Abstract
Are sexual perversions or paraphilias mental disorders? I attempt to answer this question by scrutinizing the presentation and discussion of unusual sexual behaviors and desires in the consecutive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, from its very first edition in 1952 up until the freshly printed DSM-5. My main conclusion is that due to the manual’s messy definition of mental disorder, advocates of the DSM cannot convincingly claim that paraphilias are mental disorders.
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Notes
- 1.
The word “unusual” is used here to refer to both the (relative) statistical rarity of certain sexual behaviours and desires, and their salience, i.e. their being able to generate heated debates and extreme emotions.
- 2.
Note that, for reasons of readability, I will use such expressions and terms as “unusual sexual behaviours and desires,” “sexual perversion,” “sexual deviation,” and “paraphilia” interchangeably. “Sexual deviance” refers to the set of unusual sexual behaviours and desires available to a particular society at a particular time.
- 3.
Some historians of sexuality have argued that sexual deviance had in fact been pathologized before the nineteenth century. Commenting on Avicenna ’s work, for example, the fifteenth-century French physician Jacques Despars interpreted same-sex sexuality as a disorder that is not amenable to medical treatment (Neal 2008).
- 4.
In fact both episodes in the history of sexuality are connected, to the extent that many nineteenth-century psychiatrists emphasised the role of masturbation in the aetiology of sexual deviations and various other kinds of insanity (Rimke and Hunt 2002).
- 5.
Elsewhere, however, he spoke of it as an “aberration” and an “abnormality” (Freud 1960 [1905]).
- 6.
Marmor obviously referred to the work of the American ethologist Frank A. Beach , who co-authored the classic Patterns of Sexual Behavior in 1951. Here the authors indeed made reference to “the bisexuality of the physiological mechanisms for mammalian mating behaviour” and a “fundamental mammalian heritage of general sexual responsiveness” (Ford and Beach 1951, pp. 258–9). By summarising evidence of same-sex sexual behaviour in humans and other animals, they also hoped to strengthen the view later defended by Marmor, i.e. that homosexuality should not be seen as some kind of physical abnormality, nor as a perversion of the sexual instinct. In the glossary of the book, the authors define “perversion” as “[a] term without scientific meaning. It refers to any form of sexual activity which a given social group regards as unnatural and abnormal. Activities that are classified as perversions by one society may be considered normal in another” (283).
- 7.
- 8.
In his early work, Freud indeed focused on the exclusivity of particular sexual behaviors and desires to distinguish between normal sexuality and pathological sexuality. Thus he claimed, in his Three Essays on the Theory of Sexuality : “In the majority of cases we are able to find the morbid character of the perversion not in the content of the new sexual aim but in its relation to the normal. It is morbid if the perversion does not appear beside the normal (sexual aim and sexual object), where favourable circumstances promote it and unfavourable impede the normal, or if it has under all circumstances repressed and supplanted the normal; the exclusiveness and fixation of the perversion justifies us in considering it a morbid symptom” (Freud 1960 [1905], p. 22; italics in original). .
- 9.
In the annotated listing of the differences between DSM-II and DSM-III (Appendix C; APA 1980, p. 380), Spitzer cited some evidence to warrant the exclusion of homosexuality: “The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder. A significant proportion of homosexuals are apparently satisfied with their sexual orientation, show no significant signs of manifest psychopathology […], and are able to function socially and occupationally with no impairment. If one uses the criteria of distress or disability, homosexuality per se is not a mental disorder.”
- 10.
Moreover, I have already explained that the ad hoc condition of acting cannot, in itself, be considered a sufficient condition for an unusual sexual desire or urge to be a disorder. The editors of DSM-IV-TR indeed admitted as much themselves, when they claimed that “[d]efining paraphilia based on acts alone blurs the distinction between mental disorder and ordinary criminality” (First and Frances 2008, p. 1240). Some would probably go one step further to argue that, for most paraphilias, the condition of acting cannot even qualify as a necessary condition. In Krafft-Ebing’s view, for example, one can be a paraphiliac without ever realizing any of one’s unusual sexual desires or fantasies (Oosterhuis 2000).
- 11.
Aronsson (2011) is an intriguing exception, but it is based on the assumption that paraphilias are biologically dysfunctional sexual preferences.
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Adriaens, P.R. (2015). Are Paraphilias Mental Disorders? The Case of the DSM. In: Meacham, D. (eds) Medicine and Society, New Perspectives in Continental Philosophy. Philosophy and Medicine, vol 120. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-9870-9_10
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