Pathologizing Sexual Deviance: A History

Abstract

This article provides a historical perspective on how both American and European psychiatrists have conceptualized and categorized sexual deviance throughout the past 150 years. During this time, quite a number of sexual preferences, desires, and behaviors have been pathologized and depathologized at will, thus revealing psychiatry's constant struggle to distinguish mental disorder—in other words, the “perversions,” “sexual deviations,” or “paraphilias”—from immoral, unethical, or illegal behavior. This struggle is apparent in the works of 19th- and early-20th-century psychiatrists and sexologists, but it is also present in the more recent psychiatric textbooks and diagnostic manuals, such as the consecutive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). While much of the historical literature revolves around the controversy over homosexuality, this article also reviews the recent medicohistorical and sociohistorical work on other forms of sexual deviance, including the diagnostic categories listed in the latest edition, the DSM-IV-TR: exhibitionism, voyeurism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, and transvestic fetishism.

Acknowledgments

The authors would like to thank Diederik Walravens for his assistance in selecting and collecting the relevant literature, and Marc Stroobants for finding a rare copy of the Statistical Manual.

Notes

¹Magnus Hirschfeld and Havelock Ellis were the first to see homosexuality as different from transvestism and transsexuality (Blanchard, 2005; Hill, 2005; Meyerowitz, 2001).

²Freud vacillated between aberration and anomaly but chose in the end to use the term perversion to denote pathological sexual behavior (Roudinesco & Plon, 1997). However, he deplored the word perversion because it had moralistic connotations (Kamieniak, 2003). The term paraphilia was first used to signify homosexuality by Freud's friend and colleague Sandor Ferenczi (Socarides, 1978).

³The Statistical Manual probably owed this term to Kraepelin's classification of “constitutional psychopathic states,” which included “contrary sexual instincts.” Kraepelin's work became popular in the early-20th-century United States due to an early English translation and adaptation of his famous Lehrbuch der Psychiatrie (published as Clinical Psychiatry: A Text-Book for Students and Physicians, Kraepelin & Diefendorf, 1902).

⁴Sexual orientation disturbance appeared in DSM-III as ego-dystonic homosexuality, only to be removed altogether from DSM-III-R in 1987.

⁵It is interesting to note that in DSM-III-R (APA, 1987, p. 281) the word traditionally was omitted from the general description of the paraphilias, probably because the architects felt they had “saved” these conditions as mental disorders by adding “distress” to their diagnostic criteria.

⁶This change contradicted the DSM-IV-TR's own statement that “all proposed changes were limited to the text sections…. No substantive changes in the criteria sets were considered” (APA, 2000, p. xxix; see also Hilliard & Spitzer, 2002, p. 1249; Moser & Kleinplatz, 2005, p. 98).

⁷The parallel with Krafft-Ebing's work is striking, as the latter once noted: “The nature of the act can never, in itself, determine a decision as to whether it lies within the limits of mental pathology, or within the bounds of mental physiology. The perverse act does not per se indicate perversion of instinct” (Krafft-Ebing, 1886/1965, p. 501).

⁸It is interesting to note that the DSM-5 work group on “sexual and gender identity disorders” contains more nonpsychiatrists than any of the other work groups.