DSM-V Part 2: The purpose of a woman

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:

  1. Absent/ reduced interest in sexual activity
  2. Absent/ reduced sexual/ erotic thoughts or fantasies
  3. No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
  4. Absent/ reduced sexual excitement/ pleasure during sexual activity (on at least 75% or more of sexual encounters)
  5. Desire is not triggered by any sexual/ erotic stimulus (e.g., written, verbal, visual etc)
  6. 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:

  1. Lifelong (since the onset of sexual activity) or acquired
  2. Generalized or situational
  3. Partner factors (partner’s sexual problems, partner’s health status)
  4. Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
  5. Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experience)
  6. Cultural/ religious factors (e.g., inhibitions related to prohibitions against sexual activity)
  7. 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!

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15 Responses to DSM-V Part 2: The purpose of a woman

  1. Wow. Thanks for this.

    I’m interested that no mention is made of menopause. It’s my understanding that a not-insignificant proportion of women simply close the shop after fifty. It’s not an illness, it’s “developmentally appropriate.” That doesn’t stop it from being a problem for their monogamous partners whose shops are definitely still open for business, but I can’t view it as a mental illness.

  2. Great post – you’ve just ruined my afternoon (in a good way!) – fuming merrily now. Totally agree, this stinks.

    Interesting how crit B allows for distress OR impairment – thereby leading to the situation where a woman may not experience any distress about her situation, but can still be diagnosed if she is deemed sufficiently ‘impaired’. Grrr!

    atb D

  3. Of course, what this is about is how insurance works in the USA, with the funding policies of the insurer being more important than what the doctor wants to actually prescribe

    Many insurance companies will not pay for you to be prescribed medication X unless you have diagnosis Y. For example, many insurers will veto any dx of bipolar disorder type 1 unless you have been hospitalised for a manic episode.

    Pfizer et al want to market viagra to women, but until now, most insurers will not cover it. Now they will.

  4. aethelreadtheunread says:

    Thanks for the comments.

    Alison Cummins – Glad you appreciated the post. :o)

    I hadn’t thought about menopause specifically, but it would seem to be another example of why the criteria for ‘Hypoactive Sexual Desire Disorder’ are better, because they specifically require a clinician to take into account factors like age, and life ‘context’. The fundamental problem with the new criteria, i think, is that there’s no requirement for a clinician to consider the possibility that it can be ok for a woman not to want to have sex, that a lack of interest in sex doesn’t necessarily mean there’s something wrong. As you say, it could cause relationship difficulties if one partner wants sex and the other doesn’t, but that’s something that needs to be sorted out as a couple, i think.

    abysmal musings – sorry for ruining your afternoon, even if it was in a ‘good’ way. :o) The ‘impairment’ thing stuck in my craw, too – what’s to stop some nasty piece of work psychiatrist from deciding that being sexually responsive to her partner is part of proper functioning for a woman, and so anyone who doesn’t is ‘impaired’? It’s nasty stuff all round, i think, and has no business being in the DSM.

    DeeDee Ramona – you’re absolutely right, as always. :o) I’m sure the inclusion in the DSM will factor into medication decisions made by government organisations like NICE too, which will also make the pharmaceutical companies rather happy.

  5. J. Wibble says:

    I’m having trouble seeing how a lack of sexual arousal could cause any form of ‘impairment’. Distress, yes, and I can also see how a hyperactive sex drive could cause impairment, as it’s a pain in the hole trying to concentrate on anything if you’re constantly desperately horny (the ‘second puberty’ caused by testosterone therapy in FTMs can be quite frustrating, as adults are likely to have greater time constraints and commitments than teenagers and thus not have the time to wank furiously 87 times a day). I can’t really think of any way having a low sex drive could affect productive functioning.

    I agree with DeeDee Ramona that insurance coverage is likely to be a major motivator in the creation of this supposed ‘disorder’ (that’s the nicest way I can think of saying it). I showed this post to Dorothy, and expect she would put it slightly less tactfully.

  6. Wibble,

    I think that the “impairment” resulting from your lowered sex drive is your husband leaving you for a woman who has at least fifteen years left in her before menopause — and if he’s lucky, who won’t be closing the shop when she gets there.

    I actually have a lot of sympathy for people stuck in this situation. (Confession: my ex closed the shop in an early menopause at age 38. She is now my ex. These facts are partly but not entirely coincidental. ) (Also, my shop seems to be shutting down at 45. My beloved doesn’t seem too distressed by this development at the moment, but I fear that not having the option to “kiss and make up” could be a problem in the long run. Sometimes shops reopen. I hope mine does.)

  7. Astrid says:

    While I see all the problems that are described here, I mus tnote that DSM-IV had similarly problematic diagnoses like “sexual aversion disorder” and I think an arousal disorder for females existed in DSM-IV too.

  8. ACH says:

    I’ve done some activist work in the asexual community regarding “hypoactive sexual desire disorder” and I think a number of your criticisms are dead on. There is considerable internal contradiction and the specifiers are kinda horrifying. That said, I do think that you’re going out of your way to paint this in an unfair way. The reason for differences in proposals for male and female diagnoses is that over the past decade (largely through a push by big phrama), there has been a lot of research on female not-being-interested-in-sex-“disorder” as well as attempts to avoid basing a female norm on a norm based on “male sexuality.” (I hate the term “male sexuality” because it suggests, that sexually all men are the same.)

    However, there has been a lot less research on men not being interested in sex. (I’m not saying that there aren’t social reasons for this that are objectionable.) Because of this, there hasn’t even been written a report of what to suggest for the male version of this diagnosis. There has been a report (generally well written in my opinion) about the proposals for the female version of this diagnosis.

    All of this is explained in the “rationalle” section as well as the one report that has been written and is available for free on the DSM-V site. (If you go to my blog, it’s in the most recent post.)

  9. aethelreadtheunread says:

    Thanks for the extra comments.

    J Wibble – The phrase ‘distress or impairment’ seems to be included in pretty much all the criteria across the whole of the DSM, so it’s possible it was just cut&pasted into this one without a whole lot of thought going into it. As i said to absymal musings earlier, though, it seems pretty nasty that it’s in this one, because it raises the possibility of some psych somewhere deciding that being sexually responsive to her partner is part of the proper functioning of a woman, and so treatment is mandated, even if she doesn’t want it. I’m sure that’s not the intention of the committee, but their wording does leave the possibility open, i think.

    Alison Cummins – I know you were talking to J Wibble, not me, so sorry for butting in. :o) I can certainly see your point about the possible consequences of a loss of sexual interest, but i’m uncomfortable with the implicit assumption that it’s the ‘duty’ of the woman whose sexual behaviour has changed to match her desire to her partner’s, as opposed to the change being something that the couple have to work on together. I hope things work out well for you. :o)

    Astrid – you’re absolutely right. There were plenty of problematic diagnoses in DSM-IV, and there was a female arousal disorder in the older version, too. I guess i’m just disappointed that things aren’t any better in the new version, and are in some respects worse. :o)

    ACH – sorry your comment didn’t appear straight away – for some reason the spam filter decided to get involved.

    I can reassure you on one thing, anyway – i didn’t ‘go out of my way to paint this in an unfair way’. You may feel that i’ve misinterpreted or even misrepresented things, but i can promise you it wasn’t deliberate. :o)

    I have read the ‘rationale’ sections of all of the diagnoses i discuss, and while it’s entirely possible i’ve failed to pick up on some things, i think the criticisms i make are valid in the light of what’s contained there. To address one of your concerns head on, in my last paragraph i do explicitly acknowledge that the final version of the DSM-V, if it decides to make ‘Sexual Interest/ Arousal Disorder’ gender-neutral, may not be as misogynistic as this draft suggests it will be. That won’t mean that the diagnosis has any more business being mentioned in a psychiatric context. Some people want sex less than other people do: it’s not a disorder. I remain pretty much convinced that it’s only being suggested as a disorder because it will provide drugs companies with the opportunity to sell lots of extra pills.

  10. ACH says:

    I suppose I was wrong in accusing you of deliberate misrepresentation. (Sorry!) From what I know of the people on this committee, they are very much concerned with not using a (typical heterosexual) male based norm for “female sexuality” and do recognize the considerable individual variation that exists among people. Whether they’ve done a good job of taking those concerns into account in drafting the diagnostic criteria (and the specifiers!) is another matter entirely.

    The drug company issue is a bit complicated. (If you’re interested, I would recommend the Wikipedia page on HSDD for some of the history. Also, there’s a blog post (of mine) linked on that page you may find interesting.) When “Inhibited Sexual Desire” was added in DSM-III, the drug issue wan’t really on the horizon. They did have a rather rigid idea of “normative” sexuality, combined with a perception of things largely based on people going in for sex-therapy. For a lot of people, one of the big justifications for having HSDD in the DSM is to get insurance reimbursement for people going to sex-therapists, especially since there is (as I understand it) nothing currently allowing for insurance reimbursement for relationship problems. The proposed change to switch from HSDD to SIAD is connected to the fact that there has been lots of research on “female sexuality” largely because of the drug companies, but the woman who actually wrote the diagnostic criteria for SIAD (Lori Brotto) has minimal pharmaceutical connections listed on her disclosure statement. So basically, stuff’s complicated.

  11. Pingback: Review: The DSM-5 debate « Psych Maven

  12. nephron says:

    This just seems to be a justification and continuance of the idea that if a woman doesn’t want to have sex with you, there’s something wrong with her.

  13. nephron says:

    Sorry, I don’t mean to minimise your struggles with study, that really sucks, and good luck making it in August.

  14. nephron says:

    Ho hum I posted that last comment to the wrong blog.

  15. No Spam says:

    Nothing complicated about it. Most of the folks who are writing the new DSM are getting oodles of money from big pharma.

    Something like 30% of women have been raped or sexually traumatized in some way. No pill is gonna stop those flashbacks. But there is no profit in therapy for big pharma and the writers of the DSM so they will keep looking for a drug cure while ignoring the real problems.

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