Female Sexual Dysfunction Diagnoses
Leonore Tiefer, PhD
Since the third edition in 1980, the DSM has included a group of conditions known as “sexual dysfunctions” that, while widely circulated and accepted in medical research and by the media, are biased and incomplete from feminist, scientific, and clinical perspectives (Tiefer, 2004).
I. Invalid assumptions: Errors of omission and commission
The diagnoses are based on assumptions that normal, healthy sexuality consists of the performance of certain sexual reactions and responses, specifically desire, arousal and orgasm, especially with regard to penile-vaginal intercourse. Even in the most recent revisions prepared for DSM-V, with the form of sexual activity unspecified, the requirement that normal sexuality consists of desire, arousal and orgasm is maintained. If these are deficient, sexual dysfunction is diagnosed; if they are present, there is no sexual dysfunction.
This model, while seemingly a matter of commonsense (doesn’t everyone think that sex is arousal and orgasm?) is actually riddled with errors of omission and commission that make it incomplete, and even dangerous, especially for women, whose sexual lives are profoundly connected to social context.
Errors of omission: It is obvious that people complain of many problems with sex other than desire, arousal and orgasm, but these problems have been underresearched and even dismissed because they don’t comply with the DSM classification. What about lack of pleasure or intimacy? What about a narrowed script due to past abuses? What about the inability to be empathic or tender or to cooperate with a partner’s requests? What about sexual incompatibility with a partner because of fixed preferences or aversions? If the only issues that count as “sexual dysfunctions” are performance failures or lack of desire, the entire context of sexual activity becomes invisible and somehow of secondary importance.
Errors of commission: The DSM classification includes lack of desire as a disorder, although lack of desire might be completely healthy or expected under many conditions such as grief, relationship strife, fatigue, and financial or family worries. The classification specifies that lack of orgasm is a disorder, yet an individual or couple might prefer nongenital role-play, cuddling or caressing that doesn’t produce the high intensity needed for orgasm.
The primary error of commission in the DSM list is the assumed universality of its sexual standards. All people of all religious and ethnic backgrounds, sexual orientations, ages, and relationship statuses are assumed to have the same goals for sexual conduct: desire, arousal and orgasm. There are obviously evolutionary, reproduction-oriented, species-wide, biological assumptions dictating this model, but in a world where very little sexual activity is for the purposes of reproduction, such a perspective is invalid.
II. Consequences of the DSM Classification of Sexual Dysfunctions
The focus of the DSM on physical sexual functions has been strongly encouraged by the pharmaceutical industry because of the very large sales and markets involved (Moynihan and Cassels 2005), Acknowledging and examining the complexities of sexual motivation and cataloguing the social, relational and psychologic contributions to sexual dissatisfaction would be barriers to the rapid development, testing, and dissemination of new sexuopharmaceuticals and it is no wonder that this is not the type of research supported by grants from the drug industry.
As a consequence of drug industry involvement, the small academic field of sex research has been strongly affected in the last decade by the drive for new pharmaceutical sexual enhancers and the financial support that drug-connected research provides. Various companies have developed endless, narrowly drawn questionnaires, and quantitative research (i.e., questionnaires) has been promoted as “good science” in the “evidence-based medicine” hierarchy. Qualitative research that would elaborate our understanding of the contextual aspects of sexual experience by asking people to tell their stories or describe their problems and concerns in their own words is in short supply is often not considered “good science” (Tiefer, et al, 2004). We would especially like to see more qualitative research on the impact of the drugs themselves on couple’s sexual lives, and the impact of the DSM classification on people’s judgments of their own experience. Are people who know that lack of orgasm is considered a disorder more likely to worry about their own orgasms?
The current nomenclature serves to enforce sexual uniformity and a particular meaning and style of sexual relations. By approving of women’s right to have desire, arousal and orgasm, the DSM contributes to women’s sexual emancipation, especially in cultures that do not recognize women’s sexual and bodily rights. However, mandating any one model of sexual function is ultimately constraining and not liberating.
III. Current status of the critique
Many feminists, sex therapists, and gender scholars have criticized the sexism inherent in the DSM’s approach to sexual problems. The New View Campaign on Women’s Sexual Problems (see http://newviewcampaign.org/default.asp) was convened in 1999 to challenge the medicalization of sex. One of its first activities was to write a manifesto (see http://newviewcampaign.org/manifesto5.asp or Working Group of a New View of Women’s Sexual Problems, 2004) that directly challenged the DSM and offered, instead of a classification of problems, a classification of factors that contribute to women’s sexual problems, The New View Manifesto avoided specifying norms for women’s sexual function, leaving goals and preferences to women themselves. Rather, it foregrounded the many external and internalized inhibitions and distortions of women’s sexuality that produce sexual problems. Documents advocating this approach have been submitted to the committee rewriting the Sexual Dysfunction section of DSM-V.
Moynihan, R and Cassels, A. (2005) Selling sickness: How the world’s biggest pharmaceutical companies are turning us all into patients. New York: Nation Books.
Tiefer, L. (2004) Sex is not a natural act, and other essays. 2nd edition. Boulder, CO: Westview Press.
Tiefer, L., Rosen, R., Giami, A., Popay, J., Graham, C. & Sanders, S. (2004) Qualitative Health Research and Sexual Dysfunction. In T. Lue, R. Basson, R. Rosen, F. Giuliano, S. Khoury & F. Montorsi (Eds) Sexual medicine: Sexual dysfunctions in men and women. (pp 161-170). Paris, France: Health Publications.
Working Group of a New View of Women’s Sexual Problems (2004) In P. Caplan and L. Cosgrove (Eds.) Bias in psychiatric diagnosis. (pp 233-239.) Lanham, MA: Jason Aronson