A recent study in the Canadian province of Quebec, surveying the sexual fantasies and behaviors of 1040 people, found that around 45% had fantasized about doing things the DSM 5 labels as atypical or paraphilic, and about 33% had acted on those fantasies. You can check out the study, published in the Journal of Sex Research, here.

If you’re not familiar with the DSM 5, it’s the 5th edition of the American Psychiatric Association’s Diagnostic and Statistics Manual. When somebody gets diagnosed with a mental illness, it’s likely they got that diagnosis because their doctor or therapist believed they met specific diagnostic criteria outlined in the DSM IV or the DSM 5, which came out in 2013.

A big shift from the DSM IV to 5 was renaming paraphilias as “paraphilic disorders”. In their rationale for the changes, the APA said, “Most people with atypical sexual interests do not have a mental disorder.” But notice that the APA still defined those interests as “atypical”. Many of the paraphilias are illegal and involve harming or harassing other people. But what this study was focusing on more were the legal paraphilic behaviors, things like voyeurism and BDSM, which the study showed actually aren’t all that atypical. So if you liked 50 Shades of Grey and went and bought yourself a pair of handcuffs with pink fluffy fur on them, the DSM 5 still lumps you into the same category of atypical as a criminal that gropes people on a train. The groper could be diagnosed as having a mental illness, but you would not be for using the handcuffs in bed with a consenting adult, although the APA still defines you as “abnormal”. You can read more about the changes here.


Through the DSM, the APA, has had a profound impact on many people’s lives and it affects the language we use as a society to talk about mental illness. But the APA just can’t seem to get sex right, even though it has tried so many times to tell us what sex is right.

The DSM didn’t exist when mental illnesses in women were blamed on the uterus. It’s most famous struggle with sex was probably the battle it fought in the 60s and 70s with gay rights groups over the declassification of homosexuality as a mental illness. The story of how homosexuality went from being a mental illness in the DSM III, to no longer being a mental illness in the DSM IV, is a fascinating story that can offer some insight into how these diagnoses are established through an often politicized, committee-based process. This American Life did an entire episode called, “81 Words”, on the declassification of homosexuality, that you can listen to by clicking here.

The APA has a history of trying to use the DSM to define normal and abnormal sex. But the clinical value of defining something as abnormal is dubious. The fact that a small segment of the population does something doesn’t necessarily indicate anything clinically significant or pathological. One big problem with the APA’s current approach is that it’s not about engaging in a conversation around having a healthy sex life that contributes to mental health, or how compulsions that contribute to mental illness can get expressed through any type of sexual behavior. The DSM focuses only on labeling types of behaviors. The reality is that the most vanilla, “normal” sex in the world could be a way that a person struggling with mental illness engages in compulsions. Somebody with OCD might only engage in a restricted set of sexual behaviors because of contamination fears. Somebody with BPD might be using sex as an attempt to control their own feelings or test their partner’s. We could go through every diagnosis in the DSM 5 and identify ways in which that illness would affect a person’s sex life, or ways in which a person’s sex life would contribute to the illness. But the things those people might be doing in any scenario could be “normal” sexual behaviors. That doesn’t mean they’re contributing to better mental health or they’re an expression of being mentally healthy. Why we do what we do between the sheets may matter more than what we do.

If you’re struggling with mental health issues, those issues are almost certainly being expressed through your sex life. Your sex life is also contributing to your mental health, regardless of what you’re doing in bed. Because the focus in the DSM has only been on labeling specific types of sexual behaviors as normal or abnormal, that broader discussion of sex and sexuality gets missed throughout all of the diagnoses.

The reality is that the most vanilla, “normal” sex in the world could be a way that a person struggling with mental illness engages in compulsions.

The APA gets so much flak over how it handles sex that I’m afraid they’ll eventually remove completely from the DSM any discussion of sex and sexuality. That would be a mistake. But the way the APA has engaged with sex and continues to do so through the DSM, isn’t working. The integrity and reliability of the DSM as a scientific manual is compromised when it verges off into moralizing and trying to establish social norms. Although people might jokingly refer to the DSM as “psychiatry’s bible”, it’s best to keep in mind that it’s not actually supposed to be the Bible.

I do detect some anxiety around sex over at APA headquarters, and I believe any discussion on mental health is best explored from a place of personal experience, so to get a healthier discussion happening around sex and mental health, let’s start at the APA. Their annual meeting is coming up in Atlanta, Georgia, from May 14 – 18, and there’s going to be over 10,000 attendees. That is an awesome sample size–10 times the sample size of the Canadian study. Somebody, please, replicate that study at the APA annual meeting. How many psychiatrists are abnormal between the sheets (or in whatever “atypical” places they have sex)?

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