The medicalization and demedicalization of kink: Shifting contexts of sexual politics

Abstract

BDSM (also known as kink) has been stigmatized through medicalization since the late 19th century. However, the recent publication of the DSM-5 has significantly changed the definition of Paraphilia, which used to be the catch-all diagnostic category for atypical sexual behaviors. In this study, I examined multiple sources of qualitative data to tap into the ever-changing social contexts and power dynamics of the medicalization and demedicalization of kink. The analyses of this study reveal how both activist strategies as well as approaches to social control evolve in the context of increasing reflexivity cultivated amidst sexual politics of the past few decades.

Keywords

Alternative sexuality BDSM demedicalization kink medicalization

In contrast to conventional sexual activities (or “vanilla sex”), the practice of BDSM/kink¹ stands out as the aberrant “other” that experiences formal and informal social control of various kinds. Sadism and masochism, which BDSM practitioners refrain from using as identity markers, have long been listed as sexual and psychological perversions by psychiatrists in their professional diagnostic manuals (e.g. in the Diagnostic Statistical Manual of Mental Disorder or the DSM, compiled by the American Psychiatric Association and in the International Classification of Diseases or the ICD, compiled by the World Health Organization). The risks of harm associated with BDSM practices sometimes render BDSM practices legally controversial (; Egan, 2007; Hanna, 2001; Klein and Moser, 2006; Ridiger, 2006; Weait, 2007; White, 2006). In other instances, BDSM is considered morally wrong.

However, an interesting turn of events occurred when the recently published DSM-5 (American Psychiatric Association (APA), 2013) explicitly stated that practicing or fantasizing about BDSM does not automatically constitute “paraphilic disorder,” a clinical condition that requires psycho-medical intervention. Changes in the DSM-5 had started to affect the legal consequences of many child custody cases where the parents who practice BDSM often used to be ruled against (Wright, 2010, 2014).

The redefinition of paraphilia in the DSM (and very likely in the ICD as well) is, as it seems, a step closer towards the demedicalization of various stigmatized sexual expressions. However, the processes leading to the current policy changes as well as how it may affect the prospects of kink remain unclear. In this study, I intend to analyze the medicalization and demedicalization of kink as a special case to arrive at a more general understanding of the medicalization/demedicalization of sexuality in contemporary society. The analyses of this study will reveal how both activist strategies as well as approaches to social control evolve in the shifting contexts of sexual politics in the past few decades.

Kink in social scientific research

Sociologists (and some anthropologists) were the first researchers to study BDSM outside of the clinical context. While psychiatrists and psychologists draw primarily upon clinical records of individuals who voluntarily seek psychiatric intervention (Kleinplatz and Moser, 2005) or those of the forensic population who committed sexual offenses (Krafft-Ebing 1999 [1886]; Krueger, 2010a, 2010b) as their source of data, social scientists have always been more interested in the practice of “safe, sane, and consensual” BDSM. Since the late 1970s, there has been a growing body of social scientific literature on BDSM practitioners and BDSM subcultures.

As Table 1 summarizes, the predominant majority of the empirical literature is ethnographic research on public BDSM communities.² Informed by the symbolic interactionist tradition broadly defined (Fine, 1993), most of this literature focuses on the micro-level interactions during BDSM activities and within BDSM communities. Although disagreement exists among these studies as for whether BDSM is primarily about sex (e.g. Newmahr, 2010; Taylor and Ussher, 2001; MS Weinberg et al., 1984), these studies collectively corroborate that BDSM is not ipso facto a mental problem, but a complicated form of social interaction where participants redefine emotional and sensational states conventionally perceived as displeasures into pleasures.

Table 1.

Frequency of empirical literature by methodology.

Methodology	Frequency
Survey	5
Ethnography/participant observation or interviews with members of public BDSM communities	16
Content analysis of popular culture	5
Interviews with informants recruited via BDSM magazines ads	1
Studies of online BDSM communities and interactions	3
Total	30

However, BDSM is not simply a microscopic social phenomenon featuring interactions between (or among) participants of a private BDSM “play”. At the macroscopic and public level, BDSM is a stigmatized practice associated with a stigmatized population. Being associated with BDSM automatically stigmatizes an individual: a recent survey study among college students by Yost (2010) shows that while most respondents reject the idea that BDSM is socially wrong and believe that it should be tolerated to some extent, they also believe that BDSM practitioners are more likely to act violently or become victims of violence; media studies in both the US (Weiss, 2006) and the UK (Wilkinson, 2009) have found that popular images of BDSM promote the acceptance of BDSM via normalization, but promote the understanding of it via pathologization. Discrimination against BDSM practices and practitioners is ubiquitous in workplaces and other social settings. A survey study conducted by the National Coalition of Sexual Freedom in 2008 shows that 37.5% of over 1000 respondents indicated experiencing discrimination aimed at their BDSM involvement; among all forms of discrimination, 32.2% of the total respondents report loss of job/contract or loss of promotion/getting demotion (ncsfreedom.org, 2008). BDSM as a macro-level social phenomenon that was historically stigmatized and is seemingly undergoing destigmatization has not yet been fully examined and explained; its potential contribution to the current understanding of the social control of sexuality (especially through medicalization) has not yet been fully developed, a gap that the current study is intended to fill.

Theoretical framework

Medicalization and demedicalization

Perceived as a deviant sexual practice, BDSM is controlled as a psychological and social problem via several mechanisms, among which medicalization is central. Medicalization is “[the process in which] a problem is defined in medical terms, described in medical language, understood through the adoption of a medical framework, or ‘treated’ with medical intervention (Conrad, 2007: 5).” Demedicalization, then, denotes the opposite process where a condition escapes the shackles of medical labeling and control. Over the years, there have emerged a considerable number of case studies on the medicalization of various issues, such as the medicalization of attention deficit hyperactivity disorder (ADHD) (Conrad and Potter, 2000; Malacrida, 2004), addiction including drug addiction (Netherland, 2011; Roy and Miller, 2010), gambling addiction (Rosecrance, 1985), sex addiction (Irvine, 1993), compulsive buying (Lee and Mysyk, 2004), sleeping disorder (Williams, 2002), erectile dysfunction (e.g. Potts et al., 2006). There are also well-documented studies on demedicalization: masturbation (LoCascio, 2009), homosexuality (Conrad and Schneider, 1992), male circumcision (Carpenter, 2010), breastfeeding (Torres, 2013), and childbirth (Davis and Walker, 2013).

What these studies typically depict, are the complex process of claimsmaking (and counter-claimsmaking) and the efforts to institutionalize these claims made by various social actors with very different positions (such as the medical professionals, the health market, pharmaceuticals, activists, the academics, and the general public as health consumers). A characteristic difference in pattern, however, can be observed between cases of medicalization and those of demedicalization. Case studies of medicalization predominantly identify the medical professionals as the primary force behind the medicalization of these conditions (see Conrad, 2007, for a review), although in recent years, the engines of medicalization seem to be shifting to pharmaceutical companies, consumers, biotechnology, genetics and other fields of interest (Conrad, 2005). In contrast, claims to demedicalize a certain condition often come from less powerful groups such as grassroots activists or the consumers, and are not typically institutionalized without collective movements and conflicts with the medical professionals and other powerful interest groups.

Many instances of demedicalization (such as homosexuality and masturbation) serve as the first step towards subsequent destigmatization; for others demedicalization may be the ultimate goal. In either case, the process is a concerted performance by multiple social factors. Medical experts who have the ultimate prerogative to the decision-making of demedicalization have to assess the economic and political interests of the patients against scientific standards, interests of the corporations, pressures from the demedicalization movements, as well as public opinions.

The medicalization and demedicalization of sexuality

Foucault and the medicalization of sexuality

The medicalization of sexuality is often associated with the morally stigmatized status of certain sexual practices. The relationship between sexuality, medicalization, and stigmatization is most notably analyzed by Michel Foucault. In The History of Sexuality (1978), Foucault notes that starting in the 17th century, there has been a proliferation of discourses, often in the form of religious confessions in the Christian tradition, on individual sexual experiences. Close scrutiny of these accounts of sexual experiences reveals that the Christian Church took a special interest in making individuals confess about their sexual misconducts, with the promise that they can be “forgiven” and “saved” if they “tell the truth.” Foucault argues that this approach to sexual misconducts not only generated a large body of discourses of sex, but also associates sex with confessions—a systematic practice that extracts “truth” from the subjects. These discourses as well as the confessional method in producing them enabled “sexuality” to become an independent system of reference (one that no longer depends on other contexts such as romantic love, marriage, or reproduction), and prepared it to constitute a legitimate subject of study in the modern, scientific mode of discourse/knowledge.

A science of sex, which centers on how to approximate “truths” about sex, had never existed before in history until the 19th century, and did not appear in any other cultures than the West. However, Foucault uses archival data to show that the science of sex is not so much informed by reproduction physiology, which was developed on the basis of more rigorous scientific norms, as by the medicine of sex, which shared much historical continuity with the tradition of Christian confessions. Although this emerging science of sex proclaims to discover “truths” about sex, Foucault identifies it as an elaborated process of controlling the subjects in the name of truth seeking. The “truths” of sex, which are inseparable from the pleasures of sex, are never to be revealed and articulated by the science of sex. Through various techniques such as confession, measurement, observation, experimentation, and other kinds of tampering with the body and the mind, individuals experience the power and control of this new form of knowledge over their embodiment as well as their subjectivities, which disciplines individual thoughts, behaviors, and representations in the name of hazard or disease reduction.

Individuals who are diagnosed with sexual problems are not “punished” as they were in traditional contexts. In other words, there are no “laws of prohibition”, which repression used to manifest itself into. In its stead are “promises of rehabilitation”. Foucault argues that these are two very different systems of discourses, and correspond to two different types of power relations. Laws of prohibition are external constraints that individuals have no choice but to abide by for fear of punishment, whereas promises of rehabilitation impress on the individuals the false illusion that they are making a choice, that they are surrendering their bodies and minds to the scrutiny and discipline of the doctors for their own good. The “truth” that sex can simply be a pleasure-seeking activity is permanently concealed, replaced by a system of disciplinary techniques that are supposed to produce scientific knowledge about, and orient social actors toward, “healthy” sexuality.

Sexual citizenship, reflexivity, and demedicalization

Although Foucault's theoretical perspective takes into serious account the issue of power differentials among social actors, and within discursive relations, one of the salient shortcomings of his theory is its reticence in whether and how individual social actors may be able to reflexively resist social control of their sexuality. In contrast, Jeffery Weeks (1998, 2007) celebrates social actors' resistance to institutionalized mechanisms that block their access to free expressions of sexuality. Weeks grounds these acts of resistance in the concept of “sexual citizenship”, which extends normative and political autonomy to the realm of sexuality. If the radical social movements organized by gay and lesbian activists in the 1970s to demedicalize homosexuality (Conrad and Schneider, 1992) resemble the proclamation of sexual citizenship, the rise of neoliberalism and the professionalization of sexual politics, however, have corrupted the normative substance of sexual citizenship in the LGBTQ movement of the new millennium (Richardson, 2005). Instead of freeing different expressions of sexuality from the previously private spheres of “shame” and “indignity”, claims of sexual citizenship often tend to “normalize” and “gentrify” “unsanitary” sexual practices by transforming them into irrelevant characteristics of a universal concept of citizenship predicated upon sameness and heteronormativity (Bell and Binnie, 2000; Richardson, 2000a, 2004). For sexual citizenship to maintain its promise of the free expression of sexuality, it has to redirect its focus back on the “sexual” from a sanitized notion of the “citizen.” Dianne Richardson (2000b) argues that sexual citizenship should entail not only the rights to the public recognition of sexual identities and sexual relationships, but also conduct-based rights to experiencing sexual pleasures and engaging in various sexual practices. But how can such a substantively “thick” notion of sexual citizenship realize its full potentials in the face of various erosive forces under neoliberalism, a serious concern that Richardson (2005) herself expressed?

Anthony Giddens's (1984, 1992) structuration theory as well as his analysis of the transformation of intimacy provides an alternative perspective on the shifting social contexts of sexual politics. What Giddens observes in contemporary society is an increasingly prominent tendency in the democratization of intimate relationships, epitomized by the increasingly open expressions of same-sex sex and same-sex intimacy. Against this background, the ideal of romantic love, which, in Giddens's view, often devolves into pathological forms of co-dependence, is increasingly undermined in practice and in popular discourses, making room for a different paradigm of sexuality: plastic sexuality. By “plastic,” Giddens means that sexuality is no longer confined to the purpose of reproduction, or the ideal of romantic love. Sex can be good in its own right, and relationships need not be revolving around sexual jealousy. He terms this new paradigm of intimacy “pure relationships,” where sex is liberated from the confinement of sexual jealousy and enjoyed as pleasure, yet no longer constitutes an essential component of intimacy.

Ultimately, Giddens believes that intimacy (including institutions such as marriage and the family) will be reconstituted into a much more democratic realm, and he attributes this transition at both the individual and the institutional levels to “reflexivity.” On the one hand, Giddens (1984, 1992) acknowledges that habituated and routinized social facts display an obdurate structural character, constraining individual actions. On the other hand, agentic social change at both the individual and the institutional levels is made possible by the slow cultivation of the capacity to “reflexively monitor” individual actions and institutional outputs. As individual social actors engage more reflexively with power and control, social institutions are also gradually sensitized to the evolving self-identity and lifestyles of the social actors. In other words, individual reflexivity and institutional reflexivity reciprocally inform one another in all social and political processes, and constantly restructure social relations toward democratization and emancipation (Giddens, 1991).

The medicalization and demedicalization of kink provides an empirical case that has the potential of enriching our current understanding of the medicalization/demedicalization of sexuality in contemporary society. By situating our intuitive concerns about the demedicalization of kink within the empirical and theoretical literatures, the current study seeks to address the following theoretically driven questions: (1) In comparison with the literature on medicalization/demedicalization, who are involved and who play critical roles in the medicalization/demedicalization of kink? (2) How is the medicalization and demedicalization of kink related to the social control of sexuality in contemporary society? Specifically, is medicalization a supra-moral, highly rationalized means of control? To what extent should the demedicalization of kink be attributed, if at all, to the successful claiming of sexual citizenship, to the rise of neoliberalism and the professionalization of sexual politics, and to the increasing individual and institutional reflexivity over sexuality?

Methodology

This study is first and foremost a case study of the medicalization and demedicalization of kink. To that end, I collected and analyzed both interview and textual data relating to various processes of the medicalization and demedicalization of kink. Consistent with both Foucault's (1978) and Giddens's (1992) analytic approaches, I analyze texts and discourses in their specific historical and social contexts, with a conscious focus on the contingent power dynamics between institutions and individuals, and the historical ruptures of discourse-power relations.

Four types of primary and secondary data were collected between November, 2013 and April, 2014, and were used for analysis: (a) narratives and diagnostic criteria from diagnostic manuals (various editions of the DSM and ICD) and the DSM-5 and ICD-11 revision websites, (b) narratives from peer-reviewed psychiatric journal articles (c) narratives on the websites of BDSM organizations, and (d) in-depth interviews with BDSM activists/organization leaders and psychiatrists. Narratives and content from peer-reviewed journal articles and the internet are included only when it is directly concerned with the DSM-5 revision project. A preliminary screening renders 10 articles (including letters to the editor) published between 2008 and 2012, and 29 single-spaced pages' worth of relevant internet content. In regard to the interviews, five individuals in total were interviewed. Four of them are current or past leaders of national BDSM organizations (whose websites the online content analysis of this study draws upon), and one of them is a psychiatrist who was closely involved with the DSM-5 and ICD-11 revision projects. Each interview averaged 80–90 minutes. The interviews were approved by the Institutional Review Board of the University of Delaware, and all interviewees signed Informed Consent Forms. Both interview and archival data were coded twice.³ While I understand that the sample size of the interview study is rather small, I only interviewed organizational leaders of the BDSM movement who were better capable of articulating the strategies of their movement. Moreover, the interview data only served as a complement to the analysis of textual and historical data.

The medicalization and demedicalization of kink

Sadism, masochism, and paraphilia

Although kink existed long before any academic conceptualization, it was the kinky fantasies depicted in the literary works such as those of marquis de Sade and Leopold von Sacher-Masoch that inspired Austrian psychiatrist Krafft-Ebing to first coin the terms “sadism” and “masochism” (Krafft-Ebing, 1999 [1886]). When it first appeared in American Psychiatric Association's DSM-I in 1952, sexual sadism was mentioned only once (and there was no mention of Sexual Masochism in the DSM-I) under Sociopathic Personality Disturbance (000–x60).⁴ This conceptualization is very similar to that of Krafft-Ebing's (1999 [1886]), who did not consider “sexual deviations” as ipso facto mental problems, but as an indication of underlying mental disorders such as schizophrenia. Starting in the DSM-II (APA, 1968), however, “Sexual Deviation” started to be conceptualized as an independent category of mental problem.⁵

The effort of making sexual deviance an autonomous mental disorder eventually consummated in the DSM-III-R (APA, 1987) where conditions such as Sexual Sadism, Sexual Masochism, Fetishism, Pedophilia etc. started to be classified under the category of paraphilias in place of the obscure term of Sexual Deviation. The number of diagnostic categories in the DSM grew from 60 categories in the DSM-I (APA, 1952) to almost 300 in the DSM-III-R (APA, 1987). In addition, more specific behavioral criteria for Sexual Sadism and Sexual Masochism were prescribed.⁶

In subsequent editions of the DSM, paraphilia continued to be used as the umbrella term to designate what used to be considered “Sexual Deviation”. In the meantime, the diagnostic criteria became increasingly more specific and behaviorally oriented. In the DSM-IV-TR (APA, 2000), Sexual Sadism and Sexual Masochism are classified under paraphilia.⁷ The diagnostic criteria for paraphilia in the DSM-IV-TR exclude individuals who engage in BDSM activities with consenting adults. However, paraphilia is used both as a generic concept that groups Sexual Sadism, Sexual Masochism, Fetishism and other atypical sexual behaviors together, as well as a diagnostic category of mental illness. There is a conceptual difference between paraphilia as a descriptive category and paraphilia as a clinical condition that was not acknowledged in the DSM-IV-TR (APA, 2000).

The diagnostic categories of Sexual Sadism and Sexual Masochism (or paraphilia in general) in the DSM affect the legal status of both coercive sexual offenses and consensual BDSM. Under Sexually Violent Predator (SVP) Laws, the diagnostic status of Sexual Sadism (or “paraphilic disorder otherwise specified”) are expected to be used to fulfill one of the necessary conditions, namely being diagnosed of a mental disorder, to justify involuntary civil commitment (to medical facilities) of sex offenders upon their release from prison.⁸

But even consensual BDSM is a controversial issue in the law. In the past few decades, there have been repeated instances where voluntary practices of BDSM were busted by law enforcement and the participants involved were charged with assault (Ridinger, 2006; White, 2006). A central issue in many of these cases is to what extent is consent to physical harm valid. From a legal perspective, consent as a legitimate defense for harm is difficult to establish because, in contrast to rape, kidnapping, or theft which are considered “bad” only if there is an absence of consent, causing pain, injury, or death is not morally neutral; it is regrettable (Bergelson, 2008: 696). Legal scholars argue that the risks of serious harm are high while the social utility of the activity (unlike sports or even body modification) is not compelling (Hanna, 2001: 243), even though ethnographic studies (e.g. Newmahr, 2011; Weiss, 2011) have shown that most BDSM practices are well maintained within the boundaries of safety, and BDSM practitioners do not think of these intense sensations so much as “pain” or “discomfort”, but as pleasure (Weiss, 2006; Yost, 2010).

Before the clarification issued in the DSM-5 of paraphilia in the DSM had resulted in many problematic cases regarding child custody. A partner's involvement in BDSM is often used as evidence to undermine the person's eligibility for child custody. According to a survey study by the National Coalition of Sexual Freedom (ncsfreedom.org, 2008), 11.2% of the respondents (out of over 1000) stated loss of child custody because of their involvement in BDSM.

The polemics and politics of demedicalization

Activism for demedicalization

Depathologizing kink/BDSM is a common goal among all BDSM/kink organizations, since the medicalization of kink/BDSM lies at the center of its stigmatization. The effort to reduce the stigmatization of BDSM by revising the DSM and other important medical documents started as early as the 1980s.

Bob, whom I interviewed, has been a long-time activist in the BDSM/kink community since the 1950s. He organized the very first activist group that resisted the stigmas associated with the medicalization of BDSM. He and a friend of his (who was a psychiatrist) created a list of kink-friendly psychiatrists and psychologists for individuals in the kink community who needed psychiatric assistance but fear their stigmatized condition may be judged or even used against them. He received requests (via mail) from people all over the country, and he replied with contact information of psychiatric professionals who are “kink aware”. In the first few revisions of the DSM, Bob was closely involved as a community member. He provided a lot of useful information for the DSM paraphilia sub-workgroups to consider when they were making changes to these medical categories. Bob admitted, however, that most of his involvement with the DSM revision was kept secret. No public demonstration or rallies were organized to campaign for that.

Because Bob no longer has the time and energy to manage this organization, it is now under the administration of Kelly's organization, which played a major role in the most recent DSM revision. Kelly leads a national BDSM/kink activist organization that is “committed to creating a political, legal and social environment. She told me that her personal experience with discrimination led to her participation in, and later, organization of BDSM activism:

I came to my late 20s. And I was discriminated almost immediately. I was a writer. I had actually gotten my degree to be in art history and I started writing rather late as well. But I was trying to get my first book published. And I talked to the publisher and he found out that I was in relationship with a married couple and he assumed … that made me fair game for him … if I sleep with them, I should sleep with him.

Related to her personal experience, Kelly explained why activism is much needed for the BDSM/kink community:

There is activism for gay marriage because you have to fight for that. And the reason we have such [BDSM] activism right here is because we have to fight for our rights. We get such discrimination and persecution and harassment.

According to my interview with Kelly, the role that she and her organization played in the DSM-5 revision was very similar to that of Bob and his organization in the previous revisions. As an active community voice, her organization was invited by the APA paraphilia sub-workgroup to provide information about claims of discrimination from the BDSM community. Kelly's organization collected this information through online opinion polls and online comments. The main difference between Kelly's and Bob's organizations lies in (1) the size of the organization and (2) the publicity of the organization. Unlike Bob's organization whose involvement in the DSM revision was almost secretive, Kelly's organization is not only more visible in public spaces (e.g. on the internet, academic/professional conferences, and in publications), its campaign for the DSM revision is also explicit on its website. Kelly also organized an online petition where more than 3000 people signed to support the demedicalization of kink. Unlike Bob's organization, which only focuses on referring kink individuals to professionals who are kink aware, Kelly's organization runs a host of services and awareness-raising programs along with activist campaigns.

According to Kelly, her campaign would not have been this successful without the internet. Firstly, the internet enables activists from all over the country to participate in BDSM activism with very little cost. In fact, Kelly's organization doesn't even have a physical office; the entire operation is online. Moreover, the internet enables anonymous participation from BDSM practitioners, most of whom are still very private about their involvement in BDSM.

In addition to Kelly's organization, other activist efforts exist in the kink community. Dr K is a psychologist by trade, and one of the chief administrators of a national BDSM/kink community-based research organization that was founded in the mid-2000s. When asked why his organization was established and how it furthered the course of BDSM activism, Dr K answered:

It was starting to be recognized in the community that these professions, psychiatrist, psychologists, counselors, and doctors are often saying things about BDSM and kink that don't reflect the actual lived experience, and that a lot of it was pathologizing. And that this was actually creating social barriers, legal barriers, medical barriers that were really damaging to the community … So there's this concern, I think from the community's side, that the only way to talk to those professions is to talk about evidence. That's the language they use. They use the language of science … It really comes out of this concern for stigma, disenfranchisement, and isolation from these fairly important institutions in society.

While Dr K conceded that while opinion polls might be helpful for presenting a general summary of discrimination, it is unlikely to be taken too seriously by institutions such as the APA since psychiatrists have a different standard about the scientific rigor of these studies:

When there isn't a lot of psychiatric research itself, they [psychiatrists] are more than willing to look at studies such as community surveys. That's not really scientifically designed work. They are certainly open to it, but it does have a lower standard. They recognize the weaknesses and limitations of it and for a lot of them that's enough to dismiss it because there isn't a large body of work pointing to a particular direction.

According to Dr. K, useful community-based studies should be able to dialog with the scientific community, and reduce stigmatization. For example, he is currently involved in a particular research project that examines access to health care for the BDSM/kink population. He and his colleagues are trying to document just how much and how often people in the kink community will hide or limit their use of health care because of the stigma.

Psychiatric and legal response to demedicalization

Because of their previous history with “the problem population” (such as the homosexuals), APA and WHO alike are making much effort to maintain a good public image by including public participation in the DSM revision project. On the website DSM5.org, members of the general public were able to track changes on the DSM revision process and make comments on these proposed changes throughout the entire revision process, although the public were not able to view comments made by other people. In addition, the APA invited people outside the psychiatric community as advisors to the DSM revision projects. Individuals who were invited by the APA had to promise confidentiality of the issues being discussed at the work-group meetings. Dr S is a psychiatrist and a key member in the paraphilia sub-workgroup of the DSM-5 revision project. During our interview he revealed the psychiatric professionals' intention to minimize the negative effects of medical labeling on practitioners of consensual BDSM:

You always get into trouble if you try to delineate what is normal and what is not … you get the problem particularly with labeling … there is consideration of not wanting to stigmatize certain sexual behaviors.

Although the revised drafts are no longer available on the DSM-5 website, APA published a series of “fact sheets” summarizing what major changes had been made in the DSM-5 and what were the reasons and debates leading to these changes. Concerning paraphilic disorder, for example:

In the Diagnostic and Statistical Manual of Mental Disorders (DSM), paraphilic disorders are often misunderstood as a catch-all definition for any unusual sexual behavior. In the upcoming fifth edition of the book, DSM-5, the Sexual and Gender Identity Disorders Work Group sought to draw a line between atypical human behavior and behavior that causes mental distress to a person or makes the person a serious threat to the psychological and physical well-being of other individuals … Most people with atypical sexual interests do not have a mental disorder.

It is a subtle but crucial difference that makes it possible for an individual to engage in consensual atypical sexual behavior without inappropriately being labeled with a mental disorder, or, in the case of pedophilia, to avoid being automatically considered mentally sick without any unlawful act (Leon, 2011). With this revision, DSM-5 clearly distinguishes between atypical sexual interests and mental disorders involving these desires or behaviors: “A paraphilia is a necessary but not sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention” (APA, 2013: 686).

This is a significant change in the DSM in that according to a national BDSM community service provider, in most child custody cases after the DSM-5, “attorneys were able to suppress the BDSM behavior as not relevant or the judge set it aside from the bench as not relevant, so that child custody could be determined on its own merits” (Wright, 2014).

Although records documenting work-group meetings during the revision process are kept confidential, plenty of debates reflective of the controversies throughout the DSM revision process appeared in Archives of Sexual Behaviors, a peer-reviewed journal that publishes “empirical research (both quantitative and qualitative), theoretical reviews and essays, clinical case reports, letters to the editor, and book reviews” (Springer, 2016).

As part of the DSM-5 revision procedures, Kruger (2010a, 2010b) conducted two comprehensive literature reviews on Sexual Sadism and Sexual Masochism. These literature reviews include previous studies that criticize these diagnostic categories from the perspective of the BDSM community. In response, Kruger (2010a, 2010b) suggests that the narrative sections of the DSM should be rewritten to reflect the fact that much information on sadistic and masochistic behavior is derived from the forensic population and may not apply to community populations, but the diagnostic categories should be retained because of Sexual Sadism's prevalence in the forensic population, and the high association between sadism and masochism.

The psychiatric profession is making a conscious effort to resist excessive from social control the scientific process. The paraphilia “fact sheet” discusses the legal implication of the DSM revision:

While legal implications of paraphilic disorders were considered seriously in revising diagnostic criteria, the goal was to update the disorders in this category based on the latest science and effective clinical practice.

However, on many occasions (e.g. Krueger 2010a, 2010b), the association with the forensic population is used as a justification to create and retain a diagnostic category. Even regardless of the influence of the law, the scientific process behind the DSM remains questionable. Blanchard (2011) who serves on the committee of the paraphilia sub-workgroup reviews the history of field trials of the DSM diagnostic criteria:

The field trials for DSM-III, which were sponsored by the National Institute of Mental Health, included three patients with paraphilias. That's it … (T)he sum total of patients who have been studied in conjunction with revising the DSM diagnostic criteria for the paraphilias is 3 … That means that most of the paraphilias' diagnostic criteria were never looked at with a single patient as part of the DSM production process ever.

What about the DSM-5? Blanchard (2011) introduces several studies that examine both forensic and community populations as field trials for the DSM-5. But are the quantity and quality of the research good enough to justify the creation of new diagnostic categories or revision/removal of old categories? Blanchard concludes his article saying:

(T)here is a complete lack of information from prior DSM field trials about the usefulness of various elements of the diagnostic criteria for the paraphilias. The amount of available information regarding the diagnostic criteria proposed for DSM-5 is already equal to, or perhaps greater than, the amount of information about the existing criteria. (Blanchard, 2011: 862)

The implication of this statement is that the baseline of previous DSM field trials was so low that it does not take much additional effort to supersede it, which does not translate into the high level of rigor that APA boasts to maintain.

APA's reluctance to study BDSM or any other alternative sexuality in a nonclinical context was a frustration that Dr K expressed. Dr K believes that the BDSM community itself should be producing studies that meet rigorous scientific standards to be taken seriously, and eventually contribute to the destigmatization of the community by showing the facts about the little utility of these medical categories and their damaging impacts on the BDSM/kink community.

Dr S also disliked the idea of creating a diagnostic of Paraphilic Coercive Disorder. In addition to the lack of sufficient scientific evidence, he also did not see the changes with paraphilia in the DSM-5, which specifies the difference between paraphilia and paraphilic disorder, as progressive. Instead, he believes that the proposed revision of the ICD-11, which eliminates some categories without a potential victim such as Sexual Masochism and fetishism but reserves a category of “atypical sexual behavior” to be a better model for conceptualizing alternative sexual practices that might cause societal harm or distress on the part of the participating individuals. Dr S explained that this more substantive approach, where the psychiatrist can use his/her discretion when giving these diagnoses, is considerably better than following rigid guidelines that sometimes fail to capture the severity or the actual causes of the problems. Ideally, the psychiatrist should be able to judge whether an individual should be diagnosed with paraphilic disorder with more discretion. “It's just like pornography,” Dr S said, “I know it when I see it.” Similar to the revision of DSM-5, anybody can log on the ongoing ICD-11 revision website, and make comments on the ongoing revision, a proposed item was recently added under paraphilic disorder, which seems congruent with Dr S's ideal model.⁹

Discussion

This study sheds light on a number of aspects of the medicalization and demedicalization of sexuality in contemporary society. First and foremost, consistent with Foucault's (1978) analyses of the medicalization of sexuality, this study revealed that multiple institutions of control, sometimes in collaboration with each other, actively produce social problems and the problem population. As much as modern psychiatry advocates rehabilitation rather than punishment and control, keeping such a promise proved to be difficult. Although contemporary diagnostic criteria of Sexual Sadism and Sexual Masochism lay stronger emphasis on whether the condition affects “important areas of functioning” instead of the criminality or immorality of the act as early psychiatrists prescribed, these diagnostic categories are retained and justified by their prevalence in the “forensic population” and the potential criminal consequences associated with them. The use of potential criminality as a legitimate claim for medicalization, as well as the lack of empirical evidence from scientific studies on the general population (Blanchard, 2011), weakens the claim that rehabilitation is the goal of medicalization, since the diagnostic categories were retained for the purpose of identifying and subsequently, controlling a population with criminal tendency. Even Dr S's proposal for collapsing all categories of victimless sexual deviance under “atypical sexual behavior” in the ICD-11 reveals the psychiatric professionals' implicit unwillingness to completely lose legitimate control over this population, however well intentioned their arguments for it may sound. The pathological definition of kink also reinforces the general public's reluctance to make sense of BDSM practitioners' alterative claims of pleasure from otherwise unpleasant experiences; the legitimacy of medicalizing alternative sexuality is grounded in the seemingly benign concern for the patient's social well-being, which compels BDSM practitioners to constantly align their feelings and behaviors with the diagnostic criteria, an epitome of the Foucaultian notion of disciplinary control.

Nevertheless, while it is still premature to say that kink is “vindicated”, or even completely demedicalized, the findings of this study suggest, however, that it is not naively optimistic to say that the demedicalization and destigmatization of consensual BDSM are well on their way; emerging social conditions have radically changed the dynamics between the institutions of control and its “controlled population”. One of such conditions is the popularization of the internet. The internet not only provides a safe space for individuals with stigmatized status to express their grievances and political agendas without having to expose themselves, it has also made activist mobilization much more efficient and economical. This new resource and opportunity is what Kelly's organization relies heavily upon to collect grievances and remain connected, and it is also why the organization is able to operate without a physical office.

The rise of reflexivity, especially institutional reflexivity (Giddens, 1992), also complicates the interactive dynamics between sexual minorities and the institutions of control. The proliferation of discourses on sexuality and intimate life, generated by both the institutions of control as well as progressive sexual politics, spurs more reflexive discussions on sexuality, and affords both sides a common language to effectively discuss these issues. For Kelly, although appearing in public with demands still has its import in sexual politics, it seems more effective to engage with the institutions of control by “speaking their language”, namely, producing scientifically sound studies that substantiate the claims of discrimination. Psychiatrists are also more cognizant of the effects of excessive stigmatization produced by arbitrarily attaching medical labels. This explains why Dr S and other psychiatrists believe that the proposal for ICD-11 where Sexual Masochism and Fetishism are recommended to be removed seeks to establish a more humanitarian approach to diagnosis where doctors and patients are given more freedom to express themselves beyond the established discursive legitimacy of documented diagnostic criteria. This new social context stands in sharp contrast with Bob's account of the early days of BDSM activism, when tolerance from institutions of control was next to none and making demands were out of the question. The process of demedicalizing BDSM seems to be an early sign of its ultimate destigmatization; the pathological perspective towards BDSM seems to conflate, increasingly so, with the non-pathological perspective advocated by the BDSM community.

A gloomier interpretation of the demedicalization of kink, however, can also be made based on the findings of this study: the activists' reliance on a discourse of discrimination compromised by the “thick” notion of sexual citizenship that Richardson (2000b) envisioned; hiding behind the internet sends a message of fear and weakness, rather than empowerment. It can be argued that the cost for the sympathy from the institutions of control is to curtail essential elements of the sexual autonomy that sexual politics strives to preserve. However, unlike the LGBT movement where the dominant claim of sexual citizenship is about identity, the claim of the kink movement is predominantly about freedom of sexual expressions. The grievances of discrimination, such as that of Kelly's very own, is a statement that “my sexual practices and expressions do not necessarily determine who I am, and you should not presumptuously make the connection.” The findings of this study also indicate that on the part of Dr S and the APA, the idea of freedom of sexual expression seems to be well received, more so than with the case of homosexuality where “choosing to be gay” has the coded connotation of “choosing depravity.”

Concededly, the demedicalization of kink and other “deviant” sexualities does not automatically translate into the realization of sexual autonomy. The latter is the cumulative outcome of long and complex social and political processes. Perhaps the LGBT movement has lost its integrity in maintaining the full potentials of sexual politics, but it has undoubtedly created a much more hospitable social environment for a broader scope of sexuality-related issues to receive attention in the political arena. The demedicalization of kink may reflect compromises of the grandiose ideal of sexual autonomy, but as Giddens (1991) argues, emancipatory politics holding fast to a normative ideal often fall apart before such an ideal can be realized. The potential for emancipation arises out of the institutional and discursive foundations gradually built by individuals' reflexive life politics towards self-actualization. Efforts toward self-actualization expressed through life politics require reflexivity and wisdom when engaging with power and control. This self-reflexivity connects the struggle for the contingent freedom of the individual with the institutional possibility of total emancipation.

Practically speaking, therefore, if claiming discrimination remains an effective short- to mid-term strategy to stimulate open discussions and cultivate institutional reflexivity, there is no reason for activists to jettison this strategy simply because it may seem like a temporary compromise of normative integrity. Confronted with the constant and substantial power differentials between social control and its problem population as this study shows, strategic choices (such as utilizing the anonymity of the internet to channel grievances) have to be made in order to realize the immediate goal of demedicalization and destigmatization, upon which further reflexivity and emancipatory politics can be built.

Footnotes

Notes

Kai Lin is a PhD candidate in sociology at the University of Delaware. His research areas include deviance and crime, law and society, sexualities, and cultural sociology. He has published multiple pieces of research comparing cultural perceptions between Chinese and Americans on social issues such as intimate partner violence and homosexuality. His publications appear in journals such as Violence against Women, Journal of Interpersonal Violence, Journal of Family Violence, and Sexuality Research and Social Policy.

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