English Professional work

SM: Causes and diagnoses (2002)

Why is SM (and fetishism) still diagnosed?

SM is not only categorized as a “paraphilia”, it is also diagnosed as such. “Deviant” sexuality has been looked upon as immoral (“perverse”) by the clergy as well as lay people. This typecasting has served as a means for political oppression. The controlling of people’s sexuality reaches them deep down in their personalities. With the medicalization of society, immorality has been substituted by illness. Various sexual practices have been labeled “deviant”, which means “ill” in the diagnostic context. Many of these practices are today considered normal, or at least not illnesses any more (for example oral sex, anal sex, homosexuality). One reason for that is the increasing acceptance of sexual activity as legitimately pleasurable (both for men and women); sexual activity needs not necessarily have procreation as the goal in this day and age.

Another reason is the pervasiveness and relative openness about the varieties, and the homosexuals have become a strong and influential interest group fighting for their human rights. The most authoritative psychiatric diagnostic systems worldwide are the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Forth Edition) by the American Psychiatric Association and the “Mental and Behavioral Disorders” subset of the ICD-10 (International Classification of Diseases, version 10) by the World Health Organization.

There are probably many different reasons why SM and fetishism is still diagnosed as “paraphilia”:

Categorizing and stigmatizing a minority does not stop by itself. People being stigmatized have to speak out and demand acceptance, especially when the group is invisible. Established categories tend to continue their existence (just because they exist) unless somebody fights for a change.

Many SM practitioners don’t even know that they may be diagnosed. Mostly the diagnoses are “sleeping” in our part of the world. People with SM and fetish interests don’t usually seek therapy to change their sexual interest. Those individuals that actually become diagnosed are mostly perpetrators referred by the legal system.

Within the “sadist” and “masochist” diagnostic categories there is no clear distinction between consensual games and sexual abuse.

Psychiatrists (at least the traditional ones) tend to believe that SM is caused by severe trauma and therefore is an “abnormal” phenomenon.

Actually there has been some fight for change, which has resulted in the “B-criterion” being added to all the paraphiliac subcategories in the DSM-IV: “The fantasies, sexual urges or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”. This criterion has to be met for the condition to be diagnosed as “paraphilia”. The criterion is not (at least not clearly, explicitly and consistently) implemented into the ICD-10. Both diagnostic systems have abolished the diagnosis of homosexuality.

Why should the “fetishism” and “SM” diagnoses be abolished?

It’s a human rights issue. Diagnosing types of sexuality is as disrespectful as discriminating people based on race, ethnicity or religion.

People may use the diagnoses to make harassment legitimate. There is still a lot of respect for and belief in the medical diagnoses.

The “deviants” all too often look upon themselves as less valuable (they feel the stigma).

The diagnoses are messy. For example the diagnostic criteria for “Transvestic Fetishism” (DSM-IV) apply only to heterosexual males. I am glad that homosexuals and women are exempt (and they have been good at lobbying against discrimination), but so also should men and heterosexuals. One reason that women are exempt from this diagnosis is probably that wearing men’s clothes is more socially acceptable than for a man to “degrade” his status by wearing something feminine. The diagnoses of “Sadism” and “Masochism” are certainly messy because abuse and violence is mixed into the same category as consensual sexual games. The diagnosis of “Pedophilia” has certainly nothing to do with fetishism or consensual SM, but is diagnosed as “Paraphilia” on the same level.

The “Paraphilia” labeling in the diagnostic systems appears inconsistent. Most types of paraphilia (as defined for example by John Money) are not mentioned. Since several kinds of sexual abuse are diagnosed as paraphilia, it seems strange that rape is not diagnosed. A rapist is not necessarily a sadist because he may not necessarily derive sexual excitement from the suffering of the victim. The practicing of unsafe sex is not diagnosed either (at least not as a sexual disorder).

The DSM-IV categories of fetishism and SM are redundant, because if the fantasies cause distress or functional impairment there are several other categories (outside of paraphilia) to diagnose such conditions.

SM and fetish interests are basically “normal” (like some people are attracted to legs with stockings, others to feet with “sexy” shoes, etc, and the power dimension is usually present to some extent, e.g., who is on top and who is on the bottom during sexual activity). The interests are only diagnosed if it is in a sense “too much”, but the “too much” can be applied to almost anything in life. A stamp collector is not diagnosed with “philately” just because he is too absorbed in the activity.

The ICD-10 puts a premium on intercourse: “Fetishistic fantasies are common, but they do not amount to a disorder unless they lead to rituals that are so compelling and unacceptable as to interfere with intercourse and cause the individual distress”. So, if people don’t want intercourse, it may be serious! Sadomasochism, by the way, says nothing about causing the individual distress (inconsistency).

Regardless of the causes of SM and fetishism, there is no reason to diagnose it as illnesses. It is as absurd as diagnosing people for being “Jews”, “Christian” and “Muslims”.

It is not the sexuality in itself that is problematic. However, any kind of sexuality (even “straight”, “normal” heterosexual activity) may be perverted when abuse and disrespect enters into it.

Diagnosing may affect people in various negative ways

Possible consequences of being diagnosed

People may believe they are ill, because medical authorities say so.

Negative self-image, low self esteem.

Obsessions and compulsions, for example alcoholism, drug abuse or workaholism.

Suicide or suicide attempts.

Social anxiety, social difficulties.

Various kinds of self-destructive behavior (e.g., self-mutilation and passivity).

Final comments: What is the real problem?

Stoller says: “But now, this main point. Though studying the meaning of perversion is worthwhile, what counts more is the basic question: How much harm does any individual, not just the sadomasochist, inflict on other living creatures? Actually inflict. Not just in imagination or in the theater of erotic behavior (as for instance, that of the consensual sadomasochists)”. Stoller uses the word “perversion” more or less synonymous with “paraphilia”. I think it may be useful to reserve the word “perversion” for abusive, disrespectful and other harmful sexual activities. The category of “perversion” would then include activities such as: rape, sexual coercion, sexual deceit, pedophilia, and several unsafe sexual practices. I am really talking about morale in our culture, in this day and age, and that is what is important. If we for any reason need to keep a diagnostic category of “sexual deviation”, I would certainly enter the immoral practices into that category.

Anyway, what is the real problem of people who are “perverse” in this sense? Is it a sexual problem or is it something else? When a person violates somebody’s borders or behaves in self-destructive ways, that person has a problem and it may indeed be a serious one, but it is not a sexual problem. The man who beats his wife (whether he gets sexually excited about it or not) has a serious problem, for example a personality disorder (which also is not a sexual problem). The grown up person who gets sexually involved with children has a serious problem. He probably has a problem being intimate with other adults, in other words he has a contact problem.

A few more words about intimacy: Many people, whether they are “normal” or “paraphilic”, have trouble being intimate with an appropriate partner. If the person is “paraphilic”, psychiatry is quick to attribute the problem to the person’s “deviant sexuality”. It will be more appropriate to look at the trouble with intimacy as the problem, rather than stigmatizing the kind of sexuality. There is no evidence that SM people or fetishists are less able to love their partner than is anybody else. If a person has trouble with intimacy, that is not a sexual problem. However, it may be very serious.


DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association, Washington DC.

ICD-10: The ICD-10 Classification of Mental and Behavioral Disorders, World Health Organization, Geneva.

Money, John: “Lovemaps”, Irvington Publishers, Inc., N.Y., 1986.

Money, John: “Sin, Science and the Sex Police”, Prometheus Books, Amherst, New York, 1998.

Reich, Wilhelm: “Character Analysis”, Farrar, Strauss and Giroux, N.Y. 1945.

Rosenhan, D.L. and Seligman, M.: “Abnormal Psychology, third edition”, Norton, N.Y. 1995.

Stekel, Wilhelm: “Sexual Aberrations”, Liveright Inc, N.Y., 1930

Stoller, Robert: “Pain and Passion – A Psychoanalyst Explores the World of S&M”, Plenum Press, N.Y., 1991.

Weinberg, Thomas (Ed.): “S&M – Studies in Dominance and Submission”, Prometheus Books, Amherst, New York, 1995.