Before the APA’s publication of the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013, few mental health professionals would have been able to properly distinguish between Kink/BDSM (Bondage, Discipline, Dominance, Submission, Sadism and Masochism) and the mental diagnoses of the paraphilias Sexual Masochism Disorder and Sexual Sadism Disorder.
The historical lack of a clear division between these terms stemmed from the ambiguous definitions of “paraphilia” in previous editions of the manual starting in the DSM-II (1968), in which all sexual deviances were considered to be a mental health concern. By the revision of the manual’s third edition in 1987, Sexual Sadism and Sexual Masochism were distinct disorders under the broader label of paraphilias, and were legally exploited in child custody cases to demoralize a parent who had engaged in any type of BDSM activity as a means of undermining her or his claim to custody, or even to confiscate one’s children in general family court. By the most recent edition of the DSM, consensual and safe BDSM behaviors can no longer be used in this manner because “a paraphilia is a necessary but not sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention”. This has led to a sharp drop in the number of people losing the custody of their children because of consensual BDSM sexual practices, and cases of discrimination in the BDSM community have fallen from 600 in 2002 to 200 as of 2015. Under the new definition, BDSM/Kink have effectively been de-medicalized and distinguished from the disorders
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Today’s DSM utilizes an imperatively specific catch in its diagnostic criteria for almost every disorder: “clinically significant distress or impairment in social, occupational, or other important areas of functioning”, applying the concept of the “Four D’s” of diagnosis to Sexual Masochism and Sexual Sadism. Therefore, the diagnostic criteria for these two paraphilias ought to be maintained in future publications of the manual as currently presented.
From today’s modern, scientific perspective, “BDSM is not ipso facto a mental problem, but a complicated form of social interaction where participants redefine emotional and sensational states conventionally perceived as displeasures into pleasures”. This is indeed the righteous and most accurate view. Nevertheless, a further piece of clarification dependent upon the maintenance of current DSM language is now necessary in the era of the popularization of the book and film Fifty Shades of Grey and its two sequels. In defensive analysis and application of the DSM-5 diagnostic criteria, and conceptualization of the “Four D’s” of mental diagnosis, one can conclude that the main protagonists Anastasia Steele and Christian Grey deviate from the typical practices of BDSM/Kink and fully meet diagnostic criteria for Sexual Masochism Disorder and Sexual Sadism Disorder, respectively and hypothetically.
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No condition or set of symptoms can ever truly be classified as a mental diagnosis unless a practitioner can justify that they meet DSM-5 diagnostic criteria or a subset of it, and that requires the conditions to partially or wholly fit the “Four D’s” of psychiatric diagnosis: “deviance, dysfunction, distress, and danger”. Deviance from the norm is fairly simple to comprehend: the behaviors, cognitions, moods, or other
symptoms must be different from the “typical” person in a society; dysfunction can be interpreted in many different ways and usually constitutes some type of emotional, physical, social, familial, or occupational impairment; the component of distress is usually present if a client or patient is voluntarily seeking clinical attention and may also include the distress of other individuals or that of the general society if the client or patient is treated involuntarily; finally, danger is a current or potential result of the mental illness if left untreated. The conceptualization of the “Four D’s” was taken into great consideration in the design and implementation of the DSM-5, as exemplified by the edition’s idiosyncratic diagnostic criteria for the paraphilias Sexual Masochism Disorder and Sexual Sadism Disorder. For example, the DSM clearly states the following under the diagnostic features of Sexual Masochism Disorder:
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“If these individuals also report psychosocial difficulties because of their sexual attractions or preferences for being humiliated, beaten, bound, or otherwise made to suffer, they may be diagnosed with sexual masochism disorder. In contrast, if they declare no distress, exemplified by anxiety, obsessions, guilt, or shame, about these paraphilic impulses, and are not hampered by them in pursuing other personal goals, they could be ascertained as having masochistic sexual interest but should not be diagnosed with sexual masochism disorder”.
Likewise, the manual also includes the following notation under Criterion B of Sexual Sadism Disorder: “The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Under both of these guidelines, if two consenting individuals engage in BDSM without any sort of psychosocial difficulties or other forms of distress or impairment, then the behavior would not constitute a mental disorder and be deemed typical by the mental health community because it did not meet any of the “Four D’s.” Thus, the DSM’s current language takes a positivist stance on safe and consensual forms of BDSM/Kink in pursuit of sexual pleasure and intimacy, directing practitioners to also take this stance in their professional roles as treatment providers. Today, “consenting adults are no longer deemed mentally ill for choosing sexual behavior outside the mainstream”. This concept is revolutionary in the history of mental health and psychiatry.
As fictitious personifications of the DSM’s current diagnostic criteria for Sexual Masochism Disorder and Sexual Sadism Disorder, the protagonists of Fifty Shades of Grey and its sequels perfectly embody the multifaceted nature of the “Four D’s” of mental diagnosis. Anastasia Steele’s and Christian Grey’s exemplification of a situation in which consent alone simply is not enough to deter the mental diagnoses can be applied in real-life, clinical settings, and one must also importantly note that most members of the BDSM community actually reject the Fifty Shades franchise as unreflective of their sexual stance.
Ana is very reluctant to be in the BDSM relationship with Chris and finds it to be very stressful and emotionally painful (distress); Chris is violent in his practices and tortures Ana to the point of physical and emotional injury. In this case, the sex is not only intense and involving of bondage and submission, but is also associated with violence and abusive, 24/7 dominance and control in and outside of the bedroom (deviance). Chris stalks Ana and shows up even when she doesn’t expect him or want him to, and although Ana does consent to all of the sex throughout the entire time (hence it is not legally problematic), she does so out of shyness, insecurity, and discomfort, ultimately getting harmed in multiple ways. When Chris beats her, the consent Ana gives is insufficient to protect her from the resulting damage and the relationship becomes dangerous at that point. Finally, the relationship also impacts Ana’s occupational career and both characters end up feeling the effects of social stigmatization as outcasts, causing tension with friends, relatives, and being targeted by strangers; Chris feels pain whenever he is sexually touched – all of these factors are indications of dysfunction.
In conclusion, having both met all of the “Four D’s” along with the DSM-5 descriptions of their respective conditions and symptomology, Ana and Chris would most certainly be diagnosed with the paraphilic disorders if they were clients or patients. These two fictitious characters oddly enough demonstrate where the line must be drawn between normalcy and pathological abnormality in the context of mental health diagnosis.