Electronic Journal of Human Sexuality, Volume 15, June 4, 2012


Constructing Perversions: The DSM and the Classification of
Sexual Paraphilias and Disorders

Robert Scott Stewart, Ph.D.
Department of Philosophy
Cape Breton University
Sydney, NS, Canada B1P 6L2

Ph. # 902 563-1252
The author has no conflicts of interest to disclose with respect to this paper.


This paper compares some recent philosophical accounts of perversion with recent psychological ones. The author argues that both present us with perfectionist ideals of sexual activity that are inappropriate for use in defining sexual norms, and especially inappropriate when deviations from the norm are classified as paraphilias or dysfunctions standing in need of treatment. Several factors are provided for why this process has occurred, including the influence of Big Pharma in the construction of psychological illness.


Notions of sexual perversions have a long history in philosophy, dating back at least to those two pillars of Western thought: Plato and Aristotle. The position advanced by Aristotle, who understood all phenomena within a framework of a teleological universe, has been particularly influential.  The telos of sex has traditionally been taken to be reproduction, and hence all uses of the sexual organs outside this purpose were thought to be unnatural and condemned as perverse. When the Catholic Church adopted the basic conceptual framework of Aristotelianism, via St. Thomas Aquinas in the thirteenth century, it also adopted this view of sex and turned perversions into sins. This view is, of course, still with us today. But in the past century or so, there have been attempts to alter fundamentally our conception of sexual desire and of sexual perversion. In this paper, I shall explore several current philosophical and psychological conceptions of perverse sex, broadly construed to include sexual disorders as well as paraphilias. As we shall see, these conceptions of perversity overlap in significant ways. Both disciplines have presented a normative and ‘perfectionist’ view of sex that defines normophilic sex as reciprocal, affectionate and interpersonal, and have derivatively defined sexual perversions, paraphilias, and dysfunctions as failures to attain this end. In this, while it’s true that contemporary versions of these concepts has avoided talk of sin, they continue to retain a teleological framework in which ‘normal’ sex has to attain its ‘proper end’ – in this case, reciprocal, affectionate, and interpersonal sex. Though there is nothing wrong with such sexual relationships, I suggest that this conception of sexual normality and perversion is deeply problematic when failures to match the ideal are viewed as forms of mental illness standing in need of medical correction.

In 1969, the American philosopher, Thomas Nagel, published “Sexual Perversion,” which was part of a trend that attempted to understand perversion outside the traditional context of unnatural and sinful sex. Borrowing heavily from Sartre, Nagel maintained that paradigmatic cases of sexual desire begin as self conscious desires for another that can only be completed in mutual desire. That is to say, sexual desire must not only involve awareness that another feels sexual desire towards you, but also that that awareness increases your sexual desire, and vice-versa: it is, then, a “multi-level interpersonal awareness” of escalating desire. (Nagel, 1969)  On this account, sexual perversion is any incomplete version of this complex of mutual desire thus making all narcissistic practices sexual perversions which could include many of the sexual paraphilias listed in the Diagnostic and Statistical Manual of Mental Disorders:  e.g., pedophilia, sadism, masochism, exhibitionism, fetishism, and partialism (the exclusive focus on part of the body) (APA, DSM IV TR, 2000, 566-576). It is important to note here that while these paraphilias can be narcissistic in Nagel’s sense, they need not be, with the probable exception of pedophilia. For example, while an exhibitionist might not care whether those he flashes appreciate his behavior, some exhibitionists may only become aroused when ‘performing’ before a willing and sexually aroused audience.  That is, for this later group of exhibitionists, there could be a multi-level interpersonal awareness of escalating desire.

One of the reasons we find such commonality between what Nagel offers as perversions and the DSM offers as paraphilias is that the American Psychiatric Association (APA), which publishes the DSM, sees normophilic sex in much the same way Nagel does. This becomes clear when considering how the APA describes a deviation from the norm. “The Paraphilias,” they claim, “are characterized by arousal in response to sexual objects that are not part of normative arousal-activity patterns and that in varying degrees may interfere with the capacity for reciprocal, affectionate sexual activity (APA, DSM III-R, 1987, 279: emphasis added). In defending the APA’s current description of sexual desire, Robert Spitzer says that just as the function of the heart is to pump blood and of the eyes to see, “sexual arousal brings people together to have interpersonal sex. Sexual arousal has the function of facilitating pair bonding which is facilitated by reciprocal affectionate relationships” (Spitzer, 2006, 114. Emphasis added). Clearly, then, Nagel, Spitzer, and the APA all view normophilic sexual desire as necessarily involving a reciprocal, interpersonal awareness of some sort. Moreover, as Spitzer adds: “There is a normal development of sexual arousal and sometimes it can go wrong” (Spitzer, 2006, 114).

Note that the claims being made here about perversion and normophilic sexual behavior are prescriptive in some way. There is no attempt to present them as a description of the way in which people actually behave sexually. Nor is there any empirical evidence to suggest even that the majority of people behave in such a manner sexually. Indeed, Nagel at least explicitly admits that his view of ‘non-perverse’ sex is “evaluative in some sense” even though the type of evaluation he is doing is complex. (Nagel, 1969, 16). As he says, the evaluation isn’t a moral one, nor does the evaluation even distinguish between ‘good’ and ‘bad’ sex. “It is not clear that unperverted sex is necessarily preferable to the perversions. It may be that sex which receives the highest marks for perfection as sex is less enjoyable than certain perversions; and if enjoyment is considered very important, that might outweigh considerations of sexual perfection in determining rational preference” (Nagel, 1969, 16,17). So what sort of evaluation is Nagel making regarding non-perverse sex? In answering this question, special attention must be given to the reference to sexual “perfection” in the just cited passage.  What Nagel is offering us, along with the APA, is a notion of sexual desire that is “perfectionist’” i.e., it presents us with an ideal where the ideal is defined in teleological terms as the proper end of sex. Given this, it is completely unwarranted for him, or the APA, to call deviations from the ideal a perverse desire. Think of an analogy. Let’s say we have constructed a description of what constitutes an ideal red wine. Surely, if one were to choose a deviation from this ideal – say something less expensive – this shouldn’t be thought of as a perverse red wine, or a perverse desire for red wine. Unfortunately, however, both Nagel and the APA fall into this problematic way of thinking, a point made indirectly of the APA by Moser and Kleinplatz (2005, 102) in their argument for the removal of paraphilias in future editions of the DSM: the “judgment of what constitutes reciprocal, affectionate sexual activity is clearly value laden and suggests an underlying, implicit, theoretical orientation. There are no data to suggest that individuals diagnosed with a paraphilia have any more difficulty maintaining relationships than “normal” heterosexuals, who have staggering divorce rates.”

I believe that this prescriptive and perfectionist account of normophilic sexual desire is much more problematic for the APA than it is for Nagel. This stems from the function of the DSM, namely, to present a description of, and treatments for, various types of mental illness or disorder. Hence, by their own criteria, all mental disorders must “… be associated with present distress … or disability … or significantly increased risk of suffering death, pain, disability, or an important loss of freedom (APA, DSM IV-TR, 2000, xxx1). Curiously, however, when we examine the criteria for classifying or diagnosing someone with a paraphilia in DSM IV TR, we find that such distress or disability is required only for some paraphilias but not for all of them. Specifically, a diagnosis of pedophilia, voyeurism, exhibitionism, and frotteurism require only that “the person has acted on these urges” (APA, DSM IV-TR, 2000, 566). While this may be an important issue with respect to determining criminality, it seems an odd criterion for determining mental illness (see Moser & Klienplatz, 2005; Primoratz, 1997; & Suppe 1987).

This problem gets more acute as we move beyond the rather narrow parameters of sexual paraphilias – even given the catch all classification, “Paraphilia not Otherwise Specified” (APA, DSM IV TR, 2000, 576) – to a consideration of all the “sexual disorders” listed in the current DSM. Consider sex addiction as an example. Although it is not listed explicitly in the DSM IV TR, that work does include a miscellaneous diagnosis called “Sexual Disorder Not Otherwise Specified” that includes the following two examples, both of which, I would argue, come uncomfortably close to a description of sexual addiction: (i) "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used," and (ii) “compulsive sexuality in a relationship” (APA, DSM IV TR, 2000, 582) (2). Interestingly, sexual addition has been included in the DSM before. DSM III R (APA, 1987) listed “nonparaphilic sex addiction” within the catch-all category, “Sexual Disorders Not Otherwise Classified” (NOS). The category was deleted because, as Schmidt (1992, 254) said in preparing recommendations for the DSM IV, “the results of the review reveal abundant clinical evidence of sexual activity that can be characterized as excessive” but there was “no scientific data to support a concept of sexual behavior that can be considered addictive” (cited in Manley & Koehler, 2001, 257). In their suggestions for DSM-V, however, Manley and Koehler suggest that such a diagnosis be returned to the DSM through a redesigned noslology that would include “Sexually Excessive Behavior Disorders,” which would include such ‘sex addictions’ as excessive masturbation, affairs, and attendance at strip clubs and peep shows (Manley & Koehler, 2001, 260).

One way in which to look at this issue is to see it as yet another instance of ‘disease creep’ and the medicalization of all behavior that has been occurring for more than half a century. Interestingly, this was forecast even early in the twentieth century by such luminaries as the Anglo-American poet, T.S. Elliott:  “all the world’s [becoming] a hospital,” he said. More recently, Emily Fox Gordon, who spent much of her life in therapy and recovering from it, said that, “the world we now live in is … so thoroughly indoctrinated in the ideology of therapy that society has remade itself in therapy’s image” (Gordon, 2000, 229). Specifically referring to sex, Janice Irvine has argued that “The nineteenth century marked a shift to scientific investigation of sexual matters. The medical profession usurped moral and religious authority in the area of sexuality, generated new and highly visible discourses, and promulgated the diversification of new sexual identities. Sexuality, then, represented a site of expansion and control by the medical profession. Physicians were consolidating their power to regulate and define large areas of human experience, even those, as later critics would note, that fell outside of their training and expertise (Irvine, 1995, 430; also see, Zola, 1972, Conrad and Schneider, 1992 and Friedson, 1970).

This problem of over-diagnosis and overtreatment of ‘mental illness’ has received a great deal of attention. Perhaps the so-called ‘designer drugs’ are the best example of these complaints. Designer drugs, such as Ritalin, various SSRI’s, and Viagra to name just a few well known examples, reverse the typical relationship between disease and medication. That is, historically, drugs were created in order to treat an already extant disease. With designer drugs, however, this process is reversed with a disease – such as Erectile Dysfunction or Attention Deficit and Hyperactivity Disorder – being constructed only after a drug has been developed that treats the ailment – Viagra and Ritalin in these cases respectively. In these cases just referred to, dramatic – indeed, exponential -- rises in diagnoses of these ailments have occurred after the drug and behavior were matched. To give just one example, depression in adolescents jumped from virtually 0 to 15-20% of the population once SSRI’s first came on the market in the late 1980’s and early 1990’s (Stewart, 2001).

There is, in fact, a pattern typically followed in this process. Of course, there first needs to be a drug that has some effect on a body that matches, in some fashion, a ‘problem.’ This is the process Peter Kramer detailed in Listening to Prozac (1993), the groundbreaking book on SSRI’s and identity, and the advent of “cosmetic psychopharmacology.” That is, examine the drug and its capacities instead of the disease per se. But when we do so, it typically follows that changes, perhaps subtle ones, are made with respect to how a disease is classified and/or in how liberally the classification is interpreted. Quite quickly thereafter, we find that we no longer think of problem kids as being a little restless or teenagers who are a bit blue; they are now diagnosed as suffering from ADHD and depression and are taking medications to treat and/or cure the ailment (see Stewart, 2001).

Consider the diagnosis of dysthymia in adolescents. Dysthymia is a form of depression that is relatively mild but chronic, and which is typically treated through some combination of drug and talk therapy. A diagnosis of dys­thymia requires the presence of a depressed mood most of the day, more days than not, for at least one year in children and adoles­cents. In addition, at least two of the following six symptoms must be present while in a state of depression: (1) poor appetite or overeating, (2) insomnia or sleeping too much, (3) low energy, (4) low self esteem, (5) poor concentration or difficulty making decisions, and (6) feelings of hopelessness. These symptoms must not be absent for more than a two year period (or one year in children and adolescents), and other diagnoses and/ or problems, such as bipolar and major depression as well as substance abuse, must be ruled out. Finally, the condition must be debilitating (Sarason, LG. & Sarason, B.R., 1999, 279; APA, DSM-IV, 1994).

Even a cursory examination of the descriptions of dysthymia can indicate why rates of it can be high. Con­sider a hypothetical case of a fifteen year old that makes the transition from a small junior high school populated mainly by a relatively homogeneous group, many of whom are friends, to a large high school. Due to her place of residence, she gets sent to a different school than many of her friends. Her grades drop and she seems "moody." Toward the end of the year, her parents send her to a school councilor who, during an inter­view, discovers that she often feels "blue." Upon further investigation, the councilor discovers that she suffers from insomnia, has gained fifteen pounds due to overeating and lack of exercise (which bores her), and has difficulty concentrating. This all-too-common description of a fairly "normal" teenager now has a label: dysthymia. She is also a statistic in the growing number of depressed adolescents.

This is a particularly worrisome state of affairs when we consider the extent to which Big Pharma is connected to the DSM and its construction. In a fairly recent study, Cosgrove et al. (2006) demonstrate that more than half of the experts sitting on panels to determine what will be contained in the soon to be released 5’th edition of the DSM have some “financial ties” with the pharmaceutical industry. As alarming as this figure is, it is actually a very conservative estimate, and the rates of financial ties are probably higher since Cosgrove et al. counted only those ties that could be quite easily checked and relied almost exclusively on the self disclosure of researchers. So, for example, if a journal did not require disclosure of research sources or potential conflict of interests, Cosgrove’s study would not have been able to pick this up as an instance of a “financial tie.”

Unfortunately, the relationship between Big Pharma and the diagnosis and treatment of mental illness does not end here. As Carl Elliott (2004) has noted, much of continuing education for physicians occurs under the auspices of Pharma funding and Pharma has become one of the biggest sponsors of academic papers. Elliott remarks, for example, that more than half of the articles published on SSRI’s are now funded, in one way or another, by pharmaceutical companies. And, ironically, the papers funded by Pharma dollars tend to be published in more prestigious journals and are cited more often than non-Pharma funded papers (Elliott, 2004). Of course, the Pharma sponsored papers on SSRI’s almost invariably report better results and fewer side effects than non-Pharma supported papers. Partly as a result of all this, SSRI sales are a multi-billion dollar industry. Similar stories could be told of Ritalin, Viagra, and other designer drugs.

Part of the problem emanates in North America at least from changes that were made in the law which allowed direct marketing of drugs to consumers, beginning in 1996. Clearly such marketing has had an incredible effect on sales of such drugs, almost tripling them from $ 11.4 billion in 1996 to $ 29.9 billion in 2005 (Donohue et al., 2007).

The psychiatric community as a whole also bears some responsibility for this situation. Writing as the President of the American Psychiatric Association, Steven Sharfstein acknowledged that “as a profession we have allowed the biopsychosocial to become the bio-bio-bio model.”  As a result, he says, “a pill and an appointment” is too often the preferred (or only) treatment offered (Sharfstein, 2005, 3).

These are troubling precedents for paraphilias and sexual disorders, since they are now beginning to be treated more frequently with SSRI’s, which, not coincidentally, are now coming off patent as antidepressants (See, e.g., Hill et al., 2003; Greenberg & Bradford, 1997; Saleh & Guidry, 2003; Bradford, 1999). According to Hill et al. (2003, 408): “The optimal pharmacotherapy for paraphilias should (a) reduce selectively the sexual deviant behavior, impulses, and fantasies; (b) support or at least not impair nondeviant sexuality; and (c) not cause other adverse side effects. It is no secret that the development of such a pharmacological agent still appears more like a utopian dream than a realistic goal for the near future.” In particular, while a number of studies have shown that “SSRI’s reduce sexual fantasies, desire, masturbation, and sexual deviant behavior in patients with various paraphilias,” this reduction comes at a cost: in a study of male outpatients being treated for various paraphilias, 69% of them suffered from reduced desire, while 37% suffered from erectile dysfunction, and 37% also experienced retarded ejaculation or orgasm (Hill et al., 409, 410).

From a criminal and indeed from a moral perspective as well, we might be quite pleased that pedophiles and frotteurists, for example, have a reduced sexual drive while on medication. But surely our primary concern in those cases would be avoiding harm to innocent third parties and to public order and not to mental illness per se.  But I suggest that we should be concerned about the possibility that people who ‘suffer’ from consensual BDSM activities or leather fetishists or transvestites, or sexual ‘addicts’ will increasingly be diagnosed with a mental disorder and prescribed medications, such as SSRI’s, that will reduce their sexual desires and make it less likely that they will have a pleasurable sexual experience (through, e.g., an inability to orgasm). Moreover, it is all too easy to imagine experiments done on such groups of people that demonstrate very positive results in the sense that, e.g., a sexual addict reduces his/her sexual activity and is hence deemed a treatment success. Indeed, Greenberg and Bradford (1997, 357) suggest this exact problem in their review of the effectiveness of SSRI’s in the treatment of paraphilias: “SSRI’s are known to cause adverse effects such as reduced sexual drive, impotence, and ejaculatory dysfunction. It could therefore be argued that the use of SSRI’s in the treatment of these disorders merely reflects their side effect profile.”

Let me conclude this discussion with a cautionary tale by relating a story from Daniel Bergner’s recent book, The Other Side of Desire. One of the characters he describes in the book is a man referred to as Jacob who has a foot fetish. One ‘treatment’ option for Jacob would have been to tell him that there is nothing inherently wrong with his desire since it harms no one and that he should be open with his wife about his predilection. Instead, however, faced with Jacob's self loathing over his paraphilia, he and his therapist agree to a treatment of chemical castration. Such castration is achieved through anti-androgens that work by preventing or inhibiting the biologic effects of androgens, or male sex hormones, typically by blocking the appropriate receptors in the brain thus obstructing the androgens' pathway. Unfortunately, these drugs are "horribly imprecise," and act like "a club" by "bludgeoning the hormonal foundation of desire rather than addressing specific desire" (Bergner, 2009, 24). Hence, while someone can experience some sexual desire while on a drug like Lubron, such desire will typically be faint, if extant at all. The hope is that by removing desire for aberrant objects, such as feet, one can allow for the onset of more conventional longings for genital sex. Amazingly -- perhaps bizarrely -- that burgeoning new conventional desire will then be intensified by prescribing a drug such as Viagra! While one can see readily why such a treatment would be employed for pedophiles, the case is less clear for a foot fetishist. One can imagine, then, a quite different treatment for Jacob that began by accepting foot fetishism and then working with him (and his wife) to an accommodation of his desire. But in a world where we overmedicalize behavior and where there is a great deal of financial interest in such overmedicalization and subsequent treatment, we can end up creating lots of harm. Not all of it will be as dramatic as it was for Jacob, but all diagnoses of mental disorder bring with it at least some stigmatization.


  1. Versions of this paper have been presented at the following places and conferences: Society for the Scientific Study of Sexuality, Eastern and Midwestern Joint Meeting, University of Indiana, Bloomington, Indiana, May, 2012; The Medicalization of Sex, Simon Fraser University, Vancouver, BC, April, 2011; Association of Psychology & Psychiatry for Adults & Children (APPAC), Athens, Greece, May, 2010; Atlantic Region Philosophers' Association, King's University, Halifax, NS, Oct., 2010. I thank all those who made comments on it.
  2. It should be noted as well that "nymphomania" and "satyriasis" continue to be listed in the International Classification of Diseases and Related Health Disorders in its most recent edition as subtypes of hypersexuality (WHO, ICD-10, 2007; Also see Wikipedia, “Sexual Addiction” accessed on April 15, 2010 at   http://en.wikipedia.org/wiki/Sexual_addiction.)


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