Oslo, Norway, September 24, 2009
Dead links updated November 22, 2011

ICD Revision White Paper

ICD Revision White Paper to WHO from Revise F65
(Revise F65’s first report to WHO)

ICD WHITE PAPER

By Cand. Psychol Odd Reiersøl and Revise F65 leader Svein Skeid
Proposal to the ICD-11 Revision of Chapter V, Mental and Behavioural Disorders, F65 and F64.

Invitation from WHO to Revise F65

We want to thank classification coordinator Dr. T. Bedirhan Üstün M.D. at WHO in Geneva for inviting Revise F65 to collaborate with the work leading up to the ICD-11 revision.

In an email of May 7, 2007, Dr. Üstün wrote:
“The revision process of ICD from 10 to 11 is about to start and will be revised for the 11th version tentatively in 2015. The revision work will include special attention to Chapter V Mental and behavioural disorders (F00-F99). Thanks for your interest in the ICD work and we hope to collaborate with you in the revision process.”
T. Bedirhan Üstün, M.D., Coordinator, Classifications, Assessment and Terminology, World Health Organization, Geneva, Switzerland.

Revise F65 was formally established in Norway in 1997 with the purpose to abolish the SM and fetish diagnoses in the F65 category of the ICD.  Among the Revise F65 members are health care professionals and human rights activists. During these years, articles have been published and presentations have been given (1,2,3,4,5).

In our opinion the following four ICD diagnoses should be abolished:

• F65.0 Fetishism
• F65.1 Fetishistic transvestism
• F65.5 Sadomasochism
• F65.6 Multiple disorders of sexual preference

In addition the F64.1 Dual-role transvestism diagnosis should be abolished.

Health political and professional arguments for the human rights reform

In our opinion the five above mentioned diagnoses should be repealed because they are superfluous, outdated, non scientific and stigmatizing. The article by Reiersøl and Skeid in “Sadomasochism, Powerful Pleasures” (1) gives thorough argumentation for removing the F65.0, F65.1 and the F65.5 diagnoses.

As the F65.6 diagnosis combines several diagnoses including the three above mentioned, it should also be removed. The F64.1 diagnosis is a bit special in the sense that it is classified as a gender identity disorder type diagnosis, but it is very similar to the F65.1. A separate section describes the issue in more detail.

Health political arguments

The diagnoses were repealed at a national level in Sweden January 1, 2009 (6,7). The Dual-role transvestism and the SM diagnoses were repealed in Denmark respectively August 19, 1994 and May 1, 1995 (8). The health authorities in these two countries cited in their reasoning; health political, health promoting and human rights arguments.

The Swedish board of health used the following phrases:

• “not perverse” (7,9,10)
• “not illness” (7,9,11)
• “private matters” (7,9)
• “citizens entitled to equal rights” (9)
• “no reinforcement of prejudices” (7,9,11,12)
• “from earlier times in history” (7,9)
• “risk of social stigmatizing” (11,12)
• “entitled to self confidence in the same way as homosexuals” (9)

Private matter

The Danish decision was made by the health minister, Yvonne Herløv Andersen, referring to this type of sexual preference as a private matter that has nothing to do with society (8).

The newspaper Dagens Nyheter November 16, 2008 quoted the head of the Swedish National Board of Health and Welfare (Socialstyrelsen), Lars-Erik Holm: “Society has nothing to do with the sexual preferences of these individuals” (7,9).

According to Nettavisen November 17, 2008 the head of the Norwegian Directorate of Health (Helsedirektoratet), Bjørn-Inge Larsen, said: “There is no basis, neither within today’s social norms nor within health political thinking, for labeling several of these phenomena as illnesses” (10).

Stigmatizing

The Swedish revision was done because these psychiatric diagnoses “may contribute to preserve and reinforce prejudices in society, which in turn increases the risk of social stigmatizing of individuals” (11).

“The abolition of  the diagnosis of homosexuality I believe to a certain extent has contributed to a different view than in the 60’s and 70’s of homosexuals in the general population. The abolition gave the homosexuals self confidence because they no longer have a psychiatric stigma. We hope that the current revision will give a similar result”, said  the head of the Swedish National Board of Health and Welfare (Socialstyrelsen), Lars-Erik Holm (9).

In a press release NCSF, National Coalition for Sexual Freedom, applauds the Swedish decision, and says:

“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.” (13)

The Norwegian Directorate of Health has since 1996 as a goal to work for counteracting the stigmatizing of sexual minorities (14).

The strategy plan for prevention of HIV and STD points out “the danger of stigmatizing and discriminating against vulnerable groups when doing  preventive work, and the importance of a holistic approach to sexual identity, sexual health and sexual behavior” (15) (pdf file).

Preventative measures

In our opinion, outdated and non scientific diagnoses such as these, constitute an infringement of the human rights of the minorities that are described, and they hinder prophylactic health care efforts that are needed in these groups of people. Deleting the diagnoses may strengthen the “identity building” of the SM/fetish population and contribute positively to the “collective self respect” which is necessary for reaching the group with preventative measures like HIV and STD prevention.

According to Norwegian health authorities “A person’s possibility for self protection against a virus that is sexually transmitted is only to a certain extent influenced by knowledge. The feeling of self value necessary for demanding or having a wish to protect oneself is influenced by societal factors, and only a few of these factors are under the control of the health authorities. We emphasize that the cooperation with marginalized and vulnerable groups has an influence on what could be called a collective self respect” (16).

The Norwegian health authorities have taken an active interest in improving the self respect and the identity of the SM group, to increase the ability of protection against sexually transmitted diseases (17).

Discrimination

For many people, SM and fetishism is more than just behavior, it is part of their sexual orientation and identity (23). In our opinion, stigmatizing minorities by considering their personal orientation as a psychiatric condition is as disrespectful as discriminating against people because of their race, ethnicity or religion.

Like the earlier diagnosis of Homosexuality that is no longer applied by the WHO, the SM and Fetish diagnoses are rarely used for therapeutic purposes. Instead, these definitions are abused to justify harassment and discrimination of the SM/fetish population from laymen and judicial institutions.

Much of the discrimination is directly or indirectly a result of the diagnoses. A psychiatric diagnosis may have a major influence on a person’s possibility of getting work and on the evaluation of a person’s ability to raise children, for example after a divorce.

As with other forms of abuse, women are the main sufferers, losing their jobs, or even their children, because of their SM/fetish love, lifestyle and self-expression (18).

The Norwegian National LGBT Association (LLH) and the National coalition for sexual freedom (NCSF), have published respectively a case study and a survey indicating the stigmatizing function of the F65 diagnoses and that these diagnoses legitimize discrimination (18,13,19).

By repealing the diagnoses, the sexual minorities in question may breathe a bit more easily and be less afraid of private and public discrimination.

In a letter of June 11, 2003 to Revise F65, the Norwegian Association for Clinical Sexology says:  “The Norwegian Association for Clinical Sexology in its support wishes to emphasize that the use of psychiatric diagnoses in relation to homosexual, heterosexual and bisexual fetishists, sadomasochists and transvestic fetishists is stigmatizing and therefore an encroachment upon this group as a whole”.

Safe, sane and consensual

There is no reason to doubt that the SM movement has  “grown up” and taken responsibility over the last 20-30 years, by establishing safe words, security routines, pride symbols and normative measures like the internationally recognized moral and ethical principle “Safe, sane and consensual”. As opposed to dangerous perpetration, SM activities are mutually wanted and consensual activities that produce health promoting and pleasurable hormones (20,21,22,23,38).

Dead links updated November 22, 2011

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).

 

Sincerely,

Revise F65

Svein Skeid (leader)                         Odd Reiersøl (psychologist)

Dead links updated November 22, 2011

Footnote 1.

Reiersol O. & Skeid S. (2006). The ICD Diagnoses of Fetishism and Sadomasochism.  In P.J. Kleinplatz and C. Moser (Eds.). Sadomasochism, Powerful Pleasures (pp. 243-262). Retrieved September 19, 2009, fromhttp://books.google.no/books?id=iHkT5Eyj7H0C&printsec=frontcover#v=onepage&q=&f=false

Published simultaniously in The Journal of Homosexuality, Volume 50, Issue 2&3, May 2006, pages 243-262. Retrieved September 19, 2009, from http://www.haworthpress.com/store/ArticleAbstract.asp?sid=M6XM7W1WEHBQ8K7CX9SA3CDGU3SU9LUB&ID=65910

Footnote 2.

Fetisj og SM-diagnosene i ICD-10 [The Fetish and SM Diagnoses in ICD-10]. (2008, June). Tidsskrift for Norsk Psykologforening [Journal of the Norwegian Psychological Association, Vol 45]. Pp 754-756. Retrieved September 19, 2009, from http://www.psykologtidsskriftet.no/index.php?seks_id=52392&a=2&sok=1

Footnote 3.

Retrieved September 19, 2009, from http://www.reviseF65.org

Footnote 4.

Retrieved September 19, 2009, from http://en.wikipedia.org/wiki/ReviseF65

Footnote 5.

About the ReviseF65 project. Professional and health political work 1994-2009. Retrieved September 19, 2009, fromhttp://www.revisef65.org/aboutrevisef65.html

Footnote 6.

Fetish and SM diagnoses deleted in Sweden. Retrieved September 19, 2009, fromhttp://www.revisef65.org/Sweden.html

Footnote 7.

Transvestism ‘no longer a disease’ in Sweden (2008, November 17). The Local. Retrieved September 19, 2009, fromhttp://www.thelocal.se/15728/20081117/

Footnote 8.

Denmark withdraws SM from Diagnosis-list (1995, April 1). Politiken, page A7. Retrieved September 19, 2009, fromhttp://www.revisef65.org/denmark.html

Footnote 9.

Nu ska Sara-Claes slippa bli stämplad som sjuk [Sara-Claes will not any longer be stigmatizised as sick]. (2008, November 16). Dagens Nyheter. Retrieved September 19, 2009, from http://www.dn.se/nyheter/sverige/nu-ska-sara-claes-slippa-bli-stamplad-som-sjuk

Footnote 10.

Dette er ikke perverst lenger [This is not any longer perverse]. (2008, November 17). Nettavisen. Retrieved September 19, 2009, from http://www.nettavisen.no/jobb/article2402153.ece

Footnote 11.

Koder i klassifikationen av sjukdomar och hälsoproblem utgår [Codes in the Classification of Diseases are removed]. (2008, November 17). Socialstyrelsen [The Swedish National Board of Health and Welfare]. Retrieved September 19, 2009, from http://www.revisef65.org/socialstyrelsen.html

Footnote 12.

Så blev transvestiter friska över en natt! [Transvestites taken off the sick list overnight]. (2008, November 17). QX. Retrieved September 19, 2009, from http://www.qx.se/samhalle/8544/sa-blev-transvestiter-friska-over-en-natt

Footnote 13.

Sweden takes sexual behaviors off their disease list. (2008, November 25). NCSF, National coalition for sexual freedom. Retrieved September 19, 2009, from https://ncsfreedom.org/key-programs/dsm-v-revision-project/dsm-v-program-page/item/316-press-release-sweeden-takes-sexual-behaviors-off-their-disease-list.html

Footnote 14.

Norwegian health authorities about healt preventive work. Retrieved September 19, 2009, fromhttp://www.revisef65.org/forebyggende.html

Footnote 15.

Ansvar og omtanke – Strategiplan for forebygging av hiv og soi [Responsibility and consideration – Norwegian national strategy plan to prevent hiv and sexually transmitted infections]. Helsedirektoratet [The Norwegian National Board of Health]. Pp. 3, 3, 13, 21, 26 and 40. Retrieved September 19, 2009, fromhttp://www.helsedirektoratet.no/vp/multimedia/archive/00002/Ansvar_og_omtanke_2200a.pdf

Footnote 16.

Handlingsplan mot hiv/aids-epidemien 1996-2000 [Norwegian national strategy plan to prevent HIV and STD 1996-2000]. Helsedirektoratet [The Norwegian National Board of Health]. Pp 25 and 33.

Footnote 17.

Tilskuddsbrev til fetisj & SM gruppen SMia-Oslo fra Sosial- og helsedirektoratet via kap. 719 post 70 [Letter to the Fetish & SM group SMia-Oslo from The Norwegian National Board of Health]. (2002, April 25).

Footnote 18.

Discrimination and violence towards the SM/fetish population. Revise F65. Retrieved September 19, 2009, fromhttp://www.revisef65.org/discrimination.html

Footnote 19.

NCSF’s Violence and Discrimination Survey. Retrieved September 19, 2009, fromhttps://ncsfreedom.org/component/k2/item/452-ncsfs-violence-and-discrimination-survey.html

Footnote 20.

Safe, sane, and consensual as a moral ethical principle and cornerstone of SM acticity. Retrieved September 19, 2009, from http://www.revisef65.org/sikker.html

Footnote 21.

SM versus abuse. Revise F65. Retrieved September 19, 2009, from http://www.revisef65.org/violence.html

Footnote 22.

No more psychopathology among SM-people. Revise F65. Retrieved September 19, 2009, fromhttp://www.revisef65.org/psychopathology.html

Footnote 23.

Sexual Freedom NOW. Physicians and psychiatrists about SM as a valid expression of adult consensual sexuality and an important part of people’s sexual orientation. Retrieved September 19, 2009, fromhttp://www.revisef65.org/NOWSM.html

Footnote 24.

Transvestittisme og SM ikke lenger en sykdom i Sverige [Transvestism and SM are no longer diseases in Sweden]. (2008, November 17). Dagens Medisin [Medicine Today]. Retrieved September 19, 2009, fromhttp://www.dagensmedisin.no//nyheter/2008/11/17/transvetittisme-ikke-lenge/index.xml

Footnote 25.

Meeting at the Norwegian National Board of Health, May 11, 2009.

Footnote 26.

The Hippocratic Oath. Wikipedia. Retrieved September 19, 2009, from http://en.wikipedia.org/wiki/Hippocratic_Oath

Footnote 27.

World Health Organization (1992). The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. Geneva, Switzerland.

World Health Organization (1993). The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva, Switzerland.

Footnote 28.

Quantity of the sm/fetish-population. Retrieved September 19, 2009, from http://www.revisef65.org/antall_eng.html

Footnote 29.

DSM Revision White Paper. NCSF, National coalition for sexual freedom. Retrieved September 19, 2009, fromhttps://ncsfreedom.org/key-programs/dsm-v-revision-project/dsm-revision-white-paper.html

Footnote 30.

Noyes, J. K., Ph.D. (1997). The mastery of submission: Inventions of masochism. Ithaca, NY: Cornell University Press, page 30.

Footnote 31.

Goffman, E. (1963) Stigma: notes on the management of spoiled identity. Englewood Cliffs, Prentice-Hall.

Footnote 32.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revised). Washington DC.

Footnote 33.

About The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Retrieved September 19, 2009, from http://www.revisef65.org/DSM.html

Footnote 34.

Heino Meyer Bahlburg: Presentation at the WAS (World Association for Sexual Health) conference in Goteborg, June 2009.

Footnote 35.

Moser, Charles & Kleinplatz, Peggy J. (2005). DSM-IV-TR and the Paraphilias: An Argument for Removal. Journal of Psychology and Human Sexuality (2005), 17(3/4), 91-109. Retrieved November 11, 2011, from http://www2.hu-berlin.de/sexology/GESUND/ARCHIV/MoserKleinplatz.htm

Footnote 36.

Moser, C. & Kleinplatz, P.J. (2002). Transvestic fetishism: Psychopathology or iatrogenic artifact? New Jersey Psychologist, 52(2) 16-17. Retrieved September 19, 2009, from http://home.netcom.com/%7edocx2/tf.html

Footnote 37.

Moser, C. (1999). The Psychology of Sadomasochism (S/M). In S. Wright (Ed.) SM Classics (pp. 47-61). New York, Masquerade Books. Retrieved September 19, 2009, from http://www2.hu-berlin.de/sexology/BIB/SM.htm#S/M_PRACT

Footnote 38.

Moser, C. & Wright S.. What is SM? Retrieved September 19, 2009, fromhttp://www.leatherleadership.org/library/whatsm.htm