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Is Psychiatry Getting Kinky?

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So slip into those tight leather jeans. That dog collar would look fetching. Add a piercing in a place your mother wouldn't imagine. Or take your lover to a trendy erotic play-space and make lots of fast friends.

Your therapist says it's OK. In fact, she or he might be there. (I know a few therapists who partake.)

The American Psychiatric Association has gotten kinky. Well, not quite -- its annual meetings each May are pretty buttoned-up affairs. But its newest catalog of mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (known as the DSM V) does some unzipping. You can now do whatever, with whomever (consent required, please), on your own or in groups, and be in the pink of mental health -- so long as you don't suffer "clinically significant distress or impairment."

Credit cultural change, kinky lobbyists (the National Coalition for Sexual Freedom pressed the APA to stop diagnosing edgy pleasures), or -- who knows. But the committees of psychiatrists who rethink disease categories when the APA revises its diagnostic manual dropped "fetishes" sans "distress or impairment" from their list of disorders.

If your style of kinky fun is fetish-free (the APA defines "fetishism" as sexual use of "inanimate objects"), the new erotic liberation still has you covered. The DSM used to treat all "paraphilias" (APA-speak for "atypical" sexual practices) as sicknesses; not any more, so long as the fun is distress-free.

So what Christian and Anastasia do in Fifty Shades of Grey is (mostly) healthy, as of the DSM V's May 2013 release date. So are sex parties of the sort enjoyed by Dominique Strauss-Kahn -- the next president of France, until his alleged doings with a hotel housekeeper undid him.

Psychiatry's new sexual willingness came along just in time to save the field from embarrassment. If millions of Americans are getting kinky (or want to), diagnosing kink as disease would expand the ranks of the mentally ill implausibly.

Inanimate objects have become quite the rage. More than half of American women under 60 use vibrators, according to a 2009 Kinsey study, and sellers of more hard-core sexual hardware have had trouble keeping up inventory in the face of the Fifty Shades surge. Threesomes are becoming more fashionable, according to sex surveys (though the data are sketchy). Playing well in groups has come out of the sex tent at Burning Man and into the lives of power professionals.

I live in Washington, D.C., that most frumpy of towns, but plenty goes on here besides public policy. I was invited more than once, while single, to play triples (or more), and I'd guesstimate that about a quarter of the women I dated told me they've either done this or want to.

I don't travel with a particularly racy crowd: I'm talking about law professors, lobbyists, regulators, trade negotiators, and Senate staff. You're likely to find such folks, also, at a club called Entre Nous, which parties weekly at an upscale lounge, next door to the League of Woman Voters, the American Enterprise Institute, and "Edible Arrangements."

These parties are "off-premises," swinger-speak for staying on second base. But join Entre Nous, and you'll get invites to their "underground" events -- "on-premises" parties where you can do whatever with whomever is willing. Or go underground literally: Fly to Paris and find the subterranean passage from rue du Cherche-Midi to L'Overside, where you'll run less risk of encountering officemates. Across America's heartland, local options abound. "There are no hook-ups," the Idaho White Rose warns about its campsite, but this refers to RVs, not their occupants.

Psychiatry's retreat from these play-spaces is strategic -- necessary to preserve its credibility as the bounds of culturally-permitted pleasure loosen. But this retreat from the cultural politics of sex is partial. What you do in a play-space or at home, with or without "inanimate objects," is sick if it's "atypical" and causes "distress or impairment."

So dressing in latex and tying down your lover isn't illness -- if your lover likes it and you don't feel guilty or anxious. And putting your vibrator to happy use is a healthy pleasure -- because vibrators, however "inanimate," have gone mainstream.

The APA, in other words, is still in the business of telling us what kinds of sex are healthy and what kinds are sick, based on their social acceptance. That's the business it purported to quit in 1973, when it famously announced that homosexuality was no longer an illness.

The APA keeps a hand in this unscientific business by cataloging "paraphilias" and "fetishes" even when it doesn't label them "disorders." Leather and latex are fetishistic, the DSM V says, if they're used to arouse. But what about, say, wet denim (not mentioned in the DSM V) -- is it "normal" because Taylor Swift writhes in the sea in skinny jeans for Rolling Stone? Should psychiatry answer such questions?

And what of "distress" as a criterion for calling a kink a disease? The APA makes a point of not counting distress that's due to conflict with cultural mores; to qualify, angst must ensue from unhappiness within. But this distinction often dissolves for a reason psychiatrists well-understand: Our beliefs about what's right and wrong are shaped by social cues. Angst within, over sexual feelings, commonly reflects condemnation from without.

So treating kinky desire as disease because it comes with some distress smuggles in social rejection as reason for diagnosis. Psychologist Suzanne A. Black, whose clinical practice, in New York and Paris, includes patients with kinky inclinations, says their sexual angst is inseparable from their upbringing. "It's an underworld of desire because it goes against the morals they've learned," she told me last month.

Does this mean psychotherapy has nothing to offer those whose unconventional cravings bring them distress? To the contrary: A caring, insightful therapist can help such a person to better understand inner conflicts -- and perhaps to let go of a puritanical belief or a kink that goes too far.

But psychiatry ought to retreat more fully from clinical classification of our erotic lives. Categorizing kinks as "paraphilias" wounds, to no purpose. Diagnosing them as disease when a person experiences "distress" humiliates -- and isn't necessary for therapy to help.

Some breaches of sexual convention that psychiatry calls "paraphilias" must be kept beyond-the-pale: voyeurs, pedophiles, and the like harm people who don't or can't consent. But criminal law, not the APA, should draw these boundaries.

We should welcome all that psychiatry can do to help those whose desires push them to act in ways that wound others. But the APA had the right idea back in 1973, when it began its withdrawal from the policing of our erotic lives by de-medicalizing same-sex desire. If you play well in groups, with or without "inanimate objects," psychiatry should let you alone.

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