DSM-V Catches up on “too much sex”, Kinky Sex, and Gender Issues.

What is DSM-V?

“DSM” is short for “The Diagnostic and Statistical Manual of Mental Disorders.  It is the manual used to define mental disorders. 

DSM is widely used by insurance companies, government agencies, the judicial system, and the mental health professionals.  DSM is produced by the American Psychiatric Association.

The field is currently using the revised  fourth edition of DSM ( DSM-IV-TR.)  This was published in 2000.  It takes years of work to revise DSM, as various committees sift through all the most recent research. On February 10, 2010,  the working draft  of the fifth edition – DSM-V – was published  online.

When it comes to sexuality and gender,  DSM-V is a big improvement. To start with, it is much more clear than DSM-IV.  Also, it  cleans up some of the inconsistencies of DSM-IV. Here are three important changes:

DSM-V and Hyper-Sexuality

“Hyper” means “over, above, or high.” So “Hyper-sexuality” means a level of sexual activity which is just “over the top.”

DSM-V  adds a category which which is rather ominously called “Hypersexual Disorder.” 

Thinking of the famous line attributed to Mae West – “Too much of a good thing is wonderful,” you might well ask “how can someone have too much sex?”   It turns out that a significant number of people find that thinking about sex, or engaging in sex,  is seriously getting in the way of living a full and balanced life. Some of these people spend a lot of their life pursuing on-line sex,  or having multiple anonymous sex partners (sometimes several per day).

For years DSM  lacked a clear diagnosis for people who are “sex-obsessed” or “sex-addicts.”  One reason that professionals could not agree on a diagnosis is that  neither the “addiction model” nor “obsession model” are a very good fit for sexuality.  

The proposed diagnosis of “Hypersexual Disorder”  completely bypasses the controversy about the terms “sexual addictions” and “sexual obsessions.” It uses neither term.

I prefer to just drop the jargon and call sexual behavior  behavior s client doesn’t want simply “unwanted sexual behavior.”

DSM-V and Kinky Sex

With DSM-V,  the mental health field officially catches up with what people in the “kink community” have  been saying for some 40 years: that “safe, sane and consensual” erotic play is a normal variation of sexual expression and can be integrated into healthy relationships.

Over the last 30 years, the term  “kink”  – or  “kinky sex” –  has perhaps become the most popular way to describe sexual pleasures that are outside the main-stream.  Kinky sex  includes pretty much any sexual turn-on between consenting adults  that is  not traditional “vanilla” genital-genital or oral-genital sex. For some people, oral-genital sex is considered kinky.

To some degree people into kinky sex have “come out of the closet”  although not to the same extent as gays, bisexuals and lesbians.  For some people kink may be an occasional or passing  sexual pleasure, for others it may represent a core sexual identity. The most typical variations of kinky sex are BDSM, the fetishes, and cross-dressing.

  • BDSM includes bondage, discipline and sadomasochism.  “Discipline” is usually a code-word for pain, but can also mean structured role-playing, such as “School-mistress/student.”  Sadomasochism typically involves a “power exchange” of dominance and surrender.
  • Fetishes include any erotic attraction to a non-living thing. This means getting sexually turned on to anything from lace, to leather, to baby-strollers.
  • Erotic cross-dressing involves getting sexual pleasure in wearing clothing of the other sex.  Erotic cross-dressing is very different from cross-dressing as an expression of variations in gender identity. In variations of Gender Identity,  a person dresses  in clothing of the other sex because their core identity is that of the other sex.  There is more about how DSM-V looks as  “Gender Identity next sections.

From the 19th century up to the 1980’s, psychiatry generally referred to kinky sex as “the sexual perversions.” Like homosexuality, the sexual perversions were considered a kind of pathology or character disorder.  Currently the more neutral term “paraphilias” is generally used.  The word comes from “para” for “beside” and “philia”  for “attraction” or “love.” So “paraphilia” means a sexual attraction to things “beside” typical sexual attractions.

Starting with DSM-IV, published in 1994,  the paraphilias were no longer defined as mental disorders, but neither did DSM-IV declare they were not mental disorders.

DSM-V goes a step further:

The first broad change follows from our consensus that paraphilias are not ipso facto [in themselves] psychiatric disorders.

DSM-V retains the position of DSM-IV that paraphilias may be considered a disorder if and only if  (a) they cause marked distress in a person’s life or (b) are non-consenting or (c) involve sexwith  children.   

DSM-V and Gender-Identity

Gender identity is the inner sense of being a man or a woman. 

DSM-V does away with the DSM-IV diagnosis “Gender Identity Disorder”  and replaces it with “Gender Incongruence Disorder.”

This change emphasizes that the problem is not with the sense of gender identity but with the incongruence between the gender identity and the biological identity. The new label is more flexible and less discriminatory.

The transgendered community includes people who are biolgically “plumbed” as men but think of themselves as female,  those who are biologically “plumbed” as women but think of themselves as men, and variations in between.  Some  people who are transgendered obtain surgery so they can live more fully as a member of the other sex. 

Members of the transgendered community has long viewed  the label “Gender Identity Disorder” as  discriminatory, because it suggests their sense of psychological identity is pathological, rather than focusing on the problem being the incongruence between their psychological and biological selves. 

The term “Identity Disorder” suggests  that the problem is always the person’s identity, and that their desire to be a member of the other sex always needed to be changed. 

The term “Gender Incongruence” points to the problem as simply being the discrepancy between the person’s sense of being a man or woman, and their biology.  This  gives no hint about whether overcoming the discrepancy is best achievedby changing a person’s psychological identity, by  surgery, or some combination of both.

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