In the first part of my little informal look at the proposed revisions for version 5 of the Diagnostic and Statistical Manual of the American Psychiatric Association, I had a brief glance over the parts of that document that seem most relevant to my personal situation. Having done that, I started to look around a bit more widely, and noted that, while there was some evidence to suggest that some changes had been made in the interest of reducing over-diagnosis, others changes suggested that the pharmaceutical companies would be pleased with the opportunities the DSM-V will give them to promote ever wider prescription of medication. I looked askance at the two-week qualifying period for a diagnosis of Mixed Anxiety Depression, and expressed concern that, with a qualifying period so short, many people who were simply having a normal response to a life event would be inappropriately caught-up in the diagnosed group.
Probably the most blatant example of apparent pharmaceutical influence in the revision process, though, is the creation of a new diagnosis, ‘Sexual Interest/ Arousal Disorder in Women’. This is one of the most aggressively marketed ‘illnesses’ in a long time, and almost all the pressure is coming from pharmaceutical companies who have, amazingly, discovered that drugs used to treat male impotence are ‘effective’ in enhancing sexual arousal in women, which means – my, the coincidence! – that pills which previously could only be prescribed to 50% of the population can now be given to the other half, too. It’s extremely difficult not to be cynical about this. Viagra and its ilk have known physiological effects in men, and were developed to help men who are psychologically aroused but physiologically incapable of – ahem – rising to the occasion. It is an enormous stretch to go from this to arguing that the same drug can, for reasons which are wholly mysterious, increase psychological arousal in women.
Actually, the whole of the diagnostic criteria for ‘Sexual Interest/ Arousal Disorder in Women’ can be described as eyebrow-raising, or perhaps, more accurately, jaw-dropping:
A. Lack of sexual interest/ arousal of at least 6 months duration as manifested by at least four of the following indicators:
- Absent/ reduced interest in sexual activity
- Absent/ reduced sexual/ erotic thoughts or fantasies
- No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
- Absent/ reduced sexual excitement/ pleasure during sexual activity (on at least 75% or more of sexual encounters)
- Desire is not triggered by any sexual/ erotic stimulus (e.g., written, verbal, visual etc)
- Absent/ reduced genital and/or non-genital physical changes during sexual activity (on at least 75% or more of sexual encounters)
B. The problem causes clinically significant distress or impairment
C. The sexual dysfunction is not better accounted for by another Axis 1 disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition
Addition of the following specifiers:
- Lifelong (since the onset of sexual activity) or acquired
- Generalized or situational
- Partner factors (partner’s sexual problems, partner’s health status)
- Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
- Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experience)
- Cultural/ religious factors (e.g., inhibitions related to prohibitions against sexual activity)
- Medical factors (e.g., illness, medication
See what I mean? Jaw-dropping.
For a start, some aspects of the criteria seem to lack even the most basic consistency. For example, Criterion C stipulates that a diagnosis can’t be made if the sexual dysfunction can be ‘accounted for by another Axis 1 disorder’ (Axis 1 disorders include anxiety and depression), while Additional Specifier 5 suggests that a patient can receive the diagnosis even if they have an ‘individual vulnerability’ because they are depressed or anxious. For another example, Criterion C also stipulates that the diagnosis shouldn’t be made if the sexual dysfunction is the result of ‘medication’ or ‘a general medical condition’, while Additional Specifier 7 requires a clinician to note if the sexual dysfunction presents with additional ‘medical factors (e.g., illness, medication)’.
That’s just for starters, though. Much of the rest of it is simply outrageous. Take indicator 3 under Criterion A, for example, which suggests that a woman who doesn’t respond to her partner’s demands for sex is showing evidence of a psychiatric disorder. Or indicator 5, which suggests that a woman who isn’t turned-on by pornography is mentally ill. And then there’s the open sewer that is the additional specifiers:
- Number 4, which suggests that a woman who doesn’t want sex with the same frequency as her partner is mentally ill.
- Number 4 again, which doesn’t seem to recognise that a woman who is suffering through a relationship marked by ‘poor communication’ and ‘discord’ has a damn good reason for not spreading her legs and saying “fuck me, big boy” when her non-communicative, discordant partner pesters her for sex.
- Number 6, which suggests that a woman who believes that a particular – or every – sexual act is wrong and therefore refuses to engage in it (or, at least, fails to enjoy it) can be diagnosed with a mental disorder.
- Number 2, which suggests that a woman whose sense of discomfort in particular situations makes her feel less than horny has a problem requiring psychiatric intervention.
- Number 1, which suggests that a woman who has gone through her entire life with a low libido is ill.
On their own, each of these are vile, but what makes the whole thing particularly nasty is the cumulative effect. Taken as a whole, this ‘disorder’ suggests that a woman who isn’t permanently up for sex needs treatment. It suggests that being available, willing and responsive to the sexual desires of her partner is something of paramount importance for a woman, as though it was a joyful duty, something she should want to do, even if she is ill, or in pain, or tired, or worried, or emotionally exhausted. What’s almost worse is that it doesn’t ‘only’ demand that a woman be physically available for sex, but that she takes active pleasure in it. It seeks to normalise a particular type of sexual behaviour to the extent that there is no room, even within her own head, for a woman to want something else.
Of course, there’s the standard little fig-leaf that appears in all of these diagnoses – Criterion B, which says that the problem must cause ‘clinically significant distress or impairment’, but I’m not sure that’s enough. A woman might very possibly be distressed by sexual problems within her relationship, but they might be indicative of some other problem that cannot be fixed by medication or one-to-one (as opposed to couples) therapy. The simple fact that this diagnosis exists reinforces the idea that, if a woman is suffering from sexual ‘dysfunction’, the problem is located within her, it’s something that she needs treatment, or help, or encouragement to overcome. It shifts the focus from other, external factors onto the woman herself, and more particularly onto her sexuality. Everything else – even other intrinsic psychological factors – become subservient to the necessity for a woman to exhibit a particular type of sexual behaviour.
As things stand, by the way, it is only women who stand to have their sexuality medicalised and regulated in so rigorous a way. There is a possibility that the DSM revision committee will decide to make ‘Sexual Interest/ Arousal Disorder’ gender-neutral, so that it applies equally to men and women. (Interestingly, the reason they’re not sure yet is because they’re carrying out ‘field-work’ into male sexual dysfunction, something they didn’t feel was necessary when deciding to regulate female sexuality.) It’s also possible, however, that the ‘field-work’ will return a negative result, and they’ll decide that men will continue to suffer from the current condition – Hypoactive Sexual Desire Disorder – which is markedly more open to the possibility of individual variation (click on the DSM-IV tab on the link to see the wording):
A. Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence will be made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s life.
B. The disturbance causes marked distress or interpersonal difficulty
C. The sexual dysfunction is not better accounted for by another Axis 1 disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition
So. There is a possibility that men’s sexual ‘inadequacies’ will be considered in the context of his life, but there is no such provision for women. It may turn out that a man will be able to tell his psychiatrist “My partner wants sex, but I’m having a tough time at work and I just want to kick back with a beer and relax, you know?”, and his psychiatrist will nod sympathetically. A woman in the same situation will have a tick solemnly placed against the ‘fails to respond to partner’s sexual advances’ criterion.
The potential difference in the treatment of men and women is infuriating, of course – it seems a throwback to the days when a man who had pre-marital sex could go to the pub and brag about it but a woman in the same situation would be diagnosed a ‘nymphomaniac’ and locked up for the rest of her life – but I don’t think that’s the fundamental problem. If the revision committee do make the condition the same for men and women, that will absolve them of the charge of misogyny, but it will still leave the DSM intruding into areas that it really has no business being in. It seems to me that this is perhaps the more fundamental problem: why on earth is the DSM still trying to involve itself in the regulation of consensual sexual behaviour?
And that, you persistent few who are wading through my seemingly endless thoughts on this subject, will be the subject for the third and final part of this post. See you then!