Thursday, January 21, 2016

The Tower of Babel

The Tower of Babel (1564) by Pieter Bruegel the elder, (1525-69)

“And the whole world had one language and of one speech.  And it came to pass as they journeyed from the east they found a plain in the land of Shinar; and they dwelt there.
They said to one another other, Go to, let us make bricks and burn them thoroughly. They had brick for stone, and used slime for morter.
And they said, Go to, let us build us a city and a tower, whose top may reach unto heaven; let us make us a name, lest we be scattered abroad upon the face of the whole earth.
And the Lord came down to see the city and the tower, which the children of men had built.
And the Lord said, “Behold the people is one and they all have one language; and this they begin to do; now nothing will be restrained from them, which they have imagined to do.
Go to, let us go down and there confound their language, that they may not understand one another’s speech.
So the Lord scattered them abroad from thence upon the face of all the earth; and they left off to build the city.
Therefore is name the name of it called Babel; because the Lord did there confound the language of all the earth: and from thence did the Lord scatter them abroad upon the face of all the earth.”

Genesis 11:1-9

This is the Biblical creation myth of how all the peoples of the earth came to speak different languages and cannot understand one another.

From a social constructionist view, this is an essential story for maintaining the illusion of exceptionalism that allows believers to know that, despite the fact many people in the world do not speak their language or share their symbols, believers have special understanding of The Lord’s lessons and purposes.

But the problem of shared meaning is a great deal broader and more pervasive than just shared faith.  Cultures and subcultures are established in part to concentrate meanings and beliefs.  They exist in dialectical relation to one another, and are each in tension with private, idiosyncratic meanings.  Clinicians have one language.  Organized kinksters have another.  Our separate jargons stand in relation to the larger parent culture that is part of our shared context.  Divine intervention is hardly necessary to cause us difficulties understanding one another.

This essay is going to look at some of those unshared understandings so that we might better know what the different communities mean.  Sometimes the effects are silly, like CBT translating as cognitive behavioral therapy in the clinic and cock and ball torture in the dungeon.  The real opportunities for genuine confusion are minimal given the context.  Only the willfully oppositional or the sarcastic seek to confuse the meanings.  Sometimes its political, like Polynesian activists urging the consensual non-monogamy community not to infringe on their language by calling polyamory ‘poly.’ The context overlap between Polynesia and polyamory are few and far between. And sometimes it’s a term like ‘sadism’ which has gone far beyond specific reference to the practices of the Marquis de Sade, and means a number of other things across several different contexts.

The Polynesians settled the eastern areas of the Pacific, mostly in the last 1000 years, through amazing feats of seamanship.  Mostly they were not polyamorous!

One of the consequences of the close examination and politicization of these languages is that stigmatized activities or communities have become very difficult to name satisfactorily, and the low barriers to participation that the World Wide Web has provided lubricate and publicize these discussions.  Nowhere is that more evident than in kink, which has undergone a kaleidoscopic array of name changes.  It has been called ‘The Life, The Scene, The Lifestyle, the Underground, sexual outlaws, S-M, S/M, S&M, Leather, Leather Sex, Bondage, Bondage and Discipline, Fetish, Sadomasochism, Love Bondage, and recently, BDSM followed by Kink.  Every one of these terms can be challenged on some basis.  Some terms are used by other subcultures such as prostitution or rock music.  Some are overly specific, or feature only a part of a larger community.  Some are too broad, and leave boundaries unclear.  Some changes have been advocated to choose less pejorative language, such as the drive to expunge medical terminology such as ‘sadism’ and ‘masochism’ from the community’s identity.  Some are efforts to prevent fragmentation, others are an attempt to exclude.  All of this struggle serves as background and context for individuals who choose to affiliate or not based on how they relate to and adopt the communities’ language.  The naming “Wheel of Fortune’ has stopped for now at ‘kink’, which is embraced for its generalism and its connotations in the general culture of being about minor, relatively non-pejorative difference.  It is free of medical baggage.  And it avoids privileging traditional kink activities like sadism, masochism, bondage, leather and fetish over new activities like steampunk, cosplay, furries, and activities not yet named.

The triskelion used as the logo for BDSM,...

The triskelion used as the logo for the US Department of Transportation!

Lest the reader conclude that kink community is special in these naming differences; a theme in this blog is the progression of understanding about sexual deviations, to paraesthesias, to perversions, to paraphilias has gone on in the mental health community.  These terms all refer to similar things, yet changes were made to bring them under medical authority, and to attempt to manage the stigmatizing consequences of diagnosis.  Doctors insist that the language is neutral and scientific, but are nonetheless aware of its iatrogenic consequences, and they walk a tightrope between privileged understanding, desire to avoid stigma, and the desire to have their legitimacy accepted by the larger social context where stigma is prevalent.  It turns out that when the general society is afraid and judgmental about something, terminology’s meanings drift towards the general consensus.  Perversions of reproductive purpose become moral perversions, and the pejorative properties of the term ‘perversion’ that led to the adoption of ‘paraphilia’ come to infest the replacement terminology.  In some corners of the general society, it is not possible to neutralize the language.  Stigma fighting through language alone is tricky business, even when you enjoy medical authority.

Franklin Veaux has created a wonderful glossary of kink and poly (excuse my use of poly for the more accurate but cumbersome consensual non-monogamy terminology.  In no sense am I referring to the inhabitants of Polynesia, Melanesia, or Micronesia!).  I do not intend to replicate his piece here, except to mention a few examples that I think busy clinicians mustn’t miss because many kinky clients are likely to use them.

Franklin Veaux's BDSM Glossary

BDSM is sometimes referred to as ‘the scene’, which has the attractive attribute of being vague and non-specific.  Often language is chosen because it communicates meaning to insiders that are kept opaque to the general public.  Much of this language appears to be lifted from the language of the stage. ‘Scene’ refers to kink in general, but ‘scene’ is also roughly synonymous with ‘session’.  Kinksters contract to perform scenes, or ‘play’ together.  The term ‘play’ means doing kinky behavior together and is derived from ‘sex play’, even though players may or may not regard playing as sexual behavior, and may take it very seriously indeed.  Scenes may be planned in detail, but are generally not scripted in the kind of detail that is expected in drama or stage plays.  They may or may not involve role play with characters such as Frtiz the Cat, Pinkachu, or Dracula.  In cosplay and furrie paly, some people deliberately attempt to take the roles of specific characters, and scripted dialogue sometimes plays a small part in these scenes.  But mostly players play themselves playing the roles.

It is impossible to download stock photos of cartoon furrie characters because of a serious context problem.  Can you spell "Copyright violations!"

In therapy, the wise clinician asks what the client is trying to express when certain language is used.  What does it reveal, what does it conceal, and how does this representation stand in relationship to the client’s desires and self-concept?  Sometimes the use of scene jargon is a test to see how much the clinician knows.  Perhaps it is about acceptance, and the clinician effortlessly understanding the argot is experienced as acceptance, or even sophistication and actual participation in the underground.  Sometimes the jargon is a snow job, an attempt to veneer over conflicts about which the client is defensive.  So clinicians are smart to stay abreast of the language of sexual minorities they treat.  That context frames how clients express themselves.

Sometimes our own language is a thicket, and we do not have to travel far afield to the titillating world of sexual minorities to confront a semiotic Gordian knot that requires untangling.  Take the terms ‘sadism’, ‘masochism’, and ‘sadomasochism’. 
Sadism had no standing in mental health until the work of Krafft-Ebing.  Then it was used to characterize sexual desire to harm or humiliate sexual objects.  With Freud’s popularization of the unconscious, however, the desire need not be known by the client, and its expression became generalized.  With sex in its proper Freudian role as an underlying human motivation, aggression did not need to be consciously expressed to be sadistic.  Furthermore, underlying sadistic motives could be aggressive towards others: as in traditional sadism, or internalized towards the client; as in masochism, and it became proper to speak of sadomasochism.  With the id a dark bundle of socially inappropriate impulses, just about anything could be down there, and aggression towards others that appeared sadistic on the surface might express unconscious sadistic or masochistic impulses.  So the original idea of sadomasochism, that sadism and masochism always occurred together somehow, was not remotely based upon the kind of observations of sexual sadism and masochism carefully recorded in Krafft-Ebing’s case histories.  In Freud’s view, we are all unconscious switches, alternately wielding and submitting to the lash as the occasion and internal drive states warrant.  None of this bore the slightest relationship to fluidity of BDSM expression which was then so underground and uncommon as to be largely unknown to the early 20th century psychiatric profession.  Only the most dedicated and open-minded sexologists, or the kinkiest ones, got access to the underground of their times.

Everything said above about ‘sadism’ applies with equal force to ‘masochism’.  When Freud wrote later in his career about three kinds of masochism; primary, moral, and feminine, he thought of all of them as sexual despite the fact that it was entirely uncommon for any of the three to be observed in direct sexual expression.  For psychology, masochism generally meant aggression expressed towards the ‘self’, another awkward term that is used very differently in mundane conversation than in psychology.  Indeed, in psychoanalysis, the term ‘self’ had no standing whatever as Freud went to considerable lengths to avoid the term.

Heath Ledger's breakthrough performance as The Joker.  Although commonly thought of as 'sadistic', The Joker was never depicted as sexually aroused by his psychoticly evil, mean and destructive behaviors.  Such motives were way too hot for DC Comics all the way back to Batman's origin in the 30's before the notorious comics code.
It scarcely mattered.  This pic was from a Business Insider post about how common 'sadism' is in the workplace!  PSA:  If your boss is the Joker, change your job and your medication immediately!

In kink, ‘sadism’ refers to the preference for inflicting pain on a consenting subject.  ‘Masochist’ refers to the preference for receiving pain.  In both cases, the pain in question is likely to be highly scripted:  only certain pains, inflicted under a limited set of conditions.  Nothing stoops a sadist from being submissive, or a masochist from being dominant, or from being a true algolagniac, who is turned on by giving or receiving pain.

Algolagniacs sound like switches; persons who are dominant in some conditions, but submissive in others.  But here any inference about underlying desire gets confounded by role fulfillment.  The ‘Tower of Babel’ problem not only applies to the definitions of words, but to the definitions of roles.  In mundane life, it may be properly said that most of us are ‘switches, in that we are dominant in some roles and contexts, and submissives in others.  We rarely see this need to conform in sexualized terms, and this does not really correspond to switching in a kink community.  In kink, there are people who are devoted to specific power roles, and there are a tremendous number of Veaux’s terms that refer to the various permutations of top, Dom, and Domme, switch, or sub, submissive or bottom.  I’ll spare you an exhaustive review, but provide several caveats:

•             People take roles out of availability and ability, not just out of passionate desire.
•             People are usually eager to play whatever role they are in well.
•             They are not always articulate about how and why they take the roles they do.
•             People use different criteria to tell when they are satisfied or not in their roles.

So if a person says they are a top, bottom, or switch, they may experience this is a context-dependent behavior or an essential expression of personal authenticity.  The best evidence of the nascent research on BDSM as identity or orientation suggests these power terms are the best approximation in kink of the identifications that are more extensively studied in queer theory.  So the power exchange terminology is the first place to look in treatment for signs of kink identity.

In the kink subcultures, Dom and Domme generally connote someone who is committed to the role, either socially, or in a primary relationship.  Top usually connotes a less committed or temporary assumption of the dominant role.  Likewise, for submissive and bottom.  Subs tend to be identified as submissive in a wide variety of their interactions, and bottoming is something that one might do only with certain partners or for a specific event.  Fluidity varies: some people express a lot of it, others very little.

Dominant in real life?  Most likely a model!
It is a chancy business predicting people's real life behaviors from their preferred kinky roles or identifications.

Some may debate this, but my limited observations of a few BDSM social organizations suggests that white and male privileges are modestly attenuated, but still present, and that Dominants are privileged over switches over bottoms.  This is reflected in the 2014 Consent Violations Survey.  Males and tops were least likely to report violations, switches were in the middle, and bottoms, females, and the gender fluid were most likely to report violations.  This is true despite a vast body of anecdotal evidence that in aggregate, people’s kinky roles correlate poorly with their Real Life roles.  I’m frankly more convinced by stories of top corporate execs who chose to bottom in BDSM than meek shop girls who magically transform to imposing Goddesses of the Night.  Perhaps role choice and flexibility, even in BDSM, reflects Real Life privilege behind the masks, costumes and rituals of dark theater. But it is true that the community rules for safety and anonymity make it harder to bring mundane signals of dominance and privilege into the special space of the dungeon.

Although clinicians like to be sensitive, and clients do not feel accepted when they have to explain the basic assumptions of BDSM to clinicians who haven’t taken the time and trouble to acquire the kind of basic information conveyed by this blog about The Scene, close listening is not likely to resolve all questions when the language overlaps but has specific meanings in kinky, mundane, and clinical contexts.  Hopefully, this post gives clinicians encouragement to learn kink subculture, but also to be unclear and to ask empathetic questions of their clients.  When you are puzzled and curious, it is often better to ask the clients about their feelings than to try to have the answer for them.

© Russell J Stambaugh, January 2016, Ann Arbor MI, All rights reserved

Friday, January 15, 2016

Richard Frieherr von Krafft-Ebing (1840-1902)

Richard von Krafft-Ebing

Richard von Krafft-Ebbing is the father of modern Western sexology.  While the application of social science methods to human sexuality preceded him, and many of his terms and concepts were borrowed from others, he very deliberately reframed sexual deviance from a primarily religious, moral, and legal problem into a medical one.  He did this precisely in the period of the Second Industrial Revolution when the social, biological and medical sciences began to benefit from the innovations which the hard sciences had stared to use during the Enlightenment. 

Treponema pallidum.  Not a genetic weakness or product of too much masturbation, but a bacterium!

Educated at the University of Heidelberg and at work in the Catholic operated asylums in the Palatinate, von Krafft-Ebing was appalled at the quality of care provided in these facilities.  Starting in the 18th century, the entrepreneurial spirit had caught up with alienists, the precursor profession to modern psychiatry.  Like surgeons of the time, alienists were not high status professionals analogous to modern physicians.  But rationalism had made jailing the mentally ill untenable, and privately operated insane asylums had become a booming and shady business.  With very poor methods and theories for treating bizarre behavior, patients were warehoused indefinitely by providers who profited from long stays.   Much theory still rested on the foundations of Aristotle and Galen with emphasis on maintaining a balance between bodily fluids or ‘humors.’  In sexuality, Simon Andre Tissot’s Treatise on the Diseases Produced by Onanaism (1832) advanced the idea that excessive masturbation was a sign and cause of degeneracy and many sex related diseases.  Modern syphilis was then called ‘general paresis,’ and was a principal cause of madness.  So there was lots of overlap between sexual deviance and insanity in the Victorian era popular imagination and asylum populations.  And Krafft-Ebing advanced the goal of professionalizing psychiatry by sorting out the treatment of sexual deviance from the general asylum population.  He was one of the first practitioners to suggest that general paresis and syphilis were actually the same disease, a hypothesis eventually confirmed following Louis Pasteur’s (1860-4) demonstration of the germ theory of disease and later work in 1905 that identified Treponema pallidum as its bacterial agent.

One of the many modern editions of Psychopathia Sexualis.  You may bet Krafft-Ebing would not have approved a cover featuring bondage illustrator John Willie's Sweet Gwendoline after having translated the salacious parts into Latin!
In 1886, Krafft-Ebing published the first edition of his seminal work, Psychopathia Sexualis, a compendium of case histories of sexual problems and deviations.  Although his primary hypotheses of their origin was biological, Krafft-Ebing was still sufficiently concerned about the spread of morally degenerate ideas to write the more salacious parts of his volume in Latin.  In addition to protecting the public from dangerous ideas, his tactic had the consequence of professionalizing the conversation.  In the mid to late 19th century, the intellectual training for Roman Catholic clergy, medicine and law all requiring the study of Latin.  The medicalization of this sexual content was therefore advanced by the medium.  Serious scientific language played down the potentially provocative content by emphasizing its academic context!  It is just as well, almost as soon as Psychopathia Sexualis was published, helpful scholars translated the Latin for curious and salacious lay people!

Charles Darwin (1809-82)  Darwin's inferences from the careful observations of finches revolutionized the narratives underlying 19th century biology.  He inspired Krafft-Ebing, Freud, phrenology, and eventually Nazism.

Psychopathia Sexualis also promoted medicalization of sexual deviance by tying the various sexual practices it described into the emerging biological narrative sweeping medicine at the time following Charles Darwin’s publishing of On the Origin of Species in 1859.  While it would take well into the twentieth century for evolution based upon natural selection to become the unifying narrative of biological science, Origin provoked much scientific discussion from the outset of its publication.  Krafft-Ebbing used the relationship between different sexual behaviors and evolution by relating them to procreative function as the guiding principle for categorizing sexual problems he had encountered in the case histories.
Krafft-Ebing divided sexual problems into 4 categories with respect to procreativity:

Paradoxia referred to sex drive at times and places that would not be predicted by sexual functions, such as in the young, or in post-menopausal women.

Anaesthesia referred to problems of low or absent sex drive or desire.

Hyperaesthesia referred to problems of too much sex drive, such as nymphomania or satyriasis.

Paraesthesia referred to sex drive in the perversions or fetishes where the sexual impulse was not focused on its evolutionarily expected functions.

A gratuitous picture of boot fetishism, because this is, after all, a blog about kink!  Or perhaps a sign of genetic degeneration!

Krafft-Ebing regarded perversions and anesthesia as proof of genetic weakness because of the obvious problems they might cause with effective reproduction and evolutionary fitness.  This was congruent with the pre-existing medical theories left over from the ancients that health and disease were determined by the balance of bodily fluids and humors.  The concepts of compromised reproductive fitness and physical degeneracy, and moral degeneracy dovetailed seamlessly.  The vast majority of Krafft-Ebing’s case histories were men, and many took the form of bemoaning the poor wretch’s dissipation and poor fitness for procreative success.

In his first edition of Psychopathia Sexualis, Krafft-Ebing assembled 238 case histories of sexual problems.  His main thesis is that most should be treated medically, not handled as criminal matters.  He would go on to become a powerful opponent of phrenology, a pseudo-scientific theory during the late 19th century that personality, and especially criminality could be accurately assessed by careful measurement of individuals’ heads.  By the time he died in 1902, Psychopathia Sexualis had made 12 editions, over 400 case histories, and had been translated out of German and Latin into 30 languages.

The Marquis de Sade, an 18th century author and libertine Krafft-Ebing selected for 'sadism'

Leopold von Sacher-Masoch, a 19th century novelist whose name Krafft-Ebing selected for 'masochism'.

Although he was in no case the first person to use these terms, he is responsible for the use of Donatien Alphonse Francoise, the Marquis de Sade’s name for sadism, and Leopold von Sacher-Masoch’s name for masochism in the Western imagination.  This is primarily because of the primacy and success of his work and the fact that it led a wave of psychological and medical interest.  It didn’t hurt that he was a professor at the University of Vienna contemporaneously with the more famous Sigmund Freud, although Krafft-Ebing was not enamored of his former pupil’s later theories.

Krafft-Ebing's bust at University of Vienna,  The dates are his tenure there.  Photo by the author.

There is a famous story circulating in Vienna as recently as last month that a steel magnate brought his teenage son to a sanitarium in Vienna for consultation because of the son’s ill-socialized aggressiveness.  After the son assaulted the first doctor who tried to interview him, the father called for the famous Dr. Krafft-Ebing.  Krafft-Ebing went into the room and emerged almost immediately with a hematoma above his left eye.  The magnate then insisted that he then see the junior Dr. Freud.  The staff were taking bets on how long Sigmund would last in the consulting room.  In he went, and came out after 50 minutes as planned and proceeded to provide a diagnosis and treatment plan to the attending physician.  This doctor expressed some amazement, given that the great authority on criminality had immediately been socked in the eye.  “What could we expect of a middle aged goy to understand about alienation in youth?” quipped Freud.

While Freud may have easily dismissed Krafft-Ebing in this anecdote, Krafft-Ebing produced an enduring nosology of sexual deviations that has only been modestly dismantled in the ensuing 130 years. He identified sadism, masochism, voyeurism, exhibitionism and homosexuality as ‘perversions’ of sexual desire.  This was a stroke of marketing genius.  Although Krafft-Ebing meant that the sexual drive had been perverted from its evolutionary purpose to behaviors that were evolutionarily degenerate, the similarity between his language of biology and that of moral authorities was sufficiently similar that it would be easy for moralists to understand. He termed homosexuality an ‘inversion’ but nonetheless thought it degenerative in the evolutionary sense.  All of these variations would remain standard definitions, with some modification, until after the mid-twentieth century when disunity about other diagnoses led to the creation of the ICD system and the Diagnostic and Statistical Manuals of the Mental Disorders after World War II.
Paradoxia failed to stand the test of time and suffered from the false narrative that sexual expression was not widespread in children.  While it is easy for us to dismiss paradoxia as product of Krafft-Ebing’s  Victorian times, all of his work was conducted then, framed by Victorian social assumptions.  Other contributors like Albert Moll and Sigmund Freud would challenge the idea that childhood was free of sexual desire or behavior, and it was eventually acknowledged by science, if not in the popular imagination even today. 
In the modern nosology, Anesthesia has been replaced by various sex dysfunctions, and hyperaesthesia has failed to achieve inclusion due to disagreement about how much sex is ‘too much’ across widely varying social contexts.  It has found expression in some systems as nymphomania and satyriasis as in DSM -III, and in the persistent concept of sex addiction.

W. K. Kellogg, cereal magnate and philanthropist, typified Victorian ideals about health, fitness, and repressed sexuality.  
Krafft-Ebing continued a long tradition of failing to recognize the sexual agency of women.  Between Victorian era prejudices and the misconception that women were primarily the passive recipients of male sexual attention, women did not manifest paraesthesias but often did show excessive sexual reluctance and occasional paradoxia when they were lusty after menopause.  Prostitution, while often criminalized, was evolutionarily unobjectionable, and was later blamed on male enthusiasms well into the late twentieth century.  The romantic idealization of female purity and innocence has led to the idea, still persistent, that women are only lured into prostitution by male desire and most are coerced slaves of sex traffickers. Likewise, Krafft-Ebing viewed rape as criminal behavior, but sexually, it was unobjectionable from an evolutionary point of view, thus not pathological.
A close reader will note that despite the robust durability of Krafft-Ebing’s nosology, there are rather severe weaknesses in his degenerative argument.  Oral and anal sex are surely as devastating to reproductive success if indulged in to the exclusion of coitus.  Don’t these variant activities deserve as prominent a place in the paraesthesia nosology as sadism or boot fetishism?  In fact, those behaviors were criminalized and regarded as perversions in many places during the Victorian era through the modern one, but have not been pathologized in the modern ICD and DSM systems.  Birth control in any form was stigmatized during this period, and became a cause celebre of the nascent women’s movements in the West.  Their opponents characterized sexual expression freed of the risk of reproduction as the gateway to license and perversion.  And this was done in the face of medical recognition that death in childbirth was the leading cause of death to women of reproductive age.

Alfred Binet (1857-1911)  Founding father of  associationism and inventor of the first practical intelligence test.

The biggest challenge to Krafft-Ebing’s views on sexual variation came from the associationists.  This branch of nascent experimental psychology argued that sexual expression was learned behavior.  Rather than expressing constitutional factors, different sexual behaviors were mostly learned.  The leading proponent of associationism was the French psychologist was Alfred Binet, who argued that fetishism was simply learned by early association between pleasure and some article not essential to procreation.  Binet’s primary research interest was in assessing intelligence, and he is responsible for devising the original version of the famous Stanford-Binet Intelligence Scale.

A break in this nature/nurture logjam was to come in 1905 when Sigmund Freud published his Three Contributions to a Theory of Sexuality.  Freud recognized that variant sexual expression was widespread, but many of Freud’s cases showed variations that were eventually subordinated to ‘genital’, and thus procreative sexual expression.  Thus, Krafft-Ebing’s paraesthesias, now termed, sexual perversions, did not often substitute completely for procreative sex.  Freud would make a name for himself by explaining that they arose from pre-genital sexual instincts arising from psychological development in childhood.  Perhaps these variations, if they were so common, should be diagnosed only when they entirely substituted for procreative sexual expression?  This idea looks modern indeed when compared with the recent paraphilia revisions in DSM – 5.  But Freud’s broadest interpretation of perversions and sexual dysfunctions was that they resulted from individuals’ internalization of societal repression.

By 1905, Krafft-Ebbing had died, and we do not know how he would have replied to Dr. Freud’s claims.  Krafft-Ebing was no lover Freud’s work, and he would not have counted himself a psychoanalyst despite that the two great thinkers addressed many of the same issues.  But the verdict of the popular imagination rendered at the time had largely held for 100 years.  Even in the face of Kinsey’s work in the mid-century, sexual variation which was primarily moralized before Krafft-Ebing was still moralized after him, after Freud’s liberalizing observations, after Kinsey’s survey research and has moderated only somewhat following the so-called sexual revolution, rise of feminism, and the partial success of gay rights advocacy and the removal of homosexuality as a diagnosis within the DSMs.  Krafft-Ebing succeeded in medicalizing sexuality, but he did little to destigmatize it.

But Freud’s 1905 work was a huge advance to the psychology of sexuality.  It provided a middle ground in the stiffening debate between evolutionists like Krafft-Ebing who thought sexual expression entirely in terms of essentialist drive expression, and the associationists who argued that sexual expression was learned.  Despite his defense of the idea of degeneracy, Krafft-Ebing decision to publish his opus partially in Latin to prevent the vulnerable from being damaged by disturbing ideas shows some fear that sexual deviance could be learned.

Charles Gray, as 'The Criminologist, sending up 1920's pups in The Rocky Horror Picture Show (1975)
Still doesn't have a neck!
Neither was his concern entirely misplaced.  In the 1920’s, a new form of pornographic literature would arise in which real and pornographic medical case studies were compiled precisely for sale to persons of esoteric tastes.  They took a medical tone, but were not written in proper medical jargon, designed to evade the censor’s knife.  Their production and sale would play a pivotal, bur circuitous role in the creation of modern kink organizations.  But that is another story altogether, well told in Rob Bienvenue’s dissertation, a subject for another post!  Krafft-Ebing had started the classification for modern paraphilias, but Psychopathia Sexualis, despite his best efforts, gave rise to the titillating faux case study.

© Russell J Stambaugh, January 2016, Ann Arbor MI, All rights reserved


Monday, January 11, 2016

Acceptance, Part 2


The current diagnostic manual, DSM – 5, has instituted a two-tiered system for diagnosing sexual variations.  Those sexual variations that are nonconsensual, illegal, or cause the problems categorized above are ‘paraphilic disorders.’  A sexual variation that doesn’t cause ‘clinically significant distress or impairment in social, occupational or other important areas of functioning’ is not a mental disorder but is still coded as a ‘paraphilia’, just not a disorder.  This raises the question:  if a sexual variation is not a mental disorder, why should the DSM code it as anything?  That answer is methodological.  It is pretty easy to reliably code the difference between phenotypically different behaviors, such as exhibitionism and sexual masochism, relative to coding the degree to which a sexual variation is a source of clinically significant distress or impairment.  So retaining the diagnostic distinction between stressful transvestism and stressful sexual sadism improves the statistical reliability of all the paraphilia diagnoses, and it saves the entire family from being primarily a matter of client’s opinions about how distressed they are, reserving the diagnoses to the opinions of trained professionals.

Given the potentially stigmatizing consequences of any diagnostic label, why use them at all?  Even clinicians who philosophically oppose diagnostic labels sometimes require them for billing purposes.  I prefer using the following strategies for the sake of patients’ privacy and to add as little as possible to the stigmas to which they are already subject.  First, I rarely make reference to variant sexuality when contributing information to a client’s electronic records, which is where all such information eventually goes, unless it is central to the treatment of a paraphilic disorder.  If the client is complaining of problems related to stigma related to variant sexuality, it is probably best to examine those problems through a lens of acceptance issues and not refer to any sexual variation.  In cases of non-consensual behavior, criminal conduct, and sexual behavior driven by personality disorders such as narcissistic, borderline, or antisocial personality, one is professionally obligated to diagnose a paraphilic disorder.  Note, however, that this is my opinion, and is not acknowledged in the DSM-5 criteria.   The professional reticence I am advocating comes at a price.  We can scarcely expect improvements in the construct validity, statistical reliability, or research utility of diagnostic criteria that are not consistently applied.

Another constructive strategy for dealing with the stigma of diagnostic codes is to avoid using codes that you could clinically justify, but that are not intrinsic to the treatment plan.  Many treatments of the sexually variant are for depression, relationship conflicts, anxiety symptoms and substance problems that barely touch on paraphilias.  Given that clear diagnostic criteria for Hypersexual Disorder and Compulsive Sexual Behavior have never been created to separate these from anxiety disorders or impulse problems, those non-paraphilic codes may be ethically used instead.  If coding a paraphilia creates a social vulnerability for clients while failing to provide them with a compensatory benefit in access to treatment or improved services, clinicians are in an ethical bind to be fully professional and client-centered simultaneously.  I resolve such conflicts in favor of protecting the client, rather than protecting the diagnostic system.

Being accepting of kink does not free licensed professionals from knowing and adhering to the standard of care and explaining the ways in which their practices may differ from it, even where the kink community is directly confronting stigmatizing flaws in the diagnostic process like the one I described above.  For example, when I do not wish to use a diagnostic code so as to protect the client from having material placed in an electronic database, I need to make the choice with the client’s informed consent, rather than just declining to code and telling or not telling that client as I see fit.  In client-centered therapy, the client makes the decision about what code to use.

Symbols, Meaning and Behavior:

How clients present their kink to you as their therapist is important, but the meaning of their choices may not be as clear as they appear.  At the core of this problem is a theoretical conflict in the field that has persisted for over 100 years.  This debate is about whether behaviors and symbols have more or less standard and invariant meanings because of their contexts, or whether symbols are personal and unique, their contexts a function of individuality.  With the publication of The Interpretation of Dreams in 1900, Sigmund Freud claimed that he had discovered universal symbols of the Oedipus complex; the rise of competition, phallic pride, shame, or fears of castration were all determined by unconscious love and hatred for the same-gendered parent. Jung saw the Oedipus complex as a mere example of standard symbols that every person shared as part of a collective unconscious.  So both doctors presumed that similar behaviors in different clients could be presumed to have standard and interpretable meanings.  In the 1940’s with the rise of ego psychology, clients whose personal symbologies lacked conventionality came to be seen as extremely disturbed, even psychotic.

"My words mean what I want them to mean."  Not necessarily, but don't be put off by his untimely demise!

After 50 years of hegemony, psychoanalysis encountered a backlash from the popularization of psychology and the rise of the counter-culture.  Psychedelic experience challenged the idea that all symbols automatically meant the same thing.  Psychotomimetic experiences might be freeing and self-exploratory as one explored and even created personal symbologies.  Lucid dreaming meant the client might control one’s own dreams, rather than treating them as the royal road to discovering the unconscious.

The social constructionist position of this blog is a partial compromise between these positions.  While I do not believe that there is a collective unconscious, there is a zeitgeist around the individual that provides a constant stream of symbols and meanings.  Conventional meanings are privileged in this massive discourse, and some symbologies are so pervasive, such as green for go and red for stop, that clients can scarcely avoid being influenced by them.  But personal symbologies expropriate selectively from these, and similar behaviors cannot be assumed to have similar causes.  For Freud, acceptance of clients meant listening to the inevitability of their penis envies, their castration fears, and their guilty rivalries with their same-gendered parents.  For Jung, acceptance of clients meant interpreting their conflicts in terms of universal and transcendent symbols.  For social constructionism, acceptance means probing the clients’ accounts for how their sexual expression taps idiosyncratic, sub-cultural, and conventional understandings of the meaning of sexuality.  For Liang and Leery, exploring your unique experience was a rejection of societies authority to dictate what your symbols mean.  “Tune in! Turn on! Drop out!” demanded that you find transcendent meaning in your own consciousness, not the social context.  What is it that you accept or reject, and how do you know what is sexy, good, or painful?  It might be all up to you!

Timothy Leary (1920-96) was a promising personality theorist before grief and LSD made him an advocate for hallucinogenic drugs and the spirituality of idiosyncratic meanings

My suggestion is that there is no simple formula for a right answer.  Therapy explores the client’s personal symbolism, noting where common symbols have been expropriated from the social context and sharing understandings that are unique and idiosyncratic (all the while holding these up to the client’s conscious goals and contract for treatment).  Acceptance means continually testing whether clients really want what they say they want when they see new complications and implications of their desires.  It is strongly recommended that in therapy, the clinician use the language of the client.  In order to do that effectively, the clinician must understand their meanings, a problem I will address explicitly in a later post on the Tower of Babel.  But it will do not good to use the client’s language if you do not have a good understanding of the client’s personal symbols.   Often that language will be deliberately vague, politically incorrect or downright transgressive, or based on obviously false assumptions.  There are times and places where the most accepting of clinicians may need to point out such things, or provide specific psychoeducation about clinical, medical, or conventional social meanings.  All of this is made more effective from a position of understanding and accepting the client’s inner world and how it is represented.

Initial Presentation:

Clients who bring up their kink right away, for example, may be expressing considerable initial trust in you as a clinician.  Or they may be pressured by acute anxiety over the social consequences of its discovery.  They may lack the boundaries to withhold it, or have the boundaries, but feel overwhelmed by the emotional pressures to keep their feelings private.  They may already have been outed, and hope that rapid disclosure will end discrimination quickly.  Or they may find the burden of secrecy crushing and look to therapy as the first place they feel safe to have a face-to-face conversation.  Some will eroticize the therapy and look upon the discussion of their kink as an opportunity to seduce the therapist, be seduced by them, or simply use therapy as a place where it is safe to turn themselves on. Notice that all of these different initial presentations manifest conflicts about acceptance, but in very different ways.  Not only do problems with acceptance take many forms, but clients bring widely differing adaptations, skills, and defenses to the therapy in managing acceptance challenges.  That often means that in early sessions, many good interventions by the therapist are about establishing a safe environment for clients to tell their stories, and it is best to wait to interpret a client’s stories until you have a pretty good idea about what they mean.  In complicated or ambiguous initial presentations, that may mean contracting from session to session until you understand the client’s definition of the presenting problem and the contract and consent to treatment.

Acceptance can take several common forms as a therapeutic issue.  Because sexual expression is partially about private behavior, many clients set boundaries between their different social role performances.  Clients are often not used to talking about their sexual desires with anyone other than their partners (if that), and it is not uncommon for them to hide their kink from therapists in their initial presentation.  Since Sigmund Freud’s Three Contributions to a Theory of Sexuality in 1905, sexual science had known that kinky clients are often less repressed than so called ‘neurotic’ clients.  I guess there is something about knowing that what you desire is regarded with judgment and suspicion by the surrounding society that interferes with forgetting the dangers of what you like and its potential rejection!   It is a reality that kinky people lose jobs, relationship partners, family support, child custody, get forced into various conversion therapies, and have their personal affairs discussed in judgmental and public ways.  This means a certain reluctance to bring kinky interests up early in a treatment the client believes might be about something else is often a sign of healthy boundaries and rudimentary social skills and sensitivity.  As kink becomes less stigmatized, it is not only reasonable to expect fewer acceptance issues in treatment, but it also might lead to clients bringing it up earlier and in more matter-of-fact clinical presentations.

Sigmund Freud (1856-1939) suggested that clients suffering from 'perversions' were the opposite of neurotics.  Neurotics suffered from too much repression, 'perverts' were not repressed as much as society prescribed.  As Freud matured, he became increasingly critical of societal repression.  Perhaps Nazis had something to do with that.

Taking a sexual history, and explicitly asking about sexual variations during that history, can speed up bringing sexual variation into the conversation.  Taking a full sex history models and normalizes frank sexual discussion in treatment.  But it does not mean that clients are ready to disclose sexual material early on about which they are intensely conflicted.  If you ask too forcefully, or flat out include direct inquiries about kink in tests or intake forms, you may speed up revelations from clients before they are ready and even be experienced as laying an agenda on the client.  It is the responsibility of the clinician to exclude otherwise useful assessments from their repertory if they stigmatize sexual variation by conflating it with pathology, such as sex addiction measures that count BDSM as proof of ‘addiction.’  While variant behavior may involve “excessive” sexual expression, it is culturally incompetent to consistently interpret that it is an indicator of sex addiction.  Sometimes the frequency of sexual expression is an expression of general anxiety, fear of social judgments, or realistic worries about a partner’s feelings about the client’s sexuality, not ‘addiction.’

The reputation of kinky clients to be low on repression and unusually ready to speak of material that is typically repressed by others is evident in many cases, but not characteristic of all of them.  And being open and aware of aspects of one’s sexuality does not mean that clients may not be unaware of other aspects of their narratives or histories.  Creating an accepting environment for the issues of alternative sexuality means remaining open to these possibilities, but being prepared for exceptions.  The foremost proof of acceptance is listening to the client and reflecting accurately back what you have heard to them in ways that they can recognize.

Power and boundaries:

The early readiness of many clients with kink to talk about socially disapproved of sexuality often has provoked complaints from therapists that the kinky have ‘bad’ boundaries.  On the face of it, this is an open and shut case.  Hetero-normative people mostly avoid making public displays of their sexuality even though, if they did, their practices would be familiar, albeit out of place.  On the other hand, many sadomasochistic practices, even though the practices themselves risk opprobrium, also involve dramatic boundary violations as part of explicitly consensual play.  This does not mean that kinky people usually have ‘bad’ boundaries; new boundaries have been agreed to that are appropriate to the desires of participants and their cultural context.  It is quite possible to violate these new negotiated boundaries.  But romantic assumptions in hetero-normativity idealize naturalism, spontaneity, and imply that boundaries do not need to be articulated or negotiated.  In such situations, a therapist may feel invited to mediate what acceptable boundaries ought to be.  In most situations, this is a bad idea.  Even when a client directly requests help with boundaries, it is often wise to question closely why the help is sought and what difference the client imagines the therapist’s likely responses might make if the client were to act on them.  How does the client believe that the therapist would be better at this decision than the client?  Such therapist interpretations are, on the other hand, are likely to be needed in cases where clients with low social skills and difficulty internalizing social expectations make a direct request for this kind of help.  There are kinky people who have problems with their personal boundaries.  But for clients with ordinary or good social skills, the question of boundaries is best left to be a decision of values and self-control that the client needs to make.  Often, this type of decision involves the client’s need to face and work through some feelings of loss that the general society, partner, or parents lack the capacity to be more accepting of the client’s private feelings.

Because boundaries are often about power, client-centered therapists must be exceedingly careful about inadvertently power playing clients when calling them on boundary issues.  Such interpretations are essentially disciplinary when the therapist sides with social conventionality to try to modify a client’s behavior.  In such cases, the therapists must ask themselves, ‘What about my restatement of conventional wisdom is likely to be effective where the aggregation of similar sanctions in everyday life have failed?’  Interventions that target the client’s explicitly stated values and contract for treatment are much more effective.  The client is confronting their own values, rather than substituting yours for theirs.
Not all kinky clients play with power, but it is the broadly unifying theme in BDSM.  So it is routine to encounter power dynamics in treatment.  For all of psychotherapy’s sincere concern about keeping our conversations client-centered, the professional role is one of inherent power imbalance.  Clinicians are professionally trained, degreed, licensed, command fees, set their schedules, enjoy a substantial measure of earned privilege and social authority.  So the opportunities to idly, unconsciously, or deliberately power play clients in psychotherapy abound.  Braun-Harvey and Vigorito have eloquently articulated the dangers in Chapter 1 of Treating Out of Control Sexual Behavior:  Rethinking Sex Addiction.   Genuinely accepting therapy for sexually variant clients is not only alert to the problems of social stigma that surround variant desires and behavior, but actively seeks to level clinician’s power imbalance over clients in the office.  Clients are in more danger from us than we from them.

Acceptance is also often an issue for people with variant interests who are conflicted about joining available organized BDSM and poly organizations.  Although such organizations can be very accepting of sexual minorities and gender expressions, they do have hierarchies, rules, power differences, and orthodoxies of their own.  Client issues can magnify these, fight with them, and render the potential support of communities unavailable.  It is not just kinky communities that display acceptance issues.  Clients may resist of some of the common practices in these organizations, such as consensual non-monogamy, altered gender roles, exhibitionism, or the need to be an initiate in a new organization where one lacks power or status as a new and unproven member.  They may be intolerant of some roles they see others taking in kinky communities, or see behaviors that make them uncomfortable and fear that they will lose control of their values in such a group and come to desire behaviors that are currently off-limits for them.  In such instances, it is unwise to refer clients to otherwise safe and helpful kinky organizations until the client has contracted in therapy to become ready for a successful entry.  Just as remaining closeted has costs and consequences, so does the act of joining a private social club.  Acceptance means understanding what those expectations might be for the particular climate in the social group and arming the client with the information to make their own decision about joining.

It must be noted that clients come to treatment with widely varying degrees of acceptance of their own identities, fantasies, desire and behavior.  While the clinician may be clear about the degree client behaviors vary from the norms of the conventional and variant communities, the client may not be accepting of any of this.  Clients who embrace polyamory may come in tortured by jealousy and separation issues that are normative in the general society, but at extreme variance with the consensual non-monogamy community.  Clients may be in extreme pain because they cannot accept sexual fantasies that clinicians regard as typical.  Efforts to give clients permission to express their feelings or act on their fantasies may face clients who are extremely reluctant to license any such things.  Clients who are intensely conflicted about the conflicts between their desires, values and behaviors, and prone to externalizing defenses may not feel like therapy is neutral, and may have trouble establishing a sound therapeutic alliance.

Sometimes acceptance issues manifest as relationship conflict. Clients come into therapy together as romantic partnerships.  One partner craves a certain sexual behavior, the other(s) don’t want to include this in their sexual repertory, and they come in hoping the therapist will mediate the dispute.  It is sometimes possible to do this mediation, but desire differences were among the presenting problems sex therapists have regarded as challenging since Masters and Johnson first discovered they did not submit easily to behavioral therapy.  It can be hard to use sexual pleasure to solve desire differences when which activities bring pleasure aren’t shared.  But desire differences become entrenched and compounded when partners define desire differently, when romantic ideals leave them feeling that love should solve all problems, and that failure to do one’s favorite sexual behavior is ‘proof’ that your partner is not accepting.  This type of conflict is often about something more than acceptance, but becomes stuck on it.

"The Suitor"  Theodore Levinge (1848-1912)
As Esther Perel has repeatedly and wisely pointed out, problems of acceptance often hamstring couples because of the pervasive influence of romantic idealization in Western society.  This is frequently expressed in the lovely notion that love means infinite acceptance and that one can bridge any difference if one is loved deeply enough.  This adage is troublesome because it is not true that love means infinite acceptance, and that acceptance does not mean that anyone can be taught to enjoy all sexual activities.  Acceptance does not imply that differences will evaporate, loss does not need to be tolerated, or that loving partners can stretch their self-concepts and eroticism to embrace all behaviors.  Romanticism implies that acceptance is an all or nothing proposition.  Realistic social acceptance instead suggests that we can accept more things than we can do, and that even the most experimental and open-minded partners are going to have limits.  It is an acceptance issue when one partner says to the other(s), ‘If you love me, you’d do this thing with me’ and the partner(s) reply, ‘If you loved me, you wouldn’t ask!’  Urging more acceptance does not often break such deadlocks:  acceptance cuts both ways in such arguments.  In therapy, this must often lead to another confrontation with the implications of romantic idealization:  love and sex do not automatically or entirely erase the need to face feelings of loss.

No matter how judgmental the external world is, acceptance issues often become internalized.  It is difficult to be self-accepting if one’s passions are shared by few, provoke disgust from others, make one the butt of jokes and jibes, or if you hate them yourself.  Internalized shame, fear or disgust at a client’s own desire is often the focus of therapeutic attention.  Different therapies handle this ‘internalized kinkophobia’ very different ways.  In ‘sex addiction’ therapies, labeling kinks as addictions is a common strategy.  Quality sex-positive treatment opposes this as alienating clients from their own desires by relabeling them as a kind of pathology -- an ‘addiction.’  Not only is the ordinary neurobiology of attraction making use of the rewards circuitry of our brains to motivate us to focus upon and pursue a partner, but that same circuitry is involved in many other reward-seeking adaptations.  Calling such behavior an ‘addiction’ artificially sides with therapeutic solutions that seek to reduce and control sex behaviors rather than those that encourage their expression.  This may seem reasonable when behavior is illegal, intensely socially stigmatized and the client is intensely judgmental, but can pose real problems when it comes time to license other sexual expression which the client deems to be more appropriate.  Often sex addiction treatments require the client to accept a deviant or devalued label as the precondition to treatment, leaving the problem of excessive shame and self-criticism untreated.  Where possible, clients need to be taught to manage their feelings in ways that prevent shame from inhibiting sexual satisfactions, rather than harnessing sexual shame to stop behaviors.

Echo and Narcissus by John William Waterhouse (1849-1917) Another painting in the Romantic tradition.  In modern clinical theory, narcissism is far from romanticized!

Self-acceptance also has important implications for client self-centeredness and narcissism.   It can be quite difficult to maintain a healthy self-concept when you imagine judgment and ostracism for your values and behavior.  Indeed, social stigma is administered precisely to help conventional members of a group to refrain from prohibited behavior by inculcating the belief that no good person would do such things.  Most of us refrain from bank robbery not because we lack a good plan for stealing money, but because we do not care to think of ourselves as bank robbers.  So internal conflict about one’s kink is likely to take a considerable toll on self-acceptance.  Ironically, this can lead to grandiose, domineering, haughty, and intensely self-centered behavior.  While this is not a perfect definition of the clinical concept of narcissistic personality disorder, it does conform well to the general social concept of narcissism.  And narcissistic defenses are commonly encountered in persons who are unable to get enough recognition and satisfaction from ordinary activities.  No well-designed study has been conducted and replicated demonstrating that the kinky are, as a group, more narcissistic than the general population, but clinical examples are out there to be found.  Narcissism often involves inordinate demands on others, boundary violations and feelings of entitlement that seem exaggerated.  Demanding exaggerated submission or high pain tolerance from one’s partner might be examples.   This can come from a diagnosable personality disorder, and/or from problems recognizing the needs of others through the din of the client’s neediness.   It is important to remember that clients who have long dwelt in a fantasy world, but have been unable to bring themselves to act on those fantasies, are very likely to show self-concept problems and judge themselves on the discrepancy between their dreamed of and achieved sexual adventures.  Given the risk of stigma in diagnosing such already-vulnerable people, diagnostic labels can potentially do more harm than good and therefore should be considered a last resort.  Process interpretations that focus on empathy with others or developing ways to recognize social acceptance are far more likely to be helpful to such folk.

This section would not be complete without a word about transference.  This blog has already taken up extreme countertransference reactions, which is about how the therapist is feeling.  Like The Force in the Star Wars mythology, the client’s transference pervades everything we do in therapy.  If acceptance can underlie so many different presentations in therapy, how is the clinician to decide where to intervene to help kinky clients?  Often that answer lies in the client’s process of relating to the therapist and how the therapists feels about the client’s narrative.  Teaching therapists how to use transference has gone out of fashion as society and the field have instead become enamored of cognitive behavioral techniques.  These techniques work great for clients who start with pretty good affective and behavioral control, but for cognitive behavioral therapy to work, the client and therapist must know and agree what the cognitive rewards are for the client and must be able to design interventions that use them.  When clients poorly understand their own values and rewards, they tend to enact feelings rather than deliberately discussing them in treatment.  Understanding how the client makes you feel and how they are feeling in therapy become the bases for understanding whether acceptance is the main issue, or whether it is just a stand-in for something more important that is bothering the client.

"Good fences make good neighbors" R Frost.  Boundaries are important.  On the other hand, the Great Wall was built because China did not have good neighbors.  It was designed to make retreat difficult for mounter raiders, rather than to seal them out.  It is an important case study in the many ways boundaries can function.
Acceptance of kink requires the therapist to set boundaries on what work they are prepared to undertake. Many therapists are not set up with the proper training and context to handle non-consensual behavior or clients requesting help with criminal sexual preferences.  Some decide not to work with co-morbid conditions such as psychosis, substance abuse, personality disorders or certain mental disabilities.  Some work with kink, but must decline cases that involve edge play that upsets or frightens the therapist too much to professionally treat such cases effectively.  Others refer out clients to community specialists whose expertise is better suited to specific client problems or conditions.  Knowing one’s own limits as a therapist is perhaps the toughest and most profound expression of acceptance possible, for it properly places the welfare of clients first even in the face of financial self-interest, ego, or the therapist’s own self-concept.

The history of therapeutic work in this field shows substantial risk from well-intentioned clinicians listening selectively to clients, siding with one dimension of an ambivalent and ambiguous client presentation and urging the client to accept the doctor’s expert interpretations.  In these stories, even when the clinician proves correct in one case, the theory is deployed in subsequent cases where the fit is not so good, and the professional rewards for greater glory and the wish to help more clients leads to over-generalization.  Castration anxiety, masculine protest, evolutionary fitness or degeneracy, identification with the aggressor, poorly internalized identifications: all these and many more have been evoked to explain kinks.  In my experience, explaining any individual’s kink is a cottage industry, not an opportunity for grand theory construction.  Clients chose their kinks because, no matter how deviant, dangerous, or socially outre they might be, they are the best route to sexual satisfaction, identity construction, human closeness or spiritual connection they can manage.  However painful the client’s adaptation may be, the struggle with stigma is more painful.  For therapy to be of any value, therapy needs to avoid being yet another venue in which stigma is inflicted.

American Psychiatric Association (2013)  Diagnostic and Statistical Manual of Mental Disorders- 5. American Psychiatric Publishing.

Freud, S (1900) The Interpretation of Dreams SE, 4-5.

Freud, S (1905) Three Contributions to a Theory of Sexuality SE, 7: 125-245.

Braun-Harvey, D. and Vigorito, M (2015) Treating Out of Control Sexual Behavior:  Rethinking Sex Addiction. New York: Springer Publishing.

Perel, E (2007) Mating in Captivity: Unlocking Erotic Intelligence. New York:  Harper Collins

© Russell J Stambaugh, January 2016, Ann Arbor MI, All rights reserved