第十一章性癖症与性功能障碍
Paraphilias
癖症
Fewpsychiatricdisordersarefraughtwithasmanymoralisticovertonesastheparaphilias.Todeterminethatanindividualisdeviantintheareaofsexualityimpliestheestablishmentofaclearnormforsexualbehavior.Whowillestablishsuchnorms?Shallpsychiatrybethemoralguardianofsexualbehavior?Canweusetermssuchassexualdeviation,perversion,orevenparaphiliawithoutsoundingpejorative?
很少精神障碍如同性癖症般，承载着如此多道德上的弦外之音。认定某人在性这个范畴有所偏差的同时，无形中也建构了性行为的正常规范。谁来决定这个规范?精神医学该成为性行为的道德守护者吗?当我们使用如性偏差(sexualdeviation)、性倒错(perversion)或甚至性癖症(paraphilia)这些词汇时，可以不带任何轻蔑的口吻吗?
Theevolutionofthedefinitionofperverseactivityrevealstheextenttowhichpsychiatricnosologymirrorsthesocietyfromwhichitemanates.Inthecontextofaculturethatviewednormalsexualityinrelativelynarrowterms,Freud(/)definedsexualactivityasperverseaccordingtoseveralcriteria:)itfocusedonnongenitalregionsofthebody;2)ratherthancoexistingwiththestandardpracticeofgenitalintercoursewithanopposite-sexpartner,itsupersededandreplacedsuchpractice;and3)ittendedtobetheexclusivesexualpracticeoftheindividual.Freudnotedthattracesofperversioncouldbefoundinvirtuallyanyonewhoseunconsciouswassubjecttopsychoanalyticexploration.
性倒错行为的定义一直在演变中，这显示精神疾病分类学是如何反映出它所源自的社会。身处在一个以狭隘观点看待正常性特质的文化情境中，佛洛伊德根据以下几个准则来定义倒错性行为：）此行为者着重于身上生殖器以外的部位；2）并非只是和标准性行为(与异性性伴侣进行生殖器交媾)共存而已，此行为甚至凌驾、取代了标准性行为；3）此行为倾向是个人唯一的性行为形式。佛洛伊德注意到：如果能对无意识进行精神分析式的探索，则几乎在任何人身上都可找到性倒错的迹象。
SinceFreud’searlypaper,culturalattitudesaboutsexualityhaveundergonedramaticchanges.Assexualitybecamealegitimateareaforscientificstudy,itbecameapparentthat“normal”couplesengageinavarietyofsexualbehaviors.Oral-genitalrelations,forexample,becamewidelyacceptedashealthysexualbehavior.Homosexualityandanalintercoursesimilarlywereremovedfromthelistofperverseactivities.
自佛洛伊德早年的论文以降，社会对性的态度已经历了戏剧化的转变。随着性成为科学研究正当的研究对象，人们逐渐了解所谓“正常的”伴侣亦有各式各样的性行为。举例而言，口交己是广为接受的健康性行为，而同性恋和肛交也同样从性倒错行为的名单上被移除。
PsychoanalyticwritershaverepeatedlyconfirmedFreud’sobservationthatthereisalatentperversecoreinallofus(Chasseguet-Smirgel;McDougall,;Stoller,).Thusamoreacceptingattitudeaboutperversesexualityhasac