diagnosing deviance

I’m writing from not-so-sunny San Francisco, where International Ms. Leather is fast approaching. (Thank goodness, ‘cuz I got myself a brand-new rich-smelling leather outfit to wear… mmmm.) This town is so gorgeous. No wonder I keep coming back here, year after year. If ever there were an American city I might consider living in one day, San Fran is definitely it. Yesterday, the bois and I spent the day wandering around the Haight-Ashbury district, popping in and out of vintage clothing stores, and then strolling through (or should I say up?) a hilly park full of old, mossy trees before descending the other side of the mount and heading down into the Castro, brilliant with neon signs as dusk fell, to enjoy a dinner à trois. And today is only day three of our week here. Further adventures are sure to come!

Oh, and in random news, I should mention that I was recently interviewed on BlogInterviewer.com about what this blog is about, why I write it and so forth. You can check it out here and vote for Sex Geek as your all-time-favourite blog while you’re at it. Honestly, you can skip the voting part, it’s really not that important – I’d rather exist in exactly the right niche market than win a popularity contest, but hey, they asked me to mention it, so there you go.

Anyway, right now, I’m going to wax poetic about something other than my travels both real and virtual. Yes, you guessed it… it’s another instalment in my Powerful Pleasures review series! More specifically, I’m nearing the end of my series of essay reviews for all the works contained in Peggy Kleinplatz and Charles Moser’s collection of academic essays entitled Sadomasochism: Powerful Pleasures, a brilliant gathering of scholarly works on a variety of topics related to SM and kink.

I decided to skip reviewing Marty Klein and Charles Moser’s article entitled “SM (Sadomasochistic) Interests as an Issue in a Child Custody Proceeding.” It’s a very well-written and well-documented analysis of a specific child custody case in the USA, in which the child is removed from his mother’s custody because of her SM activities, despite suffering no documented ill effects. I’m only skipping it because there’s not much to say except wow, that’s fucking awful, and I’m glad they wrote it up. It definitely serves to point out the terrible misdeeds that can be done to families in the name of justice when anti-kink prejudice comes into play. What an appalling tale. Read it and weep.

Today, I’m reviewing an article by Odd Reiersol and Svein Skeid entitled “The ICD Diagnoses of Fetishism and Sadomasochism.” Their abstract explains the premise best:

“In this article we discuss psychiatric diagnoses of sexual deviation as they appear in the International Classification of Diseases (ICD-10), the internationally accepted classification and diagnostic system of the World Health Organization (WHO). Namely, we discuss the background of three diagnostic categories: Fetishism (F65.0), Fetishistic Transvestism (F65.1), and Sadomasochism (F65.5). Pertinent background issues regarding the above categories are followed by a critique of the usefulness of diagnosing these phenomena today.”

The authors propose that the ICD be revised and the three diagnoses abolished, and their reasoning is wonderfully solid and well-laid-out. I’m going to skip talking about the second portion of the article, in which the authors discuss Norwegian activist efforts to make that change, and instead I’m going to focus on a deeper discussion of their reasoning and provide a bit of critique—not so much in the sense of trashing their work, but rather, perhaps adding a deeper queer perspective to it.

Their first point is that the basis of diagnosis, as expressed in the first of the three general criteria for such diagnosis—“The individual experiences recurrent sexual urges and fantasies involving unusual objects or activities”—is linked to the difference between statistical and normative issues. “From a statistical standpoint,” they argue, “unusual refers to rare and uncommon. However, ‘unusual’ can also be understood as ‘weird’ or ‘bizarre.’ That is, statistical criteria are being confounded at times with moral judgments. Viewing unusual objects or activities as immoral is archaic; there is no scientific basis for diagnosing individuals’ sexuality when diagnostic criteria merely mask moral indignation.”

I find this one particularly interesting because, whenever someone talks about questions of “normal” versus “abnormal” or “unusual,” I can’t help but wonder what their basis for comparison might be. For example, I move in a local, national and international social world that’s characterized by a high degree of sexual openness, curiosity and adventurousness, where fetishism of one sort or another is pretty much par for the course. So for me, a foot fetishist is extremely “normal”—as in, I’ve met literally hundreds of them in dozens of sub-permutations (dirty feet, bare feet, pedicured feet, women’s feet, men’s feet, feet in sports socks, feet in nylons, feet in open-toed sandals, feet in high-heeled boots, feet in sneakers, feet to suck, feet to massage, feet to rub on a face, feet used as penetration toys… lordy, but I could go on.) I’ve met a few hand fetishists and glove fetishists, too. But I’ve only ever met one nose fetishist. So by my comparison group, nose fetishists are very unusual, but foot fetishists are a dime a dozen. Statistically speaking, of course.

So not only are we dealing with a potential moral judgment when it comes to the question of “unusual” sexual urges, we’re also dealing with a statistical likelihood that may vary based on many factors. For example, an openly gay male psychiatrist who lives and works in a major North American urban centre, such as Toronto for example, might find himself dealing with patients who are comfortable disclosing their sexual issues fairly easily, and given the strong kink community in the city, there might be a stronger statistical likelihood of him encountering fetishists among his clientele. So his idea of “usual” versus “unusual” might be very different than that of someone practicing in a small town or in a conservative part of the world, or than that of someone who does not openly disclose their sexual orientation within their professional practice. On the other hand, in a major urban centre with a strong and visible kink community, perhaps the likelihood of a person with a sexual fetish understanding that fetish as disturbing enough to warrant a visit to a psychiatrist might be lower in the first place. Who knows? All I can say is that the idea of “usual” is necessarily biased based on any number of highly variable factors that should have nothing to do with someone’s diagnosed mental health status.

Reiersol and Skeid write, “Furthermore, a variety of sexual practices that were previously considered non-normative are not currently regarded as pathological (for example, homosexuality, fellatio and anal sex).”

It’s interesting they should bring this one up, because the second general diagnostic criteria of the ICD reads as follows: “The individual either acts on the urges or is markedly distressed by them.” As the writers go on to argue, “This kind of distress is often associated with feelings of shame rather than with maladaptive behaviour per se. In fact, individuals are more likely to experience shame if the kind of sex they prefer is frowned upon, stigmatized or subject to diagnosis.”

Of course, since homosexuality is no longer grounds for diagnosis, we can see that social norms and values do have an impact on what’s considered a mental disorder and what is not. What the authors don’t bring up is that the rates of mental illness in general—addiction, depression and others—are still much higher among queer populations than in the average population. And this is not because queers are somehow congenitally predisposed to depression or addiction, as some right-wing forces would argue. Rather, it’s because of the social oppression factor involved in living outside the acceptable norm. Sure, we can get married, but people still yell “faggot” at my partner when he walks down the street in Toronto, gay-bash dykes in Montreal, and kick their queer kids out to survive on the street because of their orientation or gender presentation. And those are all relatively mild examples of what can happen in situations so common, so everyday, as to be banal. You might say “usual.” This, in our supposedly progressive country. So really, we can’t simply strike a diagnosis from the books and emerge as a shiny, happy population of sexual minorities. That diagnosis leaves a scar that marks an entire society for many years past the period in which it’s actively used as a weapon. It leaves a scar on people who are not and who will never will be sexual minorities themselves, and in turn, such people leave scars, directly or indirectly, on all those who are.

The authors mention that non-sexual diagnoses are available for people who do experience genuine mental illness or maladaptive behaviours; they also cite poor methodology in establishing the diagnoses of fetishism and sadomasochism in the first place.

“Before Kinsey, data on sexual deviation were derived almost exclusively from fictional literature or from psychiatric case histories. Despite the obvious methodological limitations of such sources, these data are still used in the psychiatric community. For example, many cases were referred to psychiatrists, because individuals were in conflict with the law. The generalization of findings from those cases to the general population is questionable, due to representability and generalizability limitations associated with external validity and sampling issues; it is impossible to generalize findings from the criminal population to the non-criminal population. Furthermore, Kinsey (1953) indicated that there is no reason to believe that fetishism leads to crime. Indeed, what do we know about law-abiding fetishists?”

Later, they explain that “people with SM and fetish interests do not usually seek therapy to change their sexuality, and, therefore, they do not come into contact with the diagnostic system.” In other words, the biased sampling continues even now.

They also make a beautiful point about the question of safety:

“There is sometimes a concern that SM practices such as spanking and whipping can cause bodily harm. Indeed, people can be damaged from being hit in uncontrolled ways. However, there are ways to give and receive strong stimulation, including pain, that are safe. Both partners need to take responsibility in such acts. People have to learn what is safe and what is not safe, whether they practice SM or any other kind of sex. There are certainly safety issues concerning individuals who practice conventional heterosexual acts, which, once violated, are not diagnosed as sexual disorders. By the same token, individuals who practice SM acts should not be diagnosed based on occasional and naïve safety violations. Nonetheless, it is important to note that safety rules should be taken seriously. We encourage individuals with psychological problems around risk-taking to seek professional help, whether their interests revolve around sexual acts, sports, workplace hazards, etc.”

Once again, the authors make their point with simplicity and elegance, but I would add that here again there’s an apt comparison to anti-queer discrimination, particularly discrimination against gay male sexual practices as being high-risk. People love to make a big stink about how risky penis-to-anus penetration is, and it’s always challenging to try and explain that yes, sure, unprotected anal sex is dangerous… but anal penetration is, first of all, by no means the exclusive province of the gay male; and second of all, it’s chiefly dangerous if done unsafely, as in, while on drugs or drunk; without a condom; while also suffering from other conditions that compromise the integrity of the anal lining; without lube; and so forth. The whole idea that butt-fucking boys = instant AIDS is way too simple and way too homophobic. Yes, risk-taking in that department among gay men, especially if repeated and reckless, is a very bad idea. Pathological? Likely not, in and of itself—though it may be related to the aforementioned mental health issues that are more common among queer people. But such risk-taking is equally dangerous when it’s done by teenage girls and young women (in an effort to avoid pregnancy, say), who are currently the fastest-growing segment of HIV-positive people; or by any other segment of the population. Viagra has caused STI rates among elders to climb, for example. And many other forms of sexual practice are also risky—in no way do I wish to minimize the gravity and tragedy of AIDS, but unwanted pregnancy from either traditional heterosexual intercourse or rape has ruined far more lives than AIDS has over the course of human history, just for starters.

All of this does not even take into account the extremely high-risk (but non-sexual) behaviours that scads of people engage in all the time who are not then pathologized for those behaviours. Boxing, say. (I’d rather let an incompetent top at my back with a flogger than let a 250-pound bruiser aim a fist at my face, any day!) Or circus high-wire artists—ya don’t see them sent to the shrink for the “unusual” and “high-risk” practice of balancing on a tightrope thirty metres above the ground! And never mind firefighters, cops, soldiers… anyone who willingly walks into a fiery inferno or a war zone. These people are admired, not pathologized. Risk, and the concept of what’s reasonable and justifiable, are so very dependent on personal and social values that I find it pretty appalling that a mental health diagnosis, especially in the area of highly misunderstood sexual practices, would depend in any way on an individual psychiatrist’s idea of what constitutes reasonable risk.

Next, the authors take on the concept of procreation. “The ICD-10 presumes the importance of 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’ (WHO, 1993, p. 218). This interference is one of the central arguments for labelling fetishism as pathological.” They go on to make the point that Western society has radically different ideas about sexual pleasure now than it may have in the past. “Furthermore, mental health professionals no longer assume that sex results in intercourse, or that sex and intercourse are synonymous. As such, it is unclear why fetishism, due to its alleged interference with intercourse, is singled out as a disorder.”

I would add that again, there’s another problematic layer in this diagnostic criteria: the heterosexism of it. I rarely hear the term “intercourse” applied to queer sex. What, exactly, would count as intercourse when the available appendages do not match up with the available orifices in the traditional sense? What “intercourse” would a lesbian’s fetish potentially interfere with, for example? Can you honestly see a psychiatrist cluck-clucking because a dyke’s leather fetish prevents her from being fisted by her partner if no leather is present? Or noting with disapproval that a gay man’s rubber fetish means he can’t get anally penetrated if his partner’s not wearing latex? Yeah, I didn’t think so. (Besides, the latter might, oddly, be extremely healthy from an HIV prevention standpoint…) The ICD might no longer classify homosexuality as a disorder, but its heterosexist bias is still embedded in the way it deals with other sexual “pathologies,” and seems to lack any notion that healthy queer sex could even exist, let alone be interfered with by other problems.

Really, I keep seeing parallels with homophobic discrimination. I just finished reading a fascinating book entitled Wide Open Town: A History of Queer San Francisco to 1965, which is in essence the doctoral dissertation of Nan Alamillo Boyd. In it, she provides great detail about the ways in which the San Francisco police force dealt with queers in the late 1800s and early 1900s. One of the ways they persecuted gays was by charging them with “lewd behaviour.” Of course, what counted as “lewd” was extremely skewed—apparently, if you held hands with someone of the same sex, or kissed them, or danced with them, you were demonstrating lewd behaviour and therefore could be subject to arrest. Not only that, but if you were arrested for lewd behaviour two or three times, you were considered a sex offender, right on par with rapists and child molesters. In other words, the identical behaviour that was encouraged or at least tolerated among young heterosexuals in classic courtship rituals (by all but the most repressive of systems, that is) was pathologized and criminalized by the legal system when performed by queers—because queers were, of course, by nature deviant and sick.

It see a similar catch-22 here. If you’re homosexual, you’re sick, and therefore whatever you do is also deviant and sick; if you’re heterosexual, than everything you do is normal, and therefore not deviant and sick. Even if the behaviours are themselves the same, the person doing them makes all the difference. The parallels I see with kink are about the same thing. If you’re kinky and it distresses you (or someone else who has the power to send you into the psychiatric medical system), then you are sick, so everything you do that’s kinky is therefore also sick. On the flip side, if you’re kinky and it does not distress you, you will likely go an entire lifetime without being diagnosed—assuming that your social world does not pressure you into thinking you’re sick, because if they do, you’ll end up in the first category. So in theory, the ICD makes room for healthy, happy kinky people, but that health and happiness is dependent on the existence of a social world in which kink and mental health are not considered to be mutually exclusive, which is only possible if that social world does not buy into the pathologization of kink; except that the pathologization itself is laid out in black and white in the very diagnostic manual that theoretically makes room for its non-existence. Yowch. It’s hurting my brain.

In any case, for all that I think Reiersol and Skeid could have gone further in making parallels with examples from queer history, I very much appreciate the breadth and sheer logic of their article. Sadly, the activist efforts to change the ICD have thus far been fruitless, much like the petitions to change the APA’s Diagnostic and Statistical Manual (the North American equivalent to the ICD). It’s hard to concretely measure the effects of diagnosis on kinky people’s lived experience, and yet, I’m quite certain they exist, if in nothing else but that they add one more layer of stigma to the practices that are so central to some people’s already non-normative sexuality. I’m not sure how we’ll make the changes happen in these manuals, but perhaps this is another place where we should take a page from the annals of queer history—if we got homosexuality off the list, perhaps there is yet hope for kinksters.

One Response

  1. “It see a similar catch-22 here. If you’re homosexual, you’re sick, and therefore whatever you do is also deviant and sick; if you’re heterosexual, than everything you do is normal, and therefore not deviant and sick. Even if the behaviours are themselves the same, the person doing them makes all the difference.”

    That’s how I see the spurious autogynephilia diagnosis as well.

    Fetishizing your body as female…fine if you have a vagina, a paraphilia if you don’t. I can’t believe CAMH/Clarke still has authority over the gender clinic for at least 2 provinces who finance trans surgery, either (that is, you don’t go there, no financing).

    And speaking of CAMH, homosexuality is still pathologized, in childhood. Most children who go to gender therapists (usually because of parents distress, particularly over their sons) turn out to be gay as adults (75% in Green’s 1970s study, with barely 2-3% being trans – and a similar percentage in the Netherlands, with about 20-25% being trans). Though even if they *do* happen to be trans, this kind of therapy is unconsented coercion, on a victim who doesn’t have a safeword or any ‘out’ (haven’t heard about many 4 years old children getting emancipation).

    This kind of treatment wishes to squash out any non gender-normative behavior. What the child identifies as, or their sexuality, doesn’t really matter, but god forbid they play with dolls or like to dress up.

    And about fetishes, well some of them, in the DSM at least, don’t require distress of any kind, the activity itself is reason enough to be diagnosed. Meaning if I tell any psychiatrist I’m an infantilist, and that I’m fine with it and don’t want it treated (or it somehow gets to their ears), I get the diagnostic slapped on me anyways, though I’m unclear what treatment they would propose for it.

    I consider what has been called “creative-reparenting” to be a form of treatment in itself, curing childhood psychological problems, but I certainly don’t expect any therapist to do that for or with me. Personally I also consider it an interesting form of relationship, and even in that submissive position, would strive to give back as much as I take (the stereotype being that an AB is all selfish and demanding).

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