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If inmates take over the asylum and end up running it better, were they ever really crazy? It's a question that bedevils American psychiatry as more sexual minorities deemed "mentally ill" fight the label -- and along the way, rewrite the rules of mental health.

Sadomasochists are among those following in the footsteps of gay campaigners -- psychiatrists among them -- who in 1973 successfully convinced the American Psychiatric Association to take homosexuality off its roster of mental illnesses. That list is the APA's Diagnostic and Statistical Manual of Mental Disorders (widely known as the "DSM"), first compiled in 1952. The fifth revision is due out in 2012. As that date approaches, the battle to put sexual diversity outside the reach of medical censure heats up.

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"Homosexuality was re-moved from the DSM largely because activists wouldn't let the question go," says Susan Wright of the National Coalition for Sexual Freedom (NCSF). With a focus on sadomasochism, the NCSF is leading a petition drive -- with more than 1,000 signatures so far -- to take the "SM" out of the DSM. (Add your name at Dsmrevision.blogspot.com )

Parts for holes

At heart, the battle is over the scope of the concept "paraphilia" -- or whether the idea has any merit at all. The diagnosis applies, according to mainline psychiatry, if someone is unhappy or in trouble owing to their sexual feelings or actions. Not just any feelings or actions, but usually just those that involve eroticizing only an aspect of a sexual partner -- or choosing one deemed somehow deficient. A sexual focus on feet, asphyxiation, adolescents, pain, breasts, bondage, children, dogs or corpses are all lumped under paraphilia's scarlet rubric. If that seems a jumble, the DSM mixes things up even more: people who have one paraphilia, it claims, may be susceptible to others.

Feeling the pressure of activists -- and maybe common sense -- the APA has already dulled paraphilia's sting. As of DSM-IV, issued in 1994, foot fetishists, for instance, would not be mentally ill as such, but only if their feelings "lead to clinically significant distress or impairment." They'd get a clean bill of mental health so long as they felt good about themselves, didn't tickle the soles of strangers dozing on a beach, or get caught shrimping in the office toilet.

But even by those standards, it's easy to cross the line from well to sick. Go see a therapist because a strict Catholic upbringing imparts guilt over your yen for bondage and suddenly you've got a categorizable, if low-grade, mental illness -- and a permanent mark in your medical file.

Psychiatry's conceit that variant sexuality lies a hair's breadth from disturbance gives the inch that the uninformed or ill-intentioned can make into a mile. "It's still taken very seriously often by non-mental health professionals who don't have the understanding of the DSM and the current state of psychiatry -- like law enforcement, like DAs, like courts, and particularly family courts," says Wright.

A 1998 survey of NCSF's members found that 30 percent of regular BDSM practitioners said they'd faced discrimination, a quarter had lost a job, and three percent a child in a custody fight. In 2006, Peter Hayes, a resident of Vancouver, British Columbia, couldn't get a chauffeur's license owing to a note in his police file that he was a pagan who dabbled in BDSM. (Hayes went to court, and the case is still pending.)

"It's not behaviors that make people mentally ill, it's psychological patterns," says Wright. "If you use BDSM in an obsessive-compulsive way, you're an obsessive-compulsive. The behaviors you're doing don't matter -- you could be repeatedly closing and opening doors."

But NSCS's petition takes a cautious line, urging the APA "to remove all diagnoses that are not based upon peer-reviewed, empirical research, demonstrating distress or dysfunction.... The APA specifically should not promote current social norms or values as a basis for clinical judgments."

For its part, the APA insists that already it doesn't. "Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders," declares the DSM-IV-TR (a mini-revision issued in 2000).

America's shrinks say they worship at the feet of empirical objectivity. "I really want to emphasize that this entire revision process is scientifically based," says the APA's Dr. William Narrow, who is helping oversee the DSM-V update. "It requires literature reviews, and, where possible, that data be analyzed to answer any questions about the revisions."

Lost at sea?

Wright says at minimum NCSF would like to see SM removed from paraphilias in all circumstances, along with heterosexual transvestism (the homosexual variety is not listed). But she wonders if maybe the cargo ship HMS Paraphilia is simply hopelessly leaky.

One line separating paraphilias from "normal" impulses, according to the DSM, is whether a sexual impulse manifests itself nonconsensually. "If you nonconsensually do something it's a criminal matter, not a mental health issue," contends Wright -- noting that in any case, the APA has never included a disposition to rape as a paraphilia.

Some sex activists think the DSM should be expanded. Dr. Carol Queen, co-founder of San Francisco's Center for Sex and Culture, proposes a new diagnosis: "absexual." Don't think lust for rippling six-packs; that's "ab" as in "away from." The idea would be a way to diagnose people "turned on by fulminating against it" -- folks such as male-hustler-frequenting homophobe Rev. Ted Haggard and the anti-prostitution zealot / whore-enjoying former New York Gov. Eliot Spitzer.

Are paraphilias too rooted in human erotic pleasure to medicalize? "I've thought for some time that most of us, gay and straight, have a paraphilia at heart," says Dr. Richard Pillard, professor of psychiatry at Boston University School of Medicine. "Men who quite specifically like women with big breasts, blond hair, shaved pubes, huge cocks, etc., have a paraphilia from a psychological point of view but one that goes unnoticed because it doesn't bother anyone -- and may please the partner -- and is generally in line with what many or even most men prefer." As a young psychiatrist, Pillard was instrumental in convincing the APA to depathologize homosexuality in 1973.

"There are no clear guidelines in the DSM that distinguish a paraphilia from 'healthy' sexuality," say the NCSF. But Pillard says in some cases sexual feeling and activities clearly pose problems for people, and he doesn't mind keeping the category, even if he doubts psychiatry offers much in the way of solutions.

"What if the paraphilic urge is so strong and so specific that it obliterates all other sexual desires? What of a man who can only cum dressed in women's clothing while his girlfriend gives him an enema?" asks Pillard. "About all I can think to say is that these situations are really rare and I've never heard or read of anything psychiatry can do to help this poor devil."

Some contend the idea of paraphilias are just a gussied-up version Judeo-Christianity's longstanding proscriptions on onanism and sodomy. Keeping the category, they say, violates medicine's first commandment: first do no harm.

"The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas," wrote Drs. Charles Moser and Peggy Kleinplatz in a 2005 paper in the Journal of Psychology and Human Sexuality. They urged throwing the idea of paraphilias overboard. "A review of this area is not only a scientific issue, but also a human rights issue."

Author Profile:  Bill Andriette
Bill Andriette is features editor of The Guide
Email:	theguide@guidemag.com