February 16, 2011

On grammar, paraphilia and the DSM-5

Sloppy language and loose use of terminology cause a lot of confusion in the transgender debate. This especially applies to the idea that many (if not all) transgender conditions are mental illnesses or perversions.

In this post I take a look at Andrew Hinterliter's discussion of the paraphilia term.

Cause and effect

In the debate on transgender conditions there is a mix up of observed behavior and what causes this behavior (correlation vs. causation).

To give the crossdreamer example:

If a man gets turned on by imagening himself having a woman's body, this is what he is. His very being is defined by being an "autogynephiliac" (a man in love with himself as a woman).

Moreover, the condition is caused by "autogynephilia". It is, according to Blanchard, an intrinsic part of his nature. It is innate.

The alternative would be to look at crossdreaming as an effect of another underlying condition.

To give an obvous example: Let us say that some male bodied persons are biologically wired for a "female" sexual instinct. This instict, which due to the surrounding culture is suppressed and cannot find an expression in everyday life, finds its outlet through feminization fantasies.

The observed "facts" are the same, but the story used to explain them is completely different. In the first the man is a pervert, in the other -- maybe -- a sexually frustrated woman or a person living outside existing gender norms.

Another example: "Autogynephiliacs" are considered self-obsessed narcissist unable to connect in normal love relationships. They are narcissists. (This isn't true, by the way, but this is what some of the experts say).

The alternative would be to look for an explanation for such behaviour outside the observed phenomenon itself:

Some crossdreamers may appear to be self-obsessed because (1) their lack of emotional and sexual fulfillment is traumatic and extremely frustrating and (2) they have found that it is hard to integrate their own sexual needs in a traditional heterosexual relationship or they have been rejected because of them.

In other words: They are afraid of yet another rejection and have given up love alltogether.

They are not pathological narcissists, lacking the ability to connect per se. They have just come to the conclusion that their "handicap" is too severe, and that there will be noone there that could love them. (I am convinced they are wrong about this, but it is not an irrational assumption).

Again: The context changes everything.


The second fallacy is the tendency of interpreting "normal" as what the majority of people is doing. Hence abnormal is what a minority of people is doing.

A 19th century example would be the argument that since women have never been great scientists or political leaders they must in fact be biologically incapable of becoming so. (Queen Elisabeth I and Victoria would be ignored or explained away as as abnormal exeptions to the rule).

At that time you could also argue that women do not masturbate. Women who do masturbate must therefore be sexually deviant. This argument was commonly heard among doctors and scientists all the way up to the 1970's.

The alternative use of the word "normal" -- if we stick to biology -- would be "that which appears as a result of natural diverisity". According to this understanding homosexuality would be natural, even if a minority of the population understand themselves as being gay.

Understanding perversions

These distinctions are extremely important, because if you label someone as a pervert or a paraphiliac, you have -- in effect -- denied them their dignity and their humanity.

However, some people have a strong need to sort people into the clean and the unclean, the normal and the abnormal. We have seen this since the time the priests and the prophets of the Old Testament wrote their laws and regulation. They took great pleasure in telling the people what was kosher and what was unacceptable in the eyes of the Lord.

Andrew Hinderliter and Ray Blanchard

Andrew Hinderliter has published an interesting paper called "Defining Paraphilia: Do not disregard grammar" published in the Journal of Sex and Marital Therapy.

Ray Blanchard (2009a, 2009b, 2009c) proposed a definition of paraphilia for DSM-5 proposal (the American Diagnostic and Statistical Manual) that delimits a certain range of so-called normative sexual interests (normophilia) and defines paraphilia as intense and persistent sexual interests outside of that domain. He calls this a “definition by exclusion.”

Hinderliter examines the wording and intended meaning of this definition, and he argues that there are many problems with it that “correct” interpretation requires ignoring what it says. In other words: It is too imprecise and sloppy to be used for something so serious as sorting people into the straight (normophiliacs) and the bent (paraphiliacs).

Paraphilia defined

According to Blanchard and the DSM-5 proposal the term paraphilia refers to "any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners”.

In normal English the defininition says that the only normal sexual interest according to Blanchard and the DSM-5 proposal is (1) an interest in the stimulation of the sex organs and (2) fondling during foreplay with (3) normal looking adult men and women who are willing to have sex with you.

As the definition is written, it covers ordinary intercourse only. As it turns out, Blanchard believes more can be included, which is Hinderliter's point: The definition is far too narrow, even if you want to include that which Blanchard himself considers a paraphilia.

Note that "Autogynephilia" (for a man to be turned on by the idea of being a woman) and "autoandrophilia" (for a woman to get horny by imagening herself as a man) is two of the paraphilias included in the draft of the DSM-5.

Paraphilia is culturally defined

Hinderliter points out that Blanchard (2009) has given a lists of what his definition (supposedly) regards as paraphilic and nonparaphilic:

• “Paraphilic: enemas; feces or urine; generalized interest in amputees, paralyzed persons, physical deformities; bondage; whipping; cutting; hypoxia, sneezing or smoking persons, obscene telephone calls.”

• “Not paraphilic: cunnilingus, fellatio, anal penetration with the finger, penis, or dildo; anilingus, intracrural intercourse; cross masturbation; kissing; and fondling.”

Hinderliter writes:

"From this list, the influence on changing beliefs about sexuality in Western culture is obvious—masturbation, oral and anal sex (and homosexuality, which he mentioned later)—were not long ago regarded as perversions. Now they are increasingly accepted as normal. Nevertheless, his proposed definition attempted to define paraphilia—and 'normative sexuality'—in a way that made no reference to culture or changing attitudes.

"This is in stark contrast to what [D. L. ] Davis (1998) said retrospectively about the literature reviews on cross-cultural consideration for the sexual and gender identity disorders in DSM-IV that she had first authored:

"'[T]he initial literature review revealed little ethnographic data that was relevant to the DSM constructions of the paraphilias. . . . Since [the paraphilias] are rooted in Western biomedical concepts of sexual deviance . . . the lack of cross cultural data to support any universal relevance of, or concern with, these categories is hardly surprising.' "

As soon as Blanchard and his colleagues are asked to define what they consider normal and not normal, their cultural prejudices become apparent.

Blanchard's list is an example of what American doctors and university professors were likely to consider normal in the 1980's. The list is not based on any scientific study of what is statistically significant.

And how should you design such a study? Many of these sexual behaviors are not instinct driven per se; they are the result of human creativity and ingenuety, of our ability to find pleasure in love and sex. What is considered sexually acceptable is culturally relative.

At best a list of paraphilias becomes a trivial and self-evident presentation of current cultural mores, and not a list of mental diseases at all, at worst it will reinforce current prejudices and stereotypes and become a tool for cultural repression.

Are paraphilias psychiatric disorders?

Note that there is no attempt at distinguishing between cause and effect in the DSM. It looks like the observed behavior is the disease. Anyone reading the definitions in isolation must therefore come to the conclusion that anyone displaying the "symptoms" of a paraphilia, is a mentally ill pervert.

Blanchard's counterargument would probably be that he does not necessarily consider a "paraphilia" a disease. It is just a term you use to describe unusual sexual behavior and fantasies. It is clinical, and not meant to be stigmatizing.

Still, if you include abnormal behavior in fantasies in a manual for mental illnesses, you should expect the reader to think of them as perversions.

Hindterliter again:

"Blanchard (2009c), describing current proposals of the paraphilias subworkgroup for DSM-5—which he stressed are tentative—asked, 'Are all paraphilias ipso facto psychiatric disorders? Our subgroup is taking the position that they are not. We are proposing that the DSM-5 make a distinction between paraphilias and paraphilic disorders.'

"He said that a paraphilia would be 'ascertained' and a paraphilic disorder 'diagnosed' (para. 8). Essentially: Paraphilia + Clinical Significance = Paraphilic Disorder.

Hinderliter adds:

"This is curious: In creating a nonpathologizing term for so-called nonnormative sexual interests, the term paraphilia—a term used to label certain sexual interests as mental disorders for three decades now—is hardly an optimal choice. Furthermore, the DSM does not seem to be an appropriate place for classifying what are acknowledged to be nonpathological variations in human sexuality."

My point exactly!

Pedantic interpretations

Hinderliter then goes on to interpret the new DSM definitions in ways that many will find pedantic. Many of the interpretations given are clearly not intended by Blanchard and his friends.

Hinderliter has a valid point, though. The DSM is going to be used by doctors that do not know the scientific history of the terms and the discussions taking place regarding their cause and effect. Moreover, the manual may also be used in a court of law, by lawyers not familiar with the psychiatric debates of the time.

The language has to be exemplary clear and very presise.

Hinderliter argues that "...the proposed definition gets it wrong in a number of clear cases—so many that 'correct' interpretation requires simply ignoring what the definition actually says and pretending that it means what it is intended to mean (whatever that might be)."

Genital Stimulation or Preparatory Fondling

To give an example: Hinderliter discusses the term "Genital Stimulation or Preparatory Fondling". He writes:

"Presumably this is meant to regard sexual masochism, sexual sadism, telephone scatologia, klismaphilia, and transvestic fetishism/transvestism as paraphilic.... A major problem with this phase is that a number of other activities would also qualify: looking at pornography, reading erotic fiction, any sexually arousing verbal behavior, and possibly sexual role play.

"It would also include orgasming without genital stimulation—either exclusively through thought or through stimulation of the nipples. And is preparatory to be understood as a restrictive adjective or a nonrestrictive adjective? ..."

"In Blanchard’s (2009c) list of what his definition (supposedly) regards as nonparaphilic, he lists kissing and anal penetration with a finger or dildo. Are these genital stimulation or preparatory fondling? They do not seem to be genital stimulation, but it would require a rather idiosyncratic understanding of fondling for them to fall within the meaning of that term.

"Moreover, the last item on his list is fondling, suggesting that none of the other behaviors listed are to be included under that term. He lists enemas under his 'paraphilic' list, but it is unclear how the proposed definition regards erotic interest in anal penetration with a dildo as nonparaphilic but erotic interest in anal penetration with an enema nozzle paraphilic."

Hinderliter then goes on to discuss the term "phenotypically normal", showing how hard it is to delimit all interests in "amputees, paralyzed persons, physical deformities” as paraphilic.

Consenting adults

As regards the word "consenting", Hinderliter points out that:

"...use of the term consenting quickly becomes problematic if sexual fantasies are considered. For example, Greendlinger and Byrne (1987) investigated coercive sexual fantasies in a convenience sample of college men, of whom 54% endorsed the item 'I fantasize about forcing a woman to have sex.' In addition, 36% endorsed the item 'I fantasize about raping a woman.'

"Masters and Johnson (1979) found that, of the heterosexual and homosexual men and women whose sexual fantasies they studied, fantasies about 'forced sexual encounters' were either themost common or second most common sexual fantasies in all four of these groups.

" This suggests that fantasizing about someone as nonconsenting is far too common to be regarded as paraphilic—a point recognized by DSMIII (American Psychiatric Association, 1980): “[I]magery of sexual coercion [is] sexually exciting for many men; [it is] only paraphilic when [it] becomes necessary for sexual excitement”.

Anyone who has read Blanchard knows that his main focus is, actually, on sexual fantasies. But the definition proposed in the DSM-5 does not refer to fantasies.

Transvestic Fetishism

The various editions of the DMS have struggled with how to understand crossdressers and crossdreamers. One idea seems to be there throughout most of its development, though: If the motivation for crossdressing or sex change is sexual, it is a perversion. If the motivation is not sexual arousal, it is not paraphilic.

Personally I find this extremely confusing, as it is based on a view of sexual identity (or "gender identity") as being asexual. That is: If a man dreams of becoming a woman and gets turned on by it, he is a pervert, but if he does not find it arousing, he is not.

The problem with this argument is that it presupposes that a truly gender incongruent tranwoman cannot get horny imagening herself as a woman. But given that she is a sexual being, how can she not imagine herself as a woman when fantasizing about having sex?

It seems to me that this part of the history of psychiatry is based on a very old fashioned view of proper feminine sexuality.

Crossdressers who stop being paraphilic

Earlier versions of the DSM recognized the fact that some crossdressers would lose the arousal part of their fantasies later in life.

The DSM-III-R said that “in some people sexual arousal by clothing tends to disappear, although the cross-dressing continues as an antidote to anxiety. In such cases the diagnosis should be changed to Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type [GIDAANT]”.

This means that these M2F transgender persons were moved out the paraphilia category.

To understand the motivation for the change from DSM-III to DSM-III-R regarding men who continue to crossdress after it ceases to be sexually arousing, Hinderliter asked F. Berlin, a member of the DSM-III-R paraphilias subcommittee.

According to Berlin, this change was made because gender identity is about feelings of being a man or woman, not what someone finds sexually arousing. Paraphilias, on the other hand, are about what is erotically arousing to someone. Thus, if the arousal ceases and is not part of the motivation for the behavior, it is no longer a paraphilia.

Blanchard found this absurd, arguing that a man could not outgrow the diagnosis of transvestism in later life simply by failing to experience (or attend to) sexual excitement when he crossdresses.


"Blanchard proposed 'deal[ing] with [the issue of ‘post-erotic transvestites’] in the text rather than in the diagnostic criteria' with the interpretation 'that patients who have been clearly ascertained as transvestic retain that label whether or not they report that cross-dressing continues to be accompanied by penile erection or subjective feelings identifiable as sexual excitement' (p. 368).

"As with the proposed definition of paraphilia, Blanchard suggested including a definition in DSM-5 that is intended to be interpreted in a way directly contrary to what it actually says."

Again the intended meaning of the definition is different from what the definition actually says.

"There are three alternatives to this self-contradiction,"
Hinderliter argues: "Remove transvestic fetishism from the DSM, change the definition of paraphilia, or make it clear that if sexual arousal ceases to be the motivation for cross-dressing, the individual no longer has this paraphilia."

How to integrate sexual arousal

The best solution by far is to remove crossdreaming from the manual altogether.

Option three is not optimal. You see, Blanchard has a point. It is absurd to believe that sexual arousal is not part of a gender dysphoria, just because it goes away with age.

Blanchard's "solution" to this problem is to say that all non-homosexual (i.e. non-androphilic) M2F transgender are "autogynephilic" and paraphilic, regardless of whether they report feminization fantasies or not. They are lying or they have turned their erotic interest into some kind of alternative sexuality.

This means that any transwoman who do not report sexual attraction to men, must be labelled paraphilic.

The reason the androphilic transwomen are exempt from this general rule, is that Blanchard consider them homosexual men, and homosexuality is no longer a paraphilia. If a "homosexual man" (i.e. a androphilic transwoman) undergoes sex reassignment surgery, it is not caused by a perversion. If a "heterosexual man" (i.e. a gynephilic transwoman) does so, it is.

I doubt very much that all of Blanchard's colleagues understand this, or accept the premise that transwomen cannot be lesbians, but this is what the DSM implies now. You have to be attracted to men to be accepted as truly "gender incongruent".

What Hinderliter fails to point out is that it probably is the definition's very lack of precision, that makes it possible for Blanchard to get his own understanding of the transgender condition accepted.

An much more logical step would be to include sexual arousal as one of many effects of gender incongruence and not use it to define a paraphilia.

Andrew C. Hinderliter: Department of Linguistics, University of Illinois, Urbana, Illinois, USA
"Defining Paraphilia in DSM-5: Do Not Disregard Grammar"
Journal of Sex & Marital Therapy
Online publication date: 07 January 2011

You can get a copy of the paper by writing to andrewc.hinderliter@gmail.com. Hinderliter has promised that he will send you a copy.


  1. Because we understand precious little about the etiology of mental illness--and DSM-III's reacting against psychoanalytic etiological theories unsubstantiated by rigorous studies--the DSM aims to take a theoretically neutral stance with regard causation.

    That said, of the three options of what to do with TF, I'm in complete agreement with you, but in the article I didn't want to just say "I think it should be removed" without justifying this position, and giving a substantive justification would have gotten me off topic. Also, I do argue for this position in a companion article (Defining Paraphilia: Excluding Exclusion).

  2. I would seem to me that the causation issue goes both ways. Neither the etiology nor the consequence of the behavior are part of the definition or descriptions utilized by the DSM.

    All form of measurement against "the normal" is both culturally and individually biased and will inevitably lead to significant distress of the person diagnosed and injustice in the use of such diagnosis.

    What bothers me is that the harm aspect of specific behavior is not properly taken into account. The classification of a behavior is pretty irrelevant if the person diagnosing can determine harm or anticipated harm specifically to third parties or the person diagnosed. This determination would then exclude any behavior that was not harmful from classification of a mental disorder and "normative" behavior would essentially that which does not harm others or self.

    Great article by the way and thank you for bringing ACH to us.

  3. http://home.netcom.com/~docx2/AGF.htm

    This is interesting.

  4. KingofA,

    Thanks for the link!

    Moser's study is very interesting, as it shows that anyone can get aroused by the idea of being sexy and attractive.


Click here for this blog's Code of Conduct!

Discuss crossdreamer and transgender issues!