English Professional work

ICD Revision White Paper

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

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

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In our opinion the five above mentioned diagnoses should be repealed because they are superfluous, outdated, non scientific and stigmatizing.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The diagnoses were repealed at a national level in Sweden January 1, 2009 (6,7).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).


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).


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).