The DSM and Depathologisation: How BDSM Stopped Being an Illness

For one hundred and twenty-seven years, an interest in these practices was a category in the medical literature. The categories were not identical across that period and their consequences varied enormously, but the underlying proposition held: that this was something a person could be diagnosed with. The proposition was dismantled in stages, mostly between 1994 and 2019, and the dismantling is the single largest change in this subject’s history.

What Krafft-Ebing left behind

The categories were filed in 1886, in a book written for doctors and courts. Richard von Krafft-Ebing built masochism from a living novelist’s surname and adopted sadism from a French word already in circulation, and the mechanics of that naming are set out in how sadism and masochism got their names.

Two features of the original framing survived every subsequent revision. The categories were built out of the extreme cases that came before a forensic psychiatrist, so the definitions carried harm inside them from the start. And they were descriptions of what a person was, not of what a person and another person had arranged between them. Consent had no place in the framework, because the framework was constructed from cases in which there had not been any.

Through the manuals

The American Psychiatric Association’s first diagnostic manual, published in 1952, filed sexual deviation under personality disturbance and named sadism among its examples. DSM-II, in 1968, retained a sexual deviations category with sadism and masochism inside it.

The comparison that matters here is homosexuality, which was in the same category and was removed from it after the vote of 1973. The removal was the result of organised pressure by people who had a movement, allies inside the profession and a strategy. Nothing equivalent existed for sadomasochism at the time, and the organisations described in the era essay for 1970 to 1989 were only then being founded.

DSM-III, in 1980, introduced the term paraphilia and made sexual sadism and sexual masochism discrete diagnoses. DSM-IV, in 1994, made the first substantive narrowing, requiring that the interest cause clinically significant distress or impairment before several of these diagnoses could be applied. The revision published in 2000 adjusted the criteria again, and inconsistently enough that clinicians complained about it.

The campaign

Change came from two directions.

In Europe, a Norwegian project founded in the late 1990s spent years pressing national health authorities and the World Health Organisation to drop the fetishism and sadomasochism codes. Nordic countries removed the diagnoses from their national classifications in a sequence running from the mid-1990s to about 2011, Denmark first and Finland last, which established that a health system could do this without any of the consequences opponents predicted.

In the United States, the National Coalition for Sexual Freedom ran a revision project aimed at the DSM through the 2000s, working with clinicians and researchers rather than against them. The argument it made was empirical: the population surveys did not show the damage the diagnosis assumed, practitioners were not distinguishable from anyone else on measures of psychological health, and the manual was therefore describing a stigma rather than a condition.

2013 and 2019

DSM-5 appeared in 2013 with the distinction that had been argued for. A paraphilia is an unusual sexual interest. A paraphilic disorder is one that causes distress to the person or harm to someone who has not consented. The two are not the same thing, and only the second is a disorder. Sexual sadism disorder and sexual masochism disorder remain in the book, and consensual adult practice does not meet their criteria.

ICD-11, adopted by the World Health Assembly in 2019 and in force from 2022, went further. The consensual diagnoses were dropped rather than narrowed, and what remains is a coercive category covering non-consensual conduct, which is a description of an offence rather than of an orientation. Since ICD is the classification most of the world actually uses for health records, this is the more consequential of the two changes and receives a fraction of the attention.

What did not change

The clinical retreat is real and it is also narrower than the celebratory accounts suggest.

Criminal law was untouched. In England and Wales, Operation Spanner and the ruling that followed remain the law, and Parliament restated the principle in statute in 2021. A diagnosis was never the basis of that decision, so removing it changes nothing.

Family courts, employers, licensing bodies and immigration authorities continue to treat this as evidence of unfitness, and they do not require a manual entry in order to do so. Advocacy organisations still log cases of people losing jobs and custody. Clinical training remains uneven, and people still report having their reasons for seeking therapy reinterpreted as the problem.

What the change did accomplish is the removal of one specific weapon. For a century, anyone arguing that these practices indicated illness could point at a page in a manual. That page now says the opposite, which is a considerable improvement on the situation described in the era essay for 2010 onward and a good deal less than a resolution.