Challenges to the Diagnosis and New Classifications

The idea of sexuality as a disease entity was undermined, in part, by a better understanding of sexually transmitted diseases and their sequelae, which came about during the last part of the nineteenth century. The discovery and acceptance of the germ theory also undermined the belief that sexual activity caused ailments such as tuberculosis. Medicine, however, did not abandon its emphasis on the disease potential of nonprocreative sex. It was simply placed in another category.

The latter is usually associated with the efforts of Carl Westphal, professor of psychiatry at the University of Berlin, who was influenced by the German homosexual movement. Led by such individuals as Karl Heinrich Ulrichs (1881) and Karoly Kertbenny (1905), that movement sought to establish that homosexuality was inborn. In 1869 Carl Westphal had published the case histories of a young woman who from her earliest years liked to dress as a boy and of a young man who liked to dress as a woman. From these cases he argued that sexual abnormality was congenital, not acquired. He called the phenomenon "contrary sexual feeling" and insisted that, although neurotic elements were present in such individuals, they were not insane (Bullough 1989).

If the "contrary sexual feeling" was inborn, was it also incurable? Jean Martin Charcot, the director of the Salpetrifcre Hospital, and a colleague had attempted to cure several cases of "contrary sexual instinct" or "sexual inversion" with only modest success and concluded in an 1882 publication that inversion was a constitutional nervous weakness due to hereditary degeneration.

This concept was further developed by Paul Moreau (1887), who theorized that in addition to the usual senses of sight, hearing, touch, taste, and feeling, humans had a sixth sense, a genital sense that, like the others, could suffer physical or psychic injury without damage to the other senses. This propensity to injury stemmed from either a hereditary taint or a predisposition to perversion provoked by certain other factors such as age, proverty, constitution, temperament, and seasons of the year. The result could be sexual inversion, nymphomania, satyriasis, bestiality, rape, or profanation of corpses. The only way to deal with these individuals so afflicted was to turn them over to asylums, where they could be cared for. Not everyone agreed with this, however.

One of the early researchers who was most important in influencing public opinion was Richard von Krafft-Ebing, whose Psychopathia Sexualis, first published in 1886, remained in print until the 1980s. He combined several prevailing nineteenth-century theories to explain sexual "perversion": (1) the idea that disease was caused by the physical nervous system, (2) the notion that there were often hereditary defects in this system, and (3) the concept of degeneracy. Civilization, he claimed, was possible only because lust had been tempered by altruism and restraint, based on the knowledge that sexual excess weakened the body. The purpose of sex was reproduction, and sexual activities not undertaken with this ultimate purpose in mind were "unnatural practices" and a perversion of the sexual instinct. Though Krafft-Ebing distinguished between innate and acquired perversion, even acquired perversion existed only when there was hereditary weakness in the nervous system, and onanism was a causal factor in this.

Differing from Krafft-Ebing somewhat was Sig-mund Freud (1913, 1922a, 1922b, 1924-50, 1938), his younger and even more influential contemporary. Freud agreed that variant sexual behavior came from misdirected sexual drives, but he held that the cause of the misdirection lay in the nervous system and the mind through which the instinctual drive operated. Though Freud himself paid comparatively little attention to most forms of variant sexual behavior, his followers seized on his concepts to emphasize environmental and accidental causes of variant sexual impulses.

Later behaviorists carried this kind of thinking to an extreme, so that the practical result of both Freud-ianism and the learning psychologies was to suggest that everyone had the ability to channel his or her drives. Although they differed about specific factors, followers of Freud usually agreed that deviant sexu ality was caused by environmental rather than constitutional factors and was, by implication, curable. Some groups, however, still looked upon it as inborn, though treatable if not curable. In any case, variations in sexual behavior were now regarded as coming under the jurisdiction of psychiatrists, and there they have remained.

Certain forms of variant sexuality, such as homosexuality, are no longer regarded as an illness, and masturbation is considered as normal behavior. Much of this latest change in attitude grew out of challenges to the research methodologies and theories that had originally classified much of human sexual behavior as an illness.

One challenge was made by Alfred Kinsey and his colleagues (1948), whose data on what actually constituted sexual behavior resulted in a redefinition of some of the norms. A second kind of challenge was aimed at the research of earlier physicians and psychiatrists. Most of the theorizing of Tissot and his successors had been rejected as germ theory gained credence and the endocrinological forces involved in sexuality came to be understood. This left psychiatrists as the only major group to maintain the contention that deviant sexual behavior could be illness. Prominent among them were psychoanalysts, who were attacked by a number of researchers in the 1960s and 1970s for working with small samples, not using control groups, and not taking into account cultural differences.

Attitudes toward nonprocreative sex also changed with the widespread adoption of contraceptives and the acknowledgement that sex was an enjoyable activity for both men and women. The recognition that people engaged in sex for pleasure as well as for procreation also weakened hostility to forms of sexual activity other than conventional heterosexual intercourse and raised questions about medical categorization. The knowledge that other cultures and peoples had attitudes toward sex that were radically different from those of Westerners was also important in challenging the western European and U.S. notion of sexual deviation as disease. Finally, in 1974 homosexuality was eliminated from the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association as a category of illness.

Not all forms of "deviant" sexual behavior, however, have been removed from the DSM, and in fact there remains a strong tendency to categorize as ill individuals who are pedophiles, exhibitionists, or necrophiliacs and those who engage in numerous other more or less forbidden sexual activities. There is also a countermovement as of this writing to estab lish a new category — that of sexually compulsive people - perhaps to get them into the offices of behavioral psychologists to be treated through behavior modification. Thus, although theories have changed and challenges to previous categorizations have been mounted, there remains a strong belief in the helping professions that socially unacceptable sexual behavior is an illness or at least a behavior problem of one sort or another. Since the time of Tissot these professions have essentially replaced religion in determining what sexual activity is permissible and what should continue to be stigmatized.

Vern L. Bullough

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