|The ICD-11 Revision:
Scientific and political support for the Revise F65 reform
Second report to the World Health Organization
ICD Revision White Paper
Revise F65's first report to the World Health Organization, September 24, 2009.
Reiersøl, Odd & Skeid, Svein (2006). The ICD Diagnoses of Fetishism and Sadomasochism. In P.J. Kleinplatz and C. Moser (Eds.). Sadomasochism, Powerful Pleasures (pp. 243-262). Published simultaniously in The Journal of Homosexuality, Volume 50, Issue 2&3, May 2006.
Odd Reiersøl is educated as a psychologist at the University of Oslo. He has been working at Solverv Psychotherapy Institute in Oslo for the last 23 years as a psychotherapist with adults, couples and groups as well as educating other professionals. He also has a university degree in mathematics and mathematical statistics.
Svein Skeid is the leader of Revise F65, and has been working with gay and BDSM human rights for 30 years. He has been awarded prizes several times, included ‘Gay Person of the Year Award’ in 2003, the greatist honor of the Norwegian gay movement.
The Revise F65 project was established in 1996 with a mandate from the Norwegian National LGBT Association of lesbians, gays, bisexuals and transgenders (LLH). Revise F65 consists of gay and straight BDSM human rights organizations as well as mental health professionals. The purpose of Revise F65 is to remove Sadomasochism, Fetishism, Fetishistic Transvestism and Transvestism as psychiatric diagnoses from the International Classification of Diseases (ICD) published by the World Health Organization (WHO).
Sadomasochism was normative before Krafft-Ebing
Degeneration, perversion, and moralistic hierarchy
Prejudice disguised as science
Victorian stereotypes in the media
Research on pathology
Health promoting sexuality
SM versus violence
Pleasure and pain
What SM can teach us
SM and equality
Safe, sane and consensual
Ethology: Sign Stimuli
SM/fetish and love
Nordic sexual reform
SM and fetish identity
Oslo, November 11, 2011
The interdisciplinary research-based knowledge in Revise F65's second report to WHO, emphasizes that sadomasochism and sexualized violence are two different phenomena and that fetishists and sadomasochists do not present more psychopathology than the general population. The fetish/BDSM group is an equal contributor to the society and scores on the level with most people on psychosocial features and democratic values such as self control, empathy, responsibility, love, equality, and non-discrimination. Because the ICD fetish and SM diagnoses are superfluous, outdated, non scientific and stigmatizing to the fetish/BDSM minority, these diagnoses have been removed in nearly all of the Nordic countries. The diagnoses are so seldom in use, that neither care, statistics, nor research are affected by their abolition. The report concludes that a removal of the fetish- and SM diagnoses in the forthcoming edition of ICD-11, may have health promoting effects and be valuable to the society, in addition to an improved human rights situation regarding legal safety, real freedom of speech, and less experienced discrimination based on fetish- and BDSM identity and orientation.
Keywords: sadomasochism, fetishism, fetishistic transvestism, transvestism, SM and fetish identity, SM and fetish orientation, human rights
As contributors to the book ‘Sadomasochism, Powerful Pleasures’, “Reiersøl and Skeid (2006) focused their efforts [with the Revise F65 reform project] and criticism on the ICD-10, concluding: The ICD diagnoses of Fetishism, Fetishistic transvestism and Sadomasochism are outdated and not up to the scientific standards of the ICD manual. Their contents have not undergone any significant changes for the last hundred years. They are at best completely unnecessary. At worst, they are stigmatizing to minority groups in society” (Krueger, 2010).
May 7, 2007, Classification Coordinator Bedirhan Ustun, MD, at the World Health Organization in Geneva invited Revise F65 to cooperate with the work leading up to the ICD-11 revision.
In accordance with this invitation, Revise F65, September 24, 2009, sent the ‘ICD White Paper’ with the professional and health political foundation for completely removing fetishism, sadomasochism, transvestism and fetishistic transvestism in the new, revised version of the ICD, that is, the ICD-11 (Revise F65, 2009e).
In a mail to Revise F65 September 25, 2009, and a 40 minutes long phone conversation November 18, 2009, Senior Project Officer Dr. Geoffrey M. Reed, responsible for WHO’s revision of ICD-10 Mental and Behavioural Disorders, invited Revise F65 to provide additional scientific and political support for the Revise F65 reform to the ICD revision process.
In accordance with this second invitation from WHO, additional scientific and political support follows for the Revise F65 sexual rights reform, consisting of research, empirical data, official national health decisions, law commissions and consultative statements, expert opinions, testimony and careful considerations from mental health professionals, researchers, historians, national health bodies and acknowledged fetish- and BDSM authorities.
In messages to WHO’s Senior Project Officer Dr. Geoffrey M. Reed February 4, 2010 and May 20, 2011, respectively, Revise F65 informed that Norway (Revise F65, 2010c) and Finland (Revise F65, 2011b), have completely removed their national versions of five SM and fetish diagnoses. Sweden removed six diagnoses of sexual behaviours in 2009 (Revise F65, 2008), among them the same classifications as Norway and Finland deleted. Denmark withdrew the diagnoses of dual-role transvestism and sadomasochism in 1994 and 1995, respectively (Politiken, 1995:A7).
Norway and Finland removed the following diagnoses February 1, 2010 and May 12, 2011, respectively:
Sweden, January 1, 2009 removed the following diagnoses:
Denmark, August 19, 1994 and May 1, 1995 respectively, removed the diagnoses:
F64.1 Dual-role transvestism
Norwegian authorities describe BDSM and fetish as ‘sexual identities’. Finnish health authorities say that fetish/SM “has to do with sexual orientation”. The Swedish National Board of Health and Welfare says that as a fetishist or a BDSM practitioner, “You are not diseased. You are not perverse. You are a fully valued citizen!”
The following terms are being used synonymously: ‘sadomasochism’, ‘SM’, ‘S/M’, and ‘BDSM’. They denote the phenomenon of consensual power exchange between adults.
Sigmund Freud connected the concepts of ‘sadism’ and ‘masochism’ into ‘sadomasochism’ in 1938 (Moser & Madeson, 1996:23). The concept of ‘BDSM’ was introduced in 1991 as a substitute for ‘sadomasochism’ which was often associated with an outdated notion of mental illness. While ‘sadomasochism’ is often abbreviated to ‘SM’, the acronym ‘BDSM’ implies a wider definition of three activities which may, but does not always, occur within sadomasochistic practice: ‘Bondage and Discipline’ (BD), ‘Dominance and Submission’ (DS), and ‘Sadism and Masochism’ (SM) (Ernulf & Innala, 1995; Reiersøl & Skeid, 2010).
Synonymously with ‘sadist’ and ‘masochist’, we will use the terms ‘dominant’ and ‘submissive’, ‘master’ and ‘slave’, ‘giver’ and ‘receiver’, ‘S’ and ‘M’, plus ‘top’ and ‘bottom’. ‘Leathermen’ may be used synonymously with ‘homosexuals into fetish and BDSM’.
We define ‘fetishism’ as a sexual orientation characterized by the desire for seeing, hearing, smelling, tasting or touching certain objects, pieces of clothing or body parts of a real or imagined partner.
The terms 'Transvestic Fetishism' and 'Fetishistic transvestism' are used interchangeably. The former is the DSM term which is widely used for research purposes, the latter is the ICD term supposedly used in diagnostic practices world wide.
Sadomasochism was normative before Krafft-Ebing
According to the American historian and sexologist Vern Bullough, sadomasochism was neither classified as a sickness nor a sin before the Austro-German psychiatrist Richard von Krafft-Ebing published the book ’Psychopathia sexualis’ in 1886 (Bullough & Bullough, 1977:210; Moser, 1999b). Bullough documents that our Christian cultural tradition is permeated with sadomasochistic behavior and that Krafft-Ebing constructed a new pathology of a behaviour which had been endemic and normative in Western culture (Bullough, Dixon & Dixon (1994:59,58).
Both physical and mental pain were important in the Judaeo-Christian tradition and punishment was best if the one who did the punishing did so on a person he loved. ”Accompanying the suffering were ecstatic visions which involved a ’high’ similar to what some participants in sado-masochistic activities of today recount” (Bullough, Dixon & Dixon, 1994:57,54).
The Christian ideology accepting both pain and suffering as necessary has long made the Western world prone to accept and tolerate a wide variety of behaviors which have come to be called sadomasochistic but which before the term was coined were more or less normative in our culture. ”Krafft-Ebing, without quite knowing it, made much of Western history a study of pathological behaviour” (Bullough, Dixon & Dixon, 1994:51-59).
This view is supported by a submission to the British Home Office (Slemmings, 2005):
Degeneration, perversion, and moralistic hierarchy
Krafft-Ebing constructed the terms ‘sadism’ and ‘masochism’ from the authors Marquis de Sade and Leopold von Sacher-Masoch. In a letter to Krafft-Ebing Sacher-Masoch fruitlessly objected to the misuse of his family name (Moser & Madeson, 1996:22).
According to Thompson (1994:20), Krafft-Ebing’s theory was based on "a Victorian stereotype about male and female sexual responses". According to Krafft-Ebing sadism was a pathological intensification of the masculine character and masochism a pathological degeneration of the distinctive psychical peculiarities of women (Bullough, Dixon, & Dixon, 1994:48).
In 1879 Krafft-Ebing wrote ’Lehrbuch der Psychiatrie’ that became ’the German bible of degeneration theory’.
He described sadism and masochism in terms of the theory of degeneration as published by Bénédict Morel. This stated that characteristics such as perversions can be inherited (Morel, 1857). In 1886, Dr. Krafft-Ebing defined SM as ‘a disturbance in the evolution of the psychosexual processes sprouting from the soil of psychical degeneration‘.
Even though Freud rejected the degeneration theory of Morel and Krafft-Ebing, and made his own theory of psychoanalysis, the doctrine of degeneration, according to Sulloway (1979:297), was long retained as a coordinate concept by many, including Freud. Freud also adhered to Krafft-Ebing’s concept of perversion and developed it further.
After 1933 degeneration became a part of the Nazi ideology (Shorter, 1997:102). The first social circles of heterosexual sadomasochists in the USA can be traced back to sexual refugees from Nazi Germany (USA Today, 2002).
“Those who combine homosexuality with sadistic and masochistic aberrations are among the cruelest people who walk this earth. In ancient times they found employment as professional torturers and executioners. More recently they filled the ranks of Hitler’s Gestapo and SS” (Reuben, 1969:135). In other words, Reuben is talking about a “double perversion” and so did several other educators. US psychiatrist Dr. David Reuben is probably the most well known. The title of his book ‘Everything You Always Wanted to Know About Sex (But Were Afraid to Ask)’ was one of the first sex manuals that entered mainstream culture in the 1960s, and it had a profound effect on sex education and in liberalizing attitudes towards sex. It was the most popular non-fiction book of its era and became part of the Sexual Revolution of modern America. The book was translated into 54 languages and sold in 52 countries and ultimately reached more than 150 million readers. In 1972 it was parodied by Woody Allen in the comedy film of the same name. The chapter on male homosexuality has received much criticism for perpetuating stereotypes and negative images of gay men as sex obsessed beings, of homosexual expression of sexuality as almost entirely impersonal, and of abusive "butch-queen" relationships as being typical where relationships exist at all. The author asserts very clearly that he considers homosexuality to be a perversion. Also calling into question the objectivity and usefulness of the book is its assertion that all prostitutes are lesbians and all lesbians are prostitutes.
The American National Organization for Women (NOW,) that initially condemned SM lesbians as perverse, removed their 20 years old official policy against SM from their ‘Delineation of Lesbian Rights’ policy in 1999 (Wright, 2006).
The feminist writer and cultural anthropologist Gayle S. Rubin Ph.D., observed that sexual identities are arranged in a hierarchical system ranging from monogamous married heterosexuality at the top to sex workers, sadomasochists, fetishists and those who desire across generational boundaries at the bottom. Those at the top of the hierarchy are privileged while those at the bottom are stigmatized and punished (Rubin, 1984/1993). Tiefer (1997) noted in her essay, ‘Towards a Feminist Sex Therapy’: "By ignoring the social context of sexuality, the DSM nomenclature perpetuates a dangerously naive and false vision of how sex really works," separating what Gayle Rubin (1984) once called "the charmed circle [of] good, normal, natural, blessed sexuality" from "the outer limits [of] bad, abnormal, unnatural, damned sexuality."
Prejudice disguised as science
The american psychoanalyst and researcher Robert Stoller (Stoller, 1991), cautioned his fellow psychoanalysts against accepting as facts about sadomasochism a set of assumptions made plausible by repetition but based on very little evidence.
He noted: "...psychoanalysts, Freud included, cooked up a soup with too few ingredients. For me, most psychoanalytic theories of sadism and masochism are boiled water masquerading as gourmet's delight....Until recently, before loading up on facts, I had no reason to doubt the psychiatric and psychoanalytic wisdom... But then I began meeting sadomasochists...” (Stoller, 1991:9,21)
Stoller described how he changed his mind after having studied bondage and SM houses in California. "Presuming that almost everyone else is as I was, it may interest you to note my change in attitude"... "So, though I found my informants' games unappealing (just as they may find our 'vanilla' practices), I no longer extrapolate and think these people are freaks" (p. 21). ”Psychoanalytic explanations will have to be more precise, more anchored in clinical data, and more modest.... it is immoral for psychoanalysts to hide their moralizing in jargon-soaked theory.... when we have little or no evidence, we do best, regarding theory making, to tread lightly, and...when we recognize the low quality of our evidence, we should go out and collect better evidence...." (Stoller 1991:9,21).
The National Coalition of Sexual Freedom (NCSF) criticizes the DSM for not considering the latest research: “Because the scientific evidence contradicts the statements currently within the DSM, we must conclude that the interpretation of the Paraphilias criteria has been politically not scientifically based.” “Because of this, BDSM practitioners, fetishists and cross-dressers are subject to bias, discrimination and social sanctions without any scientific basis” (NCSF, 2010).
Victorian stereotypes in the media
Charlotte Ovesson points out that Krafft-Ebing’s outdated theories are still alive in Swedish reference books (Herburt, 2009) and daily newspapers. She describes this thoroughly in a social psychological oriented sociological study (Ovesson, 2011:37,44).
Words are manipulated, and quotes are taken out of context to increase sales and to promote the stereotype of the unpredictable male sadist without moral limits (Ovesson, 2011:26,31,33,37). Phrases like “violent sex”, “torture”, and “sex torture networks” are being used regardless of consent or non consent (Ovesson, 2011:37).
The media also construct a stereotype of the woman as a victim even though she participated actively and voluntarily in the SM relationship (Ovesson, 2011:23). At the same time dominant women are non existing and women enjoying SM sex are made invisible in the spirit of the victorian stereotype (Ovesson, 2011:32,40,44).
Even where sadomasochism is described positively it is evident that it is considered as a deviation from the heteronormative sexuality (Ovesson, 2011:35). Due to internalized shame, many SM people retain the stereotypes by repeating the prejudices. The word ‘sadomasochism’ is being used in reports about accidents and crimes that have nothing to do with sadomasochism (Ovesson, 2011:34).
The confounding of SM with violence also permeates dictionaries and encyclopedias. In a study of sadomasochism in Swedish reference books 1876-2006, Kim Herburt at the Historical Faculty at the University of Stockholm points out how the reference books seldom describe sadomasochism within a consensual context (Ovesson, 2011:6; Herburt, 2009:418,419).
Nowhere was it clearly stated that sadomasochism and other sexual deviations were illnesses, but they were described in the same way as illnesses because causes and treatments were part of the articles. The reader will therefore interpret the described phenomena as illnesses (Herburt, 2009:417; Ovesson, 2011:6).
Research on pathology
The Revise F65 literature review shows that regardless of how the research is conducted, whether qualitative, quantitative, via telephone, via Internet, or by face to face interviews, there is the following tendency: sadomasochists do not have any more psychopathology than others. This is supported for example by Gosselin and Wilson (1980). They did not find anything pathological about the SM group. SM people did not display particularly high guilt levels nor were they more obsessional than other people. Breslow, Evans, & Langley (1985) also found SM play practitioners to be non-pathological. “These figures do not indicate that depression plays any greater part in the lives of sadomasochists than it does in non-sadomasochist's lives. It can be concluded that, on the whole, sadomasochists seem to have accepted their SM interest” (Breslow, 1999). Breslow underlines that there is no typical sadomasochist. “The average sadomasochist is unremarkable, he or she is just like anyone else, with the one exception of having an interest in SM” (Breslow, 1999).
A lack of psychopathology is corroborated in studies by Miale (1986), Moser & Levitt (1987/1995:109), Sandnabba et al. (1999), Spengler (1977), Levitt et al. (1994), Sandnabba et al. (2002), Damon (2003), and Stiles et al. (2007).
Connolly et al. (2006), among a group with bondage and sadomasochistic interests (BDSM) showed that “no evidence was found to support the notion that major disorders -- including depression, anxiety, mania/bipolarity, and obsessive-compulsivity -- are more prevalent among the sample of individuals with BDSM interests than among members of the general population” (Connolly et al., 2006:117). Of special interest is the Connolly investigation of personality disorders. ”Paranoia and borderline pathology, the severe personality disorders described in the psychoanalytic literature as ubiquitous among BDSM practitioners, were remarkable in their absence from this sample” (Connolly et al., 2006:108). However, “While this finding does not support those psychoanalytic notions that imply a narcissistic personality structure is present in all, or even most, it does point to the likelihood that some BDSM practitioners (in this case 30.23%) are ‘clinically significant’ on this measure, indicating the presence of greater-than-average levels of narcissistic features and possibly suffer from narcissistic personality disorder” (Connolly et al., 2006:108). There was also evidence of a significantly higher level of histrionic features compared with general population estimates. The authors caution against interpreting this as pathology in the BDSM population, for example: “It has been noted that people in the Los Angeles BDSM community meet frequently for ‘play parties’ in which a high level of exhibitionism is deemed appropriate” (Connolly et al., 2006:109). On dissociative identity disorder (DID): “there is no evidence of a higher-than-average likelihood of DID” (Connolly et al., 2006:110). As with all other research there are methodological issues and the authors of this study have a thorough discussion about it. They conducted a very high number of comparisons: “After conducting over 100 statistical comparisons, a significant result on one or more disorders seemed almost guaranteed on the basis of chance alone” (Connolly et al., 2006:111).
Schmidt (1995) and Schmidt, Schiavi, Schover, Segraves, and Wise (1998) on the DSM-IV Sexual Disorders Workgroup reported that literature reviews completed for DSM-IV revealed a paucity of data supporting the scientific conceptual underpinning of current diagnostic terminology for sexual psychopathology. McConaghy (1999) suggested that, in view of the lack of a relationship of SM with psychiatric pathology, that sadomasochism, like homosexuality, should not be classified as a DSM disorder.
There is more information on the Revise website (Revise F65, 2009k). While the situation is better now than it was in 1998, we acknowledge there is still a paucity of data and that more research is welcome.
Health promoting sexuality
An early sexual rights reform advocate, the Swedish psychiatrist, Lars Ullerstam had a book published about the sexual minorities, including homosexuality, fetishism, transvestism, SM, as well as other 'perversions' that don't harm anybody. He argues in length for the rights of these people to enjoy their sexuality: “One more thing we can be dead certain of: the “perversions” allow considerable chances to achieve human happiness. And therefore the “perversions” are in themselves good, and therefore they ought to be encouraged” (Ullerstam, 1966:43)
Even though Moser & Madeson (1996:40) and Breslow (1999) warn against probable sampling bias, research indicates that sadomasochists are well educated with higher income than the average population (Breslow et al., 1985; Moser & Levitt, 1987/1995; Levitt et al., 1994; Sandnabba et al., 1999; Breslow, 1999; Alison et al., 2001; Haymore, 2002; Connolly, 2006:88).
A survey using computer-assisted telephone interviews with 20,000 Australian men and women, showed that BDSM may actually make men happier. Men into BDSM scored significantly better on a scale of psychological well-being than other men. BDSM’ers were no more likely to have suffered sexual difficulties, sexual abuse, coercion or anxiety than other Australians. “This seems to imply that these men are actually happier as a result of their behaviour, though we're not sure why”, said Dr. Juliet Richters, of the University of New South Wales. “It might just be that they're more in harmony with themselves because they're into something unusual and are comfortable with that. There's a lot to be said for accepting who you are” (Richters et al., 2007, 2008).
The implication of two studies by Sagarin et al. (2009) into hormonal changes associated with sadomasochistic activities including spanking, bondage and flogging, at the Northern Illinois University, suggests that it could bring consenting couples closer together. The increases in relationship closeness combined with the displays of caring and affection observed as part of the SM activities offer support for the modern view that SM, when performed consensually, has the potential to increase intimacy between participants. This result is supported by a qualitative study by Thomsen (2002). Several SM techniques were helpful in gaining comfort with sexual intimacy, including control/power role play, communication, trust, a sense of safety, mutual respect, an emotional bond/intimacy, and being able to get in touch with one’s body. Respondents also gained self-esteem, self-respect, and knowledge of one’s self all of which are vital to achieving comfort with sexual intimacy. Cutler (2003) and Panter (1999) also found that SM participants use SM scenes to increase the intimacy of their relationships and experience a greater sense of personal and interpersonal empowerment.