Search For a Provider Facebook Twitter Instagram YouTube ES View the Patient Toolkit

Sex Health Blog

Fetishism and DSM 5

Apr 24, 2013

When does a sexual behavior become a mental disorder?

That question is under debate as the American Psychiatric Association prepares to release the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) next month.

The DSM is the “go-to” resource that mental health professionals use to diagnose psychiatric conditions.

Reports indicate that in the DSM-5, certain sexual behaviors will no longer be considered mental disorders, unless (and that is the operative word) they cause distress or harm to the people involved.

Such conditions are categorized as paraphilias – unusual sexual attractions or behaviors. Examples include the following:

  • Sadism. Sadists get sexual pleasure from inflicting pain or humiliation on someone. Examples: urinating or defecating on someone.
  • Masochism. In contrast to sadism, masochists are sexually aroused when they are the target of the hurt or humiliation. They might enjoy being bound, beaten, or spanked.
  • Fetishism. People with fetishes are sexually aroused by objects, body parts, or situations that are not usually considered sexual. Foot fetishes are common. Fetishes might also be associated with clothing (such as shoes or undergarments) or materials (such as fur, rubber, or leather).
  • Transvestitism. This refers to cross-dressing – wearing clothing that is generally associated with the opposite sex.

In the DSM-5, the word “disorder” is expected to be added to the behavior name if the patient feels distress or if another person is harmed. For example, if someone is disturbed by having a fetish, or if that fetish brings harm to someone else, that person might be diagnosed with a fetishistic disorder.

“This was a way of saying it’s OK to have a benign paraphilia,” Dr. Ray Blanchard told LiveScience. “That does not automatically give you a mental disorder.”

Dr. Blanchard is a University of Toronto psychiatrist and chair of the working group on sexual and gender identity disorders for the DSM-5.

Like many sexual topics, the changes do spark controversy.

Some, like the writer Jillian Keenan, believe such behaviors should be removed from the DSM if they are consensual, noncriminal, and among adults.

Keenan, who has publicly acknowledged her “kinky sexual interests,” wrote in Slate last March:

"It’s a bizarre cycle. According to the APA’s paraphilias fact sheet for the forthcoming DSM, I can be diagnosed with 'sexual masochism disorder' if I feel 'personal distress' about my sexuality. Usually, I don’t. But the moments when I do feel distressed (when I wonder if, perhaps, there might really be something wrong with me) occur when I receive unsolicited emails from psychiatrists who have read my public disclosures about my sexuality and reach out to offer their services."

Keenan also points out that a person’s distress isn’t necessarily caused by sexual behaviors. “People who are stigmatized and misunderstood, such as sexual minorities, might be unhappy—but the unhappiness itself is the problem that should be treated, not the person’s sexual identity or practice,” she wrote.

Others wonder on what authority decisions on an unusual sexual behavior may be made. For example, some readers of a Daily Mail (UK) online story on the subject left the following comments (readers’ screen names are after each response; responses have been edited for spelling):

Who's to say what's normal and what not? (Roxycat2752)

I'm a little worried about the people that think THEY have the right/ability to call something kinky. (Terry T)

Other readers embraced the changes:

Whatever goes on between you and your partner, as long as you are both happy and fulfilled and not harming others, is completely your business. I've never understood people's fascinations with other people's sex lives. Worry about your own! (Louise)

These were classed as mental health issues? Really? huh, guess my mental health is or rather was worse than I thought....haha always surprises me when stories like this come up, cos I'm always surprised people thought they were to start with. (grumpy old woman)

So constantly imagining a female friend of mine in a nurse's outfit is normal, thank God for that. (Mack)

It’s healthy as long as the 2 consenting adults agree. Nothing wrong with a bit of dressing up. (Welshgirl)

What do you think? Should behaviors like masochism or fetishism be considered mental disorders? Does qualifying them with the word “distress” make a difference? Feel free to tell us your thoughts in the comments.


The Journal of Sexual Medicine

Hendricksx, Lies, MSc, et al.

“Distress, Sexual Dysfunctions, and DSM: Dialogue at Cross Purposes?”

(Full text. First published online: October 22, 2012)


Pappas, Stephanie

“What's Crazy? Sexual Fetishes Spur Psychiatric Manual Controversy”

(April 2, 2013)

MailOnline (Daily Mail, UK)

“Kinky in the bedroom? You're not crazy! People with 'abnormal' sexual interests no longer classified as mentally ill - but only if you're happy”

(March 13, 2013)

Psychology Today


(Last reviewed: October 24, 2005)


(Last reviewed: July 20, 2009)

“Sexual Masochism”

(Last reviewed: November 14, 2006)


Keenan, Jillian

“We’re Kinky, Not Crazy”

(March 8, 2013)