Commentary

Does heterosexuality belong in the DSM?

Charles Moser & Peggy J. Kleinplatz

A
NUMBER OF RECENT articles have Every human society has attempted to
criticised the DSM (American Psychi- regulate the sexuality of its members. Obvi-
atric Association [APA], 1994; APA, ously conventional forms of sexuality in any
2000) sex and gender diagnoses in general given society are not likely to be deemed
and the paraphilia section in particular sinful, criminal, or pathological, but the
(Davis, 1998; Gert, 1992; Moser; 2001, Moser, characteristics of the dominant form change
2002; Moser & Kleinplatz, 2002; Moser & from society to society and from time to
Kleinplatz, in press). These classifications time. Although societal attempts to control
have been criticised for being based on social the sexuality of its members are usually inef-
convention rather than upon a foundation of fective, these efforts can cause incredible
empirical data contrary to the stated agenda hardships to those unfortunate enough to
in the DSM. In the DSM it is written that, ‘the have their activities exposed.
utility and credibility of the DSM-IV require Questioning whether the diagnostic
that it … be supported by an extensive empir- criteria are logically consistent is not an
ical foundation’ (APA, 2000, p.xxiii). academic exercise; what is and is not a
The diagnostic process is unduly influ- mental disorder has significant legal, social,
enced by clinical, personal and social bias, and political ramifications, in addition to
rather than by objective parameters. If in fact implications for psychiatric practice. The
the diagnostic process can be demonstrated DSM is used by the courts, insurance compa-
to be subjective or arbitrary, then it calls into nies, other mental health disciplines, govern-
question the utility of the DSM diagnostic ment, other psychiatric diagnostic
nosology. The purpose of this paper is to nosologies (i.e. ICD), among other entities.
scrutinise the criteria of the DSM paraphilia If the logic and science which underpins the
section by applying them to a common DSM is faulty, then the editors have done a
sexual phenomenon, not currently listed in disservice to their patients, their colleagues,
the DSM, and not considered to be a mental medicine, society, and science.
disorder but associated with distress and About 250 years ago, medicine and espe-
dysfunction as will be discussed below. cially psychiatry were responsible for trans-
This paper argues that the strict applica- forming masturbation from sin to pathology
tion of these DSM criteria leads to the (Bullough & Bullough, 1977). Rationales
conclusion that heterosexuality is a mental provided by early psychiatrists led to
disorder. Similar reasoning was used to draconian measures to prevent children
argue against inclusion of proposed diag- from touching their genitals. The persecu-
nostic criteria for sexual addiction, by tion of homosexuals was condoned and justi-
showing that newlywed heterosexuals met fied for decades by the listing of
those criteria (see Goodman, 1992; Moser, homosexuality in the DSM. Other psychiatric
1992). If heterosexuality fits the diagnostic follies concerning sexuality from the past
criteria for a mental disorder and specifically include involutional melancholia, promis-
for a paraphilia, the validity of all the other cuity, oral sex, nymphomania, frigidity, to
paraphilia diagnoses is called into even name just a few. Relying on the clinicians’
further question. own behaviour and experiences to guide

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© The British Psychological Society 2005 ● ISSN 1467–2472
Charles Moser & Peggy J. Kleinplatz

assessment – rather than upon objective between the individual and society, so it does
criteria – has led to a conspicuous pattern of not meet that DSM exclusion criterion.
diagnoses: ‘too much masturbation’ has The question then becomes, is hetero-
been deemed excessive; ‘too many partners’ sexuality associated with present distress or
demonstrates ‘promiscuity’; ‘too frequent disability? The paraphilia section of the DSM
sex’ has been diagnosed as nymphomania or is concerned with specific sexual interests
satyriasis; ‘too little response’ is judged as an and activities. The diagnostic criteria for all
arousal disorder; ‘too little desire’ is labelled the paraphilias include a criterion that the
inhibition; ‘too few orgasms’ were consid- sexual interest leads to distress or impair-
ered frigidity and ‘too different’ sex is called ment (disability). Meeting the distress and
perverted or paraphilic. impairment criteria for a paraphilia would
satisfy the requirement that heterosexuality
Is heterosexuality a mental disorder? also meets these criteria for a mental
The following are the diagnostic criteria of disorder. Thus the question is reduced to,
the proposed, new diagnosis of heterosexu- Does heterosexuality meet the diagnostic
ality. The wording is borrowed directly from criteria for a paraphilia?
the diagnostic criteria describing other para-
philias. Is heterosexuality a paraphilia?
‘The essential features of a paraphilia are
Diagnostic criteria for 302.1 Heterosexuality recurrent, intense sexually arousing
A. Over a period of at least six months, fantasies, sexual urges, or behaviors ...’ (APA,
recurrent, intense sexually arousing 2000, p.566); heterosexuality fits this
fantasies, sexual urges, or behaviors description. The DSM then adds the
involving sexual activity with an adult of following qualifier, ‘… generally involving:
the other sex. (1) non-human objects; (2) the suffering or
B. The person has acted on these sexual humiliation of oneself or one’s partner; or
urges with a non-consenting person, or (3) children or other non-consenting
the fantasies, sexual urges, or behavior persons that occur over a period of at least
cause clinically significant distress or six months’ (APA, 2000, p.566). These quali-
impairment in social, occupational, or fiers do not necessarily exclude hetero-
other important areas of functioning. sexuality.
The DSM definition of a mental disorder is: The DSM uses the following criteria to
‘… a clinically significant behavioral or define the paraphilic pathological state,
psychological syndrome or pattern that ‘Fantasies, behaviors, or objects are paraphilic
occurs in an individual and that is associated only when they lead to clinically significant
with present distress (e.g. a painful distress or impairment (e.g. are obligatory,
symptom) or disability (i.e. impairment in result in sexual dysfunction, require partici-
one or more important areas of functioning) pation of non-consenting individuals, lead to
or with a significantly increased risk of legal complications, interfere with social rela-
suffering death, pain, disability, or an impor- tionships)’ (APA. 2000, p.568). Do these
tant loss of freedom … Neither deviant ‘distress or impairment’ criteria apply to indi-
behavior (e.g. political, religious, or sexual) viduals with heterosexuality?
nor conflicts that are primarily between the
individual and society are mental disorders Distress
…’ (APA, 2000, p.xxxi). All the psychogenic sexual dysfunction diag-
Heterosexuality is obviously a clinically noses (i.e. those not caused by a general
significant behavioural and psychological medical condition or by substance abuse)
pattern. Heterosexuality is not deviant include the same diagnostic criterion:
behaviour nor does it qualify as a conflict ‘B. The disturbance causes marked distress

262 Lesbian & Gay Psychology Review Vol 6 No 3

 Does heterosexuality belong in the DSM?

or interpersonal difficulty’ (for example see, reason to have two diagnoses that describe
APA, 2000, p.541). Sexual dysfunctions are the same mental disorder, so we must reject
found among individuals across the entire the idea that heterosexuality is diagnosable
spectrum of sexual interests, but the scien- as a mental disorder only when it is ego-
tific literature focuses on reported sexual dystonic.
dysfunctions among heterosexuals, which Attempts to reconcile one’s own sexual
can affect as much as 43 per cent of the interests with the norms of the entire society
women and 31 per cent of the men or segments of society (e.g. partners, family,
(Laumann et al., 1999). Individuals who religion, or other social groups) can even-
experience sexual dysfunctions do not always tuate in an ego-dystonic state. This leads to
seek out sex therapy; this choice does not the philosophical question: Is it healthier to
reveal whether or not these individuals are follow the social norm or to stand up for
distressed. It is generally believed that one’s own beliefs (Reiss, 1990)? Choosing
embarrassment, lack of mental health either option does not indicate the presence
coverage, cost, fear that they are beyond of a mental disorder and is another example
help, and resignation to living with their of the confusion between science and subjec-
dysfunction are prime reasons for not tive morality.
seeking sex therapy. As described in the DSM, ‘Many individ-
Heterosexuals are also distressed about uals with these disorders [paraphilias] assert
not having sex, not having enough sex, that the behavior causes them no distress …’
having too much sex, wanting sex too much, (APA, 2000, p.567). ‘These individuals are
not wanting sex enough, and wanting the rarely self-referred …’ (APA, 2000, p.566).
‘wrong’ type of sex. Some of these concerns From these statements, one can conclude
are vying for their own DSM diagnoses (see that personal distress severe enough to lead
Kafka & Hennen, 1999), others have been the patient to psychiatric consultation is
classified as pathological in the past, and rare. If the distress results from conflict
some are still listed as mental disorders. between the individual and society, then the
Without understanding what constitutes diagnosis conflicts with the DSM definition
‘normal’ sexuality, it difficult to discern what of a mental disorder, which specifically
is ‘abnormal’ sexuality. It appears that social excludes ‘… conflicts that are primarily
trends rather than empirical science have between the individual and society …’ (APA,
dictated what constitutes ‘normal’; psychi- 2000, p.xxxi). Given that American society
atry has followed these trends rather than approves of heterosexuality, personal distress
demanding objective scientific benchmarks. from this sexual interest must be even rarer
Is heterosexual distress caused by the than what is seen with other paraphilias.
individual’s unwanted (i.e. ego-dystonic) In summary, personal (ego-dystonic)
heterosexual arousal, rather than distress distress is rare and already covered by
from conflict with social expectations? The another non-paraphilic diagnosis. Distress
DSM-III (APA, 1980) contained the analo- related to the internalisation of societal
gous homosexual diagnosis, ‘Ego-dystonic values is a conflict between the individual
Homosexuality,’ but it was removed from the and society, which by definition, does not
next edition (DSM-III-R, APA, 1987). There- constitute a mental disorder. Logically, this
fore, it seems improbable that the editors would appear to preclude distress as a crite-
would want to create an ‘Ego-dystonic rion for deciding if any unusual sexual
Heterosexuality’ diagnosis. In addition, behaviour is necessarily pathological.
‘Persistent and marked distress about sexual
orientation’ is specifically included under Disability or impairment
Sexual Disorder Not Otherwise Specified Heterosexuals seek out therapists because
(APA, 2000, p.582). Logically, there is no they cannot find partners, they cannot find

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Charles Moser & Peggy J. Kleinplatz

the ‘right’ partners, they are not attracted to Heterosexuality does not require the
appropriate partners, etc. Doubts and inse- participation of a non-consenting individual,
curities about making or keeping relation- although the majority of sexual assaults are
ship commitments and subsequent attempts committed by heterosexuals. A non-consen-
to save damaged or dysfunctional relation- sual heterosexual act constitutes a sexual
ships appear to be common problems assault (or rape), which is a crime and, as
among heterosexuals. ‘The capacity for such, is not specifically listed in the
reciprocal, affectionate sexual activity’ (APA, DSM-IV-TR (APA, 2000). Committing a
200, p.567) is often quoted as a sign of sexual assault does not mean that the indi-
healthy functioning, but more than half of vidual suffers from a mental disorder. The
all American heterosexual marriages end in nature of the assault does not necessarily
divorce (National Center for Health Statis- reveal anything about that individual’s
tics, 2005). The usual anger and disdain primary sexual interests.
which characterise partners’ interactions There is another way of interpreting this
during and after the divorce process are ‘non-consenting’ part of the diagnostic
further signs of relationship dysfunction. criteria. If heterosexuality is a mental
Furthermore, many individuals suffer disorder, can an ‘afflicted’ individual freely
endlessly in heterosexual relationships provide informed consent to heterosexual
whether or not they eventually terminate acts? Does the mental disorder affect the indi-
them. vidual’s ability to make rational decisions or
In the occupational area, sexual harass- give informed consent? There are many
ment complaints against heterosexuals are examples of individuals making dangerous
all too common, unfortunately. One’s choices and acting in an unhealthy manner
emotional reactions to a new relationship, (e.g. exposing these individuals to the risks of
the ending of an existing relationship and sexually transmitted infections including HIV,
not being able to find a relationship can unwanted pregnancies, date rape or other
cause profoundly deleterious effects on job violent acts). Such behaviours cast doubt on
performance. the capacity for individuals with heterosexu-
There is little argument that heterosexu- ality to make competent decisions.
ality tends to be obligatory; it is uncommon Can heterosexuality lead to legal compli-
for heterosexual practitioners to seek other cations? Divorce is an excellent example of
sexual outlets. Even when a heterosexual possible civil legal difficulties. Sexual harass-
partner is not available, heterosexual ment, breach of promise, and child custody
fantasies typically accompany masturbatory are other common examples. Criminal legal
behaviour or other sexual acts. The strict difficulties include not only sexual assault,
interpretation of this criterion suggests that discussed above, but sex work (working in
limiting oneself exclusively to a particular adult films, prostitution, ‘strip’ clubs), statu-
sexual pattern (e.g. heterosexual) indicates tory rape, obscenity, indecency, and sodomy.
impairment. The final sign of impairment, ‘interfer-
Given the high prevalence of sexual ence with social relationships’, is worthy of
dysfunction among heterosexuals, discussed special attention. Aside from the problems
above, heterosexuality presumably is associ- facing heterosexuals within heterosexual
ated with sexual dysfunction; though it is not relationships, it would appear that hetero-
clear that heterosexuality or any other sexual sexual proclivities can affect other social
interest actually causes sexual dysfunction as relationships: Social or work contact can
implied in the DSM. It is also not clear that tempt individuals to violate healthy bound-
the prevalence of sexual dysfunction among aries and to engage in inappropriate sexual
heterosexuals is higher than found among relationships (e.g. teacher-student, profes-
practitioners of other sexual interests. sional-client, employer-employee, adultery).

264 Lesbian & Gay Psychology Review Vol 6 No 3

 Does heterosexuality belong in the DSM?

Concerns about the possibility of initiating is hard to imagine that such a profound
this contact or the probable consequences of change would not cause new distress and
prospective contacts, has led to restrictions disability symptoms.
in social and occupational contact between This raises the question of why any of the
heterosexual men and women. paraphilias are identified by their associated
These difficulties in one or more impor- sexual behaviours. There is no indication
tant areas of functioning thereby fit the that ‘paraphilic’ behaviours are related to
disability criterion for a mental disorder. the distress and disability symptoms required
Examination of the popular literature for the paraphilia diagnoses. Considering
suggests that few heterosexuals actually avoid that not all practitioners of the identified
these problems and concerns, but only a behaviours meet the DSM diagnostic criteria,
fraction of those affected seek treatment and there must be ‘healthy’ individuals who
would thus be subject to diagnosis. exhibit ‘paraphilic’ behaviour and are inap-
propriately stigmatised by the association of
Differential diagnosis their behaviour with a mental disorder.
The DSM editors do recognise there is a The DSM provides no guidance on how
difference between the arousal patterns of to distinguish ‘healthy’ from ‘unhealthy’
individuals with a paraphilia from ‘… the individuals with a paraphilic interest.
non-pathological use of sexual fantasies, Clinicians need unambiguous diagnostic
behaviors, or objects as a stimulus for sexual criteria to distinguish ‘healthy’ from
excitement in individuals without a Para- ‘unhealthy’ individuals with all sexual inter-
philia’ (APA, 2000, p.568, boldened in the ests or the present confusion will continue to
original). Unfortunately, the DSM provides be propagated.
no guidance for the clinician to make that
distinction. If, however, the paraphilia diag- Conclusions
nostic category can be construed to include This discussion leads inevitably to the
all sexual interests, including heterosexu- conclusion that heterosexuality meets the
ality, then the DSM distinction between DSM-IV-TR (APA, 2000) definitions of both a
‘paraphilic’ and ‘non-paraphilic’ arousal mental disorder and a paraphilia, at least as
becomes conceptually meaningless and clin- well as the other listed paraphilias. Previous
ically useless. literature has catalogued the problems in
Is it the heterosexuality itself which is the DSM diagnostic criteria as applied to
pathological? Or is this a case of correlation those with unusual sexual interests (Moser &
between heterosexuality and impairment Kleinplatz, in press). These same flawed
rather than causation? Just because relation- criteria also lend themselves to diagnosing
ship and occupational problems are more common sexual interests, not usually
endemic among heterosexuals does not believed to be mental disorders, and specifi-
mean that the heterosexuality is the cause of cally, as paraphilias.
these problems. Furthermore, it is improb- Diagnostic criteria that could include
able that ‘converting’ from a heterosexual everyone or could be used to pathologise
arousal pattern to another sexual arousal anyone, which cannot reliably and appropri-
pattern, would resolve these problems or ately distinguish between those with a
impairments. Analogously, it is unclear if mental disorder from those without one, are
changing other paraphilic arousal patterns fatally flawed and clinically useless. These
(even if that were possible), would resolve diagnoses do not appear to be based on any
the distress or impairment from which those objective scientific definition of disease;
individuals reportedly suffer, except for these criteria are not capable of distin-
potential legal complications inherent with guishing disease from normal variants. The
paraphilias which involve illegal activities. It obvious conclusion is that classification of

Lesbian & Gay Psychology Review Vol 6 No 3 265

Charles Moser & Peggy J. Kleinplatz

the ‘paraphilias’ as mental disorders appears (APA, 2000) diagnostic criteria by demon-
to be an attempt at pathologising unusual strating their selective application and how
sexual interests and provides a vehicle for general these criteria actually are. If the DSM
social control. The act of specifically pathol- is to be seen as a credible and clinically
ogising unusual (as opposed to the common, useful reference, its editors will have to
conventional and accepted) sexual interests demonstrate how the paraphilia diagnoses
obviously serves to regulate them. actually distinguish pathology from normal
The omission of heterosexuality exempli- variations.
fies the underlying heterosexual bias which
pervades the DSM nosology. The possibility Correspondence
that heterosexuality could be a mental Charles Moser, PhD, MD, is Professor and
disorder is not mentioned in the text and it Chair of the Department of Sexual
appears no one even conceived of it as a Medicine, Institute for Advanced Study of
possibility. Human Sexuality, San Francisco. He also
For the record, this is not a proposal to maintains a private practice in Sexual
reclassify heterosexuality as a mental Medicine and Internal Medicine, in San
disorder or to include it in the next edition Francisco. His research focuses on BDSM,
of the DSM. Concluding that heterosexuality sexual minorities, classification of unusual
is a mental disorder, according to the DSM sexual interests, and the practice of sexual
criteria, does not imply that heterosexuality medicine.
meets other definitions of a mental disorder.
Similarly, the other paraphilias may or may Dr Charles Moser
not fit these other definitions. 45 Castro Street, #125,
Some might argue that it is important to San Francisco, California, 94114, USA.
keep the paraphilia section in the DSM E-mail: [email protected]
because identifying perpetrators as ‘sick’ is
necessary to keep ‘sex crimes’ illegal. We Peggy J. Kleinplatz, PhD, is a Clinical
believe that criminal acts should be adjudi- Psychologist, AASECT-certified sex therapist
cated in the criminal justice system and and sex educator. She teaches in the Faculty
society should not use psychiatric diagnoses of Medicine and in the School of Psychology,
to justify criminalising unusual sexuality. The University of Ottawa, Canada. Dr Kleinplatz
current DSM (APA, 2000) appropriately has been teaching Human Sexuality since
distinguishes crimes from psychiatric disor- 1983 and was awarded the Prix d’Excellence
ders; the paraphilia section confounds by the University of Ottawa in 2000. Her
mental disorders with crimes. Any interpre- work focuses on eroticism and transforma-
tation that this article supports any criminal tion. Dr Kleinplatz is the editor of New Direc-
behaviour is incorrect and misguided. Such tions in Sex Therapy: Innovations and
allegations misconstrue our position and Alternatives, and with Dr Charles Moser of
deflect attention from the substance of the the forthcoming Sadomasochism: Powerful
arguments presented here. Pleasures.
This article asserts that diagnosing
heterosexuality as a paraphilia according to Dr Peggy J. Kleinplatz
the DSM-IV-TR (APA, 2000) criteria demon- 161 Frank Street,
strates that they are illogical, inconsistent, Ottawa, Ontario, K2P 0X4, Canada.
unworkable, conceptually unsound, and lack E-mail: [email protected]
construct and discriminant validity – but no
more so than using these criteria to patholo-
gise other sexual proclivities. This expands
upon previous criticism of the DSM-IV-TR

266 Lesbian & Gay Psychology Review Vol 6 No 3

 Does heterosexuality belong in the DSM?

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