Review of Removing Homosexuality and Masturbation from the List of Sexual Dysfunctions in DSM

Received: 03-Jun-2021 Accepted Date: Jun 17, 2021 ; Published: 24-Jun-2021, DOI: 10.3371/CSRP.MS.062421

Introduction

Since 1973, homosexuality and masturbation have been considered as normal and healthy behaviors, so removed from DSM. The purpose of this article is to review the reasons for this decision. This article attempts to answer the question of whether homosexuality and masturbation are really healthy behaviors. It is clear that the conclusion will affect the ways in which clinicians deal with clients who complain of these conditions. Educational planning will also be affected.

Literature Review

Evidence acquisition

We tried to provide enough accurate data about different perspectives on homosexuality and masturbation, the evolution of these perspectives, the history of removing these two conditions from DSM, the real reasons and the announced reasons for doing so, as well as real indicators for healthy and unhealthy situations, in order to conclude, whether it is correct and scientific to consider these two behaviors as healthy situations so remove them from DSM. Required data was obtained by reviewing a significant volume of related scientific books, articles and research, which lasted from 2015 to 2021.

Discussion

Sex masturbation definition

Sex masturbation is the most prevalent sexual perversion and can be defined as the act of touching or otherwise stimulating one's own body, particularly one's genitals, for the purpose of sexual pleasure and/or orgasm. [1]. People who do this may be able to have an orgasm by stimulating and manipulating their sensitive organs, imagining lustful and stimulating scenes, stimulating their penis or vagina sexually by imagining a person who wants to be his/her partner and by other abnormal methods.

Evolution of perspectives about masturbation

Freud believed that neurasthenia (weakness of the nerves) is created as a result of excessive masturbating [2]. In the early years of the twentieth century, masturbatory insanity was a common diagnosis in hospitals for the criminally insane in the United States [3]. In DSM-1 (1952), masturbation was considered as a mental illness, but after some time and in its newer versions; this sexual activity was removed from the list of mental illnesses. The most important reason was high prevalence of masturbation among individuals. According to researchers such as Alfred Kinsey almost all men and three quarters of all women have done this procedure once in their lifetime. So that some authors argued that masturbation is a natural progression of the object-related sexual behavior. They have also indicated that masturbating has no side effects [3]. Renshaw also claimed from a medical point of view that masturbation had no physical or psychological adverse effects and did not lead to death or physical disability [4].

In a few words, two major reasons for removing masturbation from the list of disorders are as follows:

a. High prevalence of masturbation in human society

b. Lack of side effects.

Homosexuality definition

According to the Webster dictionary, homosexuality is defined as a sexual attraction to (or sexual relations with) people of the same sex. Homosexuals may also be male (gay) or female (lesbian). Some people may also be at the same time sexually oriented towards the same sex or opposite sex; in this case, they are called bisexuals. But in any case, all of these groups would have homosexual behavior.

Evolution of perspectives about homosexuality

In Europe, in the first half of the nineteenth century, scientific studies of homosexuality began as a disorder. Bergler believed that homosexuality was a neuroticism condition, not one of the natural ways to live. From his point of view, this type of neuroticism is very intense and involves the inevitable self-destruction that affects all the personality and emanates from a kind of masochistic conflict with the mother at the infancy period [5]. In the early twentieth century, psychiatrists considered homosexuality an incurable illness. In DSM-I, homosexuality was classified as a sexual behavior disorder. In 1973, the American Psychiatric Association voted to eliminate homosexuality from the list of mental illnesses, provided that the person is comfortable with his/ her sexual orientation and does not feel distressed about that. The decision was confirmed by a 58% majority of 10,000 voting members! So, that the decision was not based on official scientific investigations but was based on a majority desire. This happened after the social movements supporting gays and their pressures on the American Psychiatric Association [6-10]. As a result, homosexuals were able to find a way to get rid of psychiatric interventions and social labels. Studies as the one presented by Hooker supported this view. He claimed that the Rorschach test, MMPI, and the Thematic Apperception Test (TAT) did not show any difference between gay and normal people [11]. These findings have led homosexuals to be considered as normal functioning people. In addition, some studies showed that most homosexuals have no problem with their sexual orientation [7]. Kinsey, Pomeroy, and Martin point out that there is evidence that homosexuality is associated with left-handedness, as well as a greater number of older brothers. They believe there should be hormonal, brain, and genetic differences between homosexuals and others because lefthandedness is related to the genes, brain evolution, and the parental hormones. In addition, homosexuals show the same pattern of fingers length. On the other hand, if a man has more brothers older than himself, the more likely he is to become homosexual. From the perspective of these authors, it can be assumed that the mother, due to the fact that she had developed more males fetal in her womb, had more anti-male antibodies that lower the testosterone levels in the last male's fetus and caused homosexual tendencies [12].

Some homosexuality advocates may point out that homosexual behaviors have been seen in animals, so it's natural and should be considered a normal attitude in human beings too [13]. Other people also claimed that because homosexuality is an untreatable situation, so it should be considered as normal behavior [14].

In summary, the reasons why the American Psychiatric Association was persuaded to remove homosexuality from the list of sexual behavior disorders are as follows:

a. At least some homosexuals have no problem with their sexual orientation, and they do not feel annoyed.

b. The various functions of homosexuals are not damaged.

c. Homosexuality has biological roots.

d. Homosexual behaviors have been seen in animals occasionally.

e. Homosexuality is often untreatable or cureless.

Reviewing indicators of healthy and unhealthy status

As the American Psychiatric Association stated in DSM-5 that “mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above” [15]. APA also emphasizes on dsm5 that “The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cul tures, social settings, and families. Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians” [15]. In conclusion, the American Psychiatric Association considers four characteristics for mental disorders, including distress, disability (defects in some important areas of life, and social and occupational functions), dysfunction (behavioral disturbance and inefficiency), and violations of social norms. It has been claimed that some sexual behaviors have been removed from the list of disorders due to the lack of any of the four above characteristics. As mentioned previously, other arguments, such as the statistical prevalence and the biological etiology of these disorders, were effective. In the following sections, I will review and critique the application of these criteria to masturbation and homosexuality.

Feeling healthy vs. distress: One of the criteria used to distinguish between normal and abnormal conditions is whether the person feels well-being or not. In other words, is the person himself comfortable with the situation? Of course, a person suffering from a situation or feeling lack of health should be considered sick and in need of a therapeutic intervention although not physically problematic. But the opposite is not true, and the mere feeling of health does not mean complete health and no need for intervention. For example, someone may have a dangerous disease, such as diabetes, which, if left untreated, endanger many body organs and can ultimately kill, but many diabetics have no distress about their illness or do not even know that their blood glucose is elevated. They often find out about their diabetes during periodic or random blood tests. Many people also have coronary artery stenosis and are at risk for heart attack, but they do not have any annoying symptoms and are unaware of their problem [16]. By no logic can such people be considered healthy or avoid therapeutic intervention for them. Also, many people with the prodrome of manic episodes may not feel dissatisfaction with their condition and, conversely, may feel healthier than ever [17]. This is also true for many people with personality disorders. There symptoms are usually ego-syntonic. In other words, most people with personality disorders are not distressed about their condition and often refuse to be treated [3]. One of the characteristics of people with antisocial personality disorder is that patients lack remorse for their actions, appear to lack a conscience and are unable to feel guilt [18]. In other words, they do not feel distressed about their harassing behaviors. Should we consider these people normal and avoid helping them and repelling their evil from society? Obviously, people with antisocial personality disorder should be fined and sometimes penalized to avoid community harm if they do not want to be given therapeutic assistance. Another example is patients with Obsessive-Compulsive Personality Disorder (OCPD). They also do not consider themselves ill and do not complain about their mental and behavioral status. These patients, on the other hand, consider normal people who do not idealize like them and do not conform to their extremist order as the cause of their suffering. OCPD characteristics and behaviors are known as ego-syntonic, as people with this disorder view them as suitable and correct. On the other hand, the main features of perfectionism and inflexibility can result in considerable suffering in an individual with OCPD as a result of the associated need for control [19]. So, in fact, these patients are not under pressure from their situation, but they are under pressure from others not adapting to them, just as homosexuals may be dissatisfied with the way others treat them, not their own. Therefore, even if homosexuals or people who masturbate do not feel uncomfortable with their issue, this is not enough to consider these situations normal or to avoid therapeutic interventions and this is a very clear issue.

Dysfunction and disability: Another important criterion for identifying normal conditions from abnormal ones is to create or not to create impairment in the optimal performance of the individual. One of the most important criteria in distinguishing normal from abnormal conditions is whether or not a person has dysfunction or disability. Realistically, this is the most important and true indicator of health because the spirit of health is optimal performance. But are the functions of homosexuals and those with masturbation really normal as Hooker claimed [11]? Do these behaviors have any physical or psychological adverse effects? Several studies have shown that homosexuals have more mental health problems than heterosexual people; they suffer from depression, generalized anxiety disorder, substance abuse, and suicidal ideation more than normal people. Although these differences are sometimes attributed to social discrimination against homosexuals, it has not been proved through research [20]. Feldman and Meyer showed that eating disorders are more common among homosexuals than others [21]. The American College of Pediatricians reviewed a significant number of studies and concluded that children raised by homosexual parents may be at increased risk of emotional, mental, and even physical harm [22]. Studies that show no difference between the two groups of children have been criticized because of problems in their methodologies and lack of scientific standards [23]. On the other hand, Judson, Penely, Robinson, and Smith showed that sexually transmitted infections among gay men are more prevalent than heterosexual men [24]. In addition, passive gay men gradually lose the structure of the anal canal, lose the anal sphincter performance and develop fecal incontinence [25]. Also, hemorrhoids, fissures, sexually transmitted disorders and condylomata acuminata are more common in gays than others [26]. Hemorrhoids are severe in these people and are associated with prolapse, fasciitis, and fissure of the anus and rupture of the intestine. Urethritis, herpes of the rectum and anus, amoebiasis, giardiasis, shigellosis, typhoid fever, pinworm and hepatitis A and B has been diagnosed in men as negative results of homosexual intercourse [27]. It is obvious that such complications are due to non-anatomical and non-physiological application of the body organs. This principle applies to all organs of the body, and abnormal uses of the organs cause them to be damaged. In other words, each organ, such as the genitals, rectum, or anal sphincter, is made for a specific purpose, and if it is used for another purpose, it would be reasonable to expect harm.

On the other hand, there are also many functional problems for people with masturbation. They are often not satisfied with a normal sexual relationship, and I am facing with numerous examples of this kind of clients. This observation has been widely confirmed in experimental research. Das, Parish and Laumann, Brody and Costa, Gerressu, Mercer, Graham, Wellings and Johnson, Lau, Cheng, Wang and Yang and Nutter and Condron showed that men who masturbated had lower levels of sexual satisfaction than men who did not [28-32]. Also, Shaeer, Shaeer and Shaeer, Das, Brody and Costa, Weiss and Brody, Gerressu and Lau showed that women with masturbation also had lower levels of sexual satisfaction than other women [28-31,33,34]. After reviewing the data of some masturbation advocates, Wakefield concluded that the claim that women's masturbation was helpful in improving their or their partner's orgasm was not true [35]. Brody and Costa and Brody found that as the frequency of masturbation increased, dissatisfaction with normal sex increased, and interest in the spouse decreased [29,36]. In addition, Costa showed that the risk of prostate cancer increases in men who masturbate. He also found that masturbation was associated with reduced prostate normal function and decreased waste clearance. Again he showed that masturbation is related to psychopathology [37]. On the other hand, Costa and Brody, Brody and Weiss, Brody and Brody and Costa showed that those who masturbate have lower levels of physical and mental health than those who have only normal sex [29,36,38-40]. Also, Brody and Costa found that people with masturbation had lower life satisfaction levels than those with normal sexual activity [29]. Cordner reported masturbation in some cases resulted in sudden death due to asphyxia (lack of oxygen leading to suffocation) [41]. Autoerotic asphyxiation is defined in Merriam-Webster's dictionary as: “a state of asphyxia intentionally induced (as by smothering or strangling oneself) so as to heighten sexual arousal during masturbation”. According to Gosink and Jumbelic, about 1,000 people die each year in the United States from asphyxia due to masturbation [42]. Doychinov and Markova and Staneva reported a case in which an 18-year-old male strangled himself with a leather belt. Evidence showed that he did not intend to commit suicide but had suffocated due to autoerotic asphyxiation. Because he had no history of bisexuality other than the history of bisexuality that led to suicide, and on the other hand, pornographic images were found around him on the ground, and he wore women's clothes at the time of his death [43]. McLennan, Sekula-Perlman, Lippstone and Callery reported three deaths from autoerotic asphyxiation in which propane gas was used to cause asphyxia [44]. Marc, Chadly and Durigon reported a case in which a 40-year-old woman developed an air embolism while masturbating using a foreign object and then died [45]. Other objective examples of dangerous and sometimes fatal complications of masturbation have been seen, such as Fournier's gangrene (necrotizing perineal infection), the retention of foreign bodies in the vagina, and the development of infection and tumor-like tissue and acute peritonitis due to the use of a foreign body in the vagina [46-48]. Calabrò, Galì, Marino and Bramanti showed that obsessive masturbation can lead to lymphedema in the male genitalia [49]. Therefore, it is very clear that the advice of some psychologists to their patients about masturbating, which is done to justify emotional discharge or satisfaction of sexual needs, is unprofessional and will expose clients to risks. We saw how the claim that "masturbation has no physical and psychological side-effects"! Which is regularly propagated by some people, it is not documented at all, and it has no scientific basis. On the other hand, it is very likely that such advice will lead clients to obsessive and addictive masturbation (which even the DSM-5 acknowledges to be abnormal) and double their problems. Because, according to the findings of physiological psychology, any behavior that can strongly stimulate the accumbence nucleus (which is the most powerful reward center in the brain) will have the potential for addiction [50]. Because masturbation, like any other sexual activity, stimulates the nucleus accumbens [51], and on the other hand, masturbation is a fully available activity, it is easily repetitive, so the risk of addiction is higher than normal sexual activity. Finally, given that, sexual behaviors such as homosexuality and masturbation are obviously nonanatomical and non-physiologic applications of the genital system, and in the presence of such behaviors, a sexual performance that is naturally needed in order to reproduce and consolidate family is impaired. Therefore, such behaviors clearly disrupt the function of a person in many areas of life (sexual function, physical well-being, family formation, parenting and mental health, etc.), and the claim that the function of these individuals is normal at least in many aspects of life is not true, and the normality of such behaviors is faced with a serious problem.

Violation of social norms: Social norms will be determined by the general judgment of the people or, in other words, the custom. As stated in the 2001 WHO report, mental health has a cultural-related definition [52]. In other words, what is perceived as normal in one culture may need to be considered inappropriate in another culture. With this statement, even if we consider the decision of the American Psychiatric Association for their own society as a right and sound decision (which is not, and some of the reasons for it was mentioned), for Muslim societies, masturbation and homosexuality that are perceived to be abnormal in the cultural view of these societies, should remain on the list of sexual behavior disorders.

The DSM-5 is entitled “Cultural Issues” as follows: “Mental disorders are defined in relation to cultural, social, and familial norms and values. Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, revised, and recreated within the family and other social systems and institutions. Diagnostic assessment must therefore consider whether an individual's experiences, symptoms, and behaviors differ from sociocultural norms and lead to difficulties in adaptation in the cultures of origin and in specific social or familial contexts. Key aspects of culture relevant to diagnostic classification and assessment have been considered in the development of DSM-5” [15].

The American Psychiatric Association has so far taken a realistic view and considered “maladaptive” behavior to the cultural environment to be important in diagnosing disorders. But it seems that the political and social pressures of individuals and groups such as homosexuals have worked, and that the American Psychiatric Association has finally been caught up in the trade-off between accepting and rejecting social and cultural values because a few pages later in the DSM-5, the following definition of mental disorder is given: “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above (dysfunction in the psychological, biological, or developmental processes)” [15].

Although the latter statement potentially contradicts the first view of the DSM-5, in other words, it could have examples to the contrary, even if we accept the second statement, it still fails to solve the problem of homosexuality and masturbation. Because in the following lines on the subject of “Etiology” we will see why homosexuality and masturbation are caused by underlying psychological, biological or other developmental disorders in the individual and, in other words, have pathological origins.

In any case, one cannot ignore the fact that homosexuality is clearly maladaptive because, except for a small minority, the general public of the world does not show that tendency, but does not accept it and may be disgusted with the idea. Although masturbation is widespread, it is a culturally maladaptive behavior, at least in Muslim and a number of other communities.

Murphy points out that the DSM-5, while trying to address the cultural diversity of the people of the world through reform, tends to see Western psychology as a “human norm,” as in its predecessor [53]. This is an example of the ideological and value basis of the so-called “science”.

Statistical measure: What is the true measure of normal and healthy conditions compared with abnormal and unhealthy ones? Obviously, impaired normal functioning can be considered an abnormal and unhealthy condition, but sometimes it is difficult to determine which condition has caused functioning impairment. In such a situation, an alternative method for explaining abnormal situations can be used, and this method is a statistical explanation, which means that a large random sample of society is selected and the relevant status is measured in them. Then, two standard deviations which are higher and lower than the mean normal curve are considered normal, and the rest are regarded as abnormal. In other words, normality and abnormality are explained by the outbreak, and more common situations are more normal (Figure 1) [54].

Figure 1: Normal curve standard distribution.

To clarify the issue, pay attention to the following example: The determination of normal blood pressure was first performed using statistical explanation because at that time there was not enough empirical evidence to show what level of the blood pressure can harm. Examination of a relatively large sample (2400 people) showed that normal human systolic blood pressure up to 140 mm Hg is normal [55]. But later experimental evidence showed that even systolic blood pressure of 120 mm Hg was capable of cardiovascular damage and considered this level of blood pressure to be a “precursor to hypertension” [56,57]. Therefore, contrary to the statistical standard, completely normal systolic blood pressure is considered below 120 mm Hg.

Thus, if after a while, it is observed that what was considered normal according to the outbreak was actually caused, functional damage, the explanation of the normal situation should be revised because the statistical method is only suitable when it is not possible to detect dysfunction. In fact, the high prevalence of an impairment is not necessarily related to the normality and naturalness of it, for example, if for any reason the prevalence of depression among people is very high and everyone at least once in their lifetime suffered from depression, depression cannot be considered normal and natural at all, and it cannot be removed from the list of mental disorders, as the “cold”, while still afflicting almost everyone, but remains on the list of diseases. Indeed, due to the high prevalence, depression is called mental cold, but nobody claims that it should be removed from the list of psychiatric disorders, perhaps because there are no social and political pressures and no individual or collective interests. Also, if in the future AIDS is so prevalent that the majority of people become infected; it cannot be removed from the list of abnormalities. With the above explanation, the high incidence of masturbation cannot be sufficient for its naturalness. Although, masturbation prevalence may have changed repeatedly during the various periods of human life and these changes may have been related to alterations in lifestyle and culture of mankind. In fact, there is no evidence that masturbating is necessarily inherent in nature. The reason for this conjecture is that some tribes and races do not recognize homosexuality and masturbation at all and there is no name for these behaviors in their culture, and they laugh if such behaviors are described to them [58].

Etiology: Another criterion that needs to be considered for judgment about normality or abnormality of a condition is its normal or abnormal origin or etiology. Obviously, we do not expect normal results derived from the abnormal situation.

As we have seen, in defending the view that homosexuality should be regarded as a normal state, the potential biological roots of homosexuality are cited. Although there is still a long way to go to ensure the biological roots for homosexuality, but, first, I would like to say it is obvious that the biologic origin does not indicate a condition to be normal. It becomes clearer with examples. Many disorders have biologic roots and are inherited as structural and functional disorders of the brain, including OCD, schizophrenia, seasonal depression, bipolar mood disorders etc. [59].

Secondly, the biological roots that are claimed for homosexuality all have pathological aspects. The hormonal origin considered for homosexuality, even if true, is nothing but a form of deviation from the natural state that is due to the repeated exposure of pregnant women to fetal testosterone that result in excessive sensitization of the mother's immune system to the hormone, and causes abnormal antibody production by the mother's body against the fetus so it deviates the development of the embryonic hormone system from the normal state. Just like the Rh- mother who in repeated pregnancies becomes sensitive to the Rh+ antigen of subsequent fetuses and causes jaundice in the baby by improper production of antibodies against fetal red blood cells [60].

Thus, the anti-testosterone antibody hypothesis about homosexuality, even if it finds evidence, clearly describes a pathological process. Obviously, we do not expect normal results from pathological or abnormal conditions.

In the case of masturbation, determining its origin requires research. In the research that we conducted in this regard, the relationship of obsessive compulsion, impulsivity, spiritual well-being and self-esteem with sex masturbation was investigated in the students of Shahid Chamran University of Ahvaz [61]. To this end, 285 students were selected by cluster random sampling method, and they completed 5 obsessive-compulsive, impulsive, spiritual, self-esteem and researcher-made questionnaire on masturbation. The research design was correlational, and the data were analyzed by using Pearson correlation coefficient and multivariate regression analysis. The findings of the research showed a significant positive relationship between obsession/compulsion and impulsivity with sex masturbation and a negative significant relationship between spiritual health and self-esteem with sex masturbation (Table 1). Regression analysis coefficients with frequent entry method were significant for a linear combination of obsession/compulsion, impulsivity, spiritual well-being and self-esteem variables with sex masturbation in a level less than 0.001 (Table 2). The results of regression analysis on sex masturbation scoring with repeated entry method showed that the predictor variables explained 27 percent of the variance of sex masturbation (Table 2). The results of the stepwise regression analysis show that among the predictor variables of sex masturbation, spiritual well-being, obsession/compulsion and impulsivity are the most important factors in the explanation of sex masturbation variance (Table 3). According to the findings the most important predictor is spiritual well-being; in fact, spiritual health can be a protective factor against sex masturbation.

Table 1: Pearson correlation coefficient of predictor variables with sexual masturbation scale.

Table 2: Regression coefficients of predictor psychological variables with sexual masturbation score using frequent entry method

Table 3: Regression coefficients of predictor psychological variables with masturbation score using stepwise method.

As mentioned earlier, it is obviously expected that what may be of pathological origin cannot be normal, and from this perspective, placing masturbation in the normal range of behaviors is problematic.

False criterions: In the field of psychology and medicine, the existence of a condition in animals has not been considered as a reason for categorizing that condition as a normal state in human beings. If so, diseases such as “rabies” and “congenital defects” should be considered normal in human beings. Also, conditions such as “drug addiction” or “learned helplessness” that may be seen in animals should be considered normal in human beings and no intervention should be applied for these conditions. So, homosexuality could not be considered normal even if seen in animals, because animals also get sick!

As we have seen, homosexuality is claimed to be incurable and therefore to be considered natural. Although there are reports of successful treatment of homosexuality [14], but it is not rational that intractability or incurability be considered an index for normal conditions. Many of disorders were cureless in the past that are curable today. In addition there are many of cureless or intractable disorders, such as some cancers, that no one says such disorders are normal situations. In the field of psychology and psychiatry, conditions such as antisocial personality disorder rarely respond to interventions. However, these conditions could not be removed of disorder list. So, homosexuality should not be known as a normal state even if it be resistant to treatments.

However, in our clinical experience, drug therapy for homosexuality and masturbation has been very successful in too many cases. Only some case reports include the following.

1. A 21-year-old male who had been suffering from homosexuality since the age of 15 and was referred to our clinic with symptoms of major depression and generalized anxiety showed high Hs, D, Hy, Pd, Pa, Pt, Sc, and Ma indices in the MMPI-2 test. After two weeks of understanding with depakine and olanzapine, he lost all of his symptoms, including homosexuality, and decided to marry a female.

2. A 29-year-old male student and employee who also showed signs of obsessive-compulsive disorder came to our clinic complaining of homosexuality and masturbation. After 14 weeks of treatment with escitalopram and then the addition of venlafaxine, he reportedly stopped masturbating altogether and lost his homosexuality almost completely, without any problems with his general sexual desire.

3. An 18-year-old woman who had just gotten married complained of masturbating and came to our medical center. After 8 months of treatment with escitalopram, venlafaxine, quetiapine and lamotrigine, she gradually stopped masturbating completely and returned to normal sexual activity. She finally reported that she had very pleasant sex with his husband.

4. A 29-year-old single man complained of masturbating. He was able to completely stop masturbating within 5 weeks of treatment with escitalopram, venlafaxine, along with low doses of lamotrigine and quetiapine.

Results and Discussion

In the case of masturbation, the following points indicate that this behavior is a disorder

1. Its high prevalence is not an indicator of normality because there are other illnesses with high prevalence, and on the other hand, the issue of statistical prevalence will be taken into account only in the absence of other indicators such as malfunction or complications.

2. Masturbation, contrary to what is promoted, has serious physical and psychological consequences and sometimes even death.

3. Evidence shows that the habit of masturbation reduces satisfaction with normal sexual activity and thus reduces marital satisfaction.

4. Masturbation seems to have neurotic origins (such as obsession, weakness of self-esteem, weakness of spiritual health, and impulsivity).

5. Masturbation is not consistent with cultural norms of Muslim societies, and cultural and social norms are considered important indicators of mental health.Recommending masturbation for any therapeutic purpose can easily lead to addictive masturbation and makes more complex the problems of people who refer to therapists.

In the case of homosexuality, the following points indicate that it should be considered as a sexual dysfunction

1. Despite the fact that homosexuality is claimed to be associated with normal functioning, these individuals are more likely to suffer from parenting dysfunction, impairment in normal reproduction, disturbance in the formation and consolidation of the normal family, fecal incontinence, hemorrhoid, sexually transmitted infections, depression, eating disorders, suicide, general anxiety, and substance abuse.

2. Even if homosexuality, like masturbation, was so prevalent, this was not a reason for it to be normal when this sexual activity is rejected by the majority of people as disgusting. Thus, the statistical criterion not only does not contribute to the naturalization of homosexuality, but is also against it.

3. Lack of suffering or distress that may be observed in people with this behavior is not an indicator for its normality since in many other disorders no distress is witnessed (such as mania and some personality disorders).

4. The biological, genetic, and hormonal foundations that are expressed to indicate the normality of homosexuality are all defective and pathologic and, on the contrary, they are themselves the indicator of homosexuality abnormality.

5. Like masturbation, homosexuality is also associated with breaking social norms, especially in Muslim societies, which is itself a reason to consider this behavior unhealthy in this cultural environment.

6. Occasional observations of homosexual behavior in some animals do not provide reasonable evidence that homosexuality is normal, because humans and animals have other common physical and behavioral disturbances also.

7. It is not rational that intractability or incurability be considered as an index for normal conditions. If so, many intractable disorders in the field of medicine or psychology should be considered normal.

Conclusion

For a long time, some sexual behaviors in various cultures have been regarded as behavioral deviations. It seems that the orientation of this regularity of sexual behavior is to preserve the family's structure, or at least maintaining the foundation of the family is one of its reasons. The early scientific views on homosexuality and masturbation also suggested that these behaviors were not healthy but disorders. The movement of sexual liberalism has not taken these limits and made many efforts for "taboo-breaking". One of these efforts was the removal of social tags such as "deviant" or "abnormal" or "needing treatment" from those who were engaged in these behaviors. Since the social influence of some people with these behaviors has increased and they have reached governmental or scientific positions, one of the actions taken in this regard was to push the American Psychiatric Association to delete two sexually-oriented acts – homosexuality and masturbation – from the list of sexual behavior disorders in DSM in 1973. Collected data revealed that this decision did not have enough scientific backing. On the other hand, according to accepted criteria for healthy situations, homosexuality and masturbation could not be considered normal behaviors. In other words, there are evidences that these behaviors arise from pathologic backgrounds and also are associated with numerous and important dysfunctions. Data and argumentations also revealed that reasons such as incurability, being comfortable or the statistical and biological reasons are not logical reasons for considering masturbation and homosexuality as healthy behaviors. Based on our findings via the study on Shahid Chamran University students, it is recommended that masturbation is considered as a pathologic behavior, as before, and not as a therapeutic recommendation, but clinical actions have to be taken to treat it. These actions can include spiritual therapy and cognitive and behavioral therapies to increase self-control and reduce impulsivity, as well as increase self-esteem and Acceptance and Commitment Therapy and drug therapy (for example SSRIs) to control obsessions and compulsions.

In general it is recommended that therapists consider homosexuality and masturbation as defective functions and try to treat these disorders through medication and psychotherapy. Even if these diseases are resistant to treatment, considering them as disorders makes therapists and researchers seek more effective treatments and at least do not encourage and reinforce these behaviors in patients and the community.

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Citation: Marashi, Sayed Ali. “Review of Removing Homosexuality and Masturbation from the List of Sexual Dysfunctions in DSM.” Clin Schizophr Relat Psychoses 15(2021). Doi:10.3371/CSRP. MS.062421.

Copyright: © 2021 Marashi SA. This is an open-access article distributed under the terms of the creative commons attribution license which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.