same tendency whether the surveys are qualitative or quantitative, whether they are performed by telephone, on the Internet or by personal interview: Sadomasochists have no more psychiatric problems or disorders than others (22).

In our opinion, diagnoses of fetishism and SM should be based on a scientific foundation, not on cultural prejudices.

Is being different an illness?

In our opinion the following criterion, G1, labeling people as ill, is unclear, judgmental and unscientific: “[]urges and fantasies involving unusual objects or activities” (27).

Fetishists and SM-people represent a group of perhaps 5-10 percent of the population and is increasingly considered a normal variation in society (28).

“Unusual” sexual interests are commonly found in the general population (29).

An important question: Is  “unusual” meant as a statistical or a normative concept? In earlier days several sexual practices were regarded as abnormal, for example homosexuality, masturbation, oral and anal sex. Extreme sports and religious flagellation may also be regarded as unusual. But so far neither  base jumpers or bullfighters nor flagellators have been labeled perverse (1).

Sick without intercourse?

In the HIV preventative efforts in Norway, non penetrating fetish and SM sex is regarded as one possible way  to reduce contagion in the target group. This stands in opposition to the ICD-10 where lack of intercourse is one main argument for labeling fetishism as pathological.

“Fetishistic fantasies are common, buy they do not amount to a disorder unless they lead to rituals that are so compelling and unacceptable as to interfere with sexual intercourse[….]” (ICD-10, F65.0 Fetishism).

Perhaps the World Health Organization should start looking at non penetrating sex as one of several ways to stop the HIV epidemic and the population explosion?

“These diagnoses are rooted in a time when everything other than the heterosexual missionary position were seen as sexual perversions”. Head of the Swedish National Board of Health and Welfare (Socialstyrelsen), Lars-Erik Holm (7).

Confusing SM with violence

Any kind of sexuality may be perverted, not the least “normal” heterosexual activity, if it is not based on equality and consent.

Violence is usually understood  as use of physical force, and there must also be a lack of consent and a wish to do harm.

ICD-10 does not distinguish between consensual SM and harmful violence. This non distinction stands in opposition to modern research and contributes to maintaining the stigma towards that group of people.

“Sexual sadism is sometimes difficult to distinguish from cruelty in sexual situations or anger related to eroticism. Where violence is necessary for erotic arousal, the diagnosis can be clearly established” (Chapter F65.5 Sadomasochism).

  • In a survey from 2003, professor in psychology Pamela Conolly found that SM masters do not experience greater pleasure during non consensual cruelty than do the control group of non SM people, and the masochists did not seek compulsive or harmful forms of pain (22).
  • This finding is corroborated by the psychologists Cross and Matheson in their research from 2006. They found no evidence for contentions about antisocial, psychopathic or violent SM sadists (22).
  • John Noyes goes even further and says that SM may even contribute to the reduction of societal violence: “As a staged aggression, [sadomasochism] may even be in a position to defuse social violence and to put forward alternative and socially viable models of coping with aggression in a manner that minimizes its negative effects.” (30)

See also: “SM versus abuse” (21)

Psychological stress

Another main criterion for chapter F65 is the G2:

“The individual either acts on the urges or is markedly distressed by them”. The concept of “distress” also appears under “F65.0 Fetishism”.

The criterion does not take into account updated knowledge on stigma. Stigmatization by society causes self stigmatization, guilt, shame and psychological distress in minority groups (31). It is not necessarily the SM or fetish activity in and of itself that is problematic.

The American DSM manual in 1994 introduced a B-criterion which states that fetishists or SM people are not ill unless the activities cause significant psychological, physical or social problems.

“The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (32).

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 (33). See also “DSM Revision White Paper” (29).

The dual-role transvestism diagnosis

Although the F64.1 diagnoses is not within the F65 category, we find it logical to include it in the list of  diagnoses we want to repeal. It resembles the F65.1 Fetishistic transvestism. The main difference seems to be that there is no sexual excitement involved in the F64.1. In our opinion it is just as discriminating and stigmatizing as the F65 diagnoses, so the general arguments for removing the F65 diagnoses also apply to the F64.1.

Modern gender research shows that there is no longer any basis for claiming only two genders.  In later years individuals have presented with gender variations beyond woman and man, and these individuals are not confused, even though they may confuse people around them (34). A few people, on the other hand, may suffer from gender dysphoria. These people may need medical attention and intervention, and the basis for that should be covered, if not in the other F64 categories, then certainly somewhere in the diagnostic system. Another interesting fact is that there is no transvestism diagnosis under Gender Identity Disorders in the DSM IV. This supports our contention that the phenomenon of “transvestism” is not something to diagnose.

Cooperation between DSM and ICD

We understand that there is substantial cooperation between revisions in the American DSM and revisions in the ICD. In that context we would like to point out the NCSF website (29) which has references to among others Charles Moser who has written several articles about the DSM paraphilia diagnoses over the last years (35,36,37,23,38).



Revise F65

Svein Skeid (leader)                         Odd Reiersøl (psychologist)