Monday, December 28, 2009

The Pathologization of Asexuality?

Since finding the asexual community, two terms that have entered my vocabulary are “pathologize” and “medicalize.”

The OED defines "pathologize" (in its modern sense) as a transitive verb meaning, "To regard as pathological or a suitable subject for pathology; esp. to regard as psychologically unhealthy or abnormal," with the first quote coming from 1980. In OED's quotes, it always carries a negative connotation (though some authors use the term with an air of skepticism towards this judgment.) Medicalize is defined as, " trans. To give a medical character to; to involve medicine or medical workers in; to view or interpret in (esp. unnecessarily) medical terms." Likewise, it has a negative connotation. The OED's second quote:
1979 Daily Mail 27 Jan. 7/7 The drug industry, the Government, the chemist, the taxpayer and the doctor all have vested interests in ‘medicalising’ problems that should not really belong in the sphere of medicine at all
The terms are often used to criticize what is seen as regarding “normal behavior” or “normal variation” as disease, disorder, or dysfunction. They are used to critique regarding as a medical problem what might be better seen as a legal problem, a social problem, or maybe just an everyday-life sort of problem--or maybe not even a “problem” at all, arguing that the only problem is the perception as such.

While asexuality is not, strictly speaking, presently regarded as a mental disorder, the diagnosis Hypoactive Sexual Desire Disorder is too close for comfort for many in the asexual community.

A question that I have long wrestled with is this: Why does it bother us that asexuality is (almost sort of) considered a mental disorder? Why do we feel that this is a problem?

When I get sick, I don’t protest against medicalization or insist that there is nothing wrong with me. I don’t feel that I am somehow less of a person for having an illness. There are many things that I readily regard as pathological, and few would argue that nothing is properly the domain of medicine. (The only ones I can think of do so from a mystical bent.)

The question concerning the pathologization of asexuality is this: If there is nothing wrong with admitting one has an illness/disorder/dysfunction when one does have one, and if we often find nothing wrong with saying that various things about ourselves or others may be pathological without negative judgment on our (or their) value as people, why are we so opposed to regarding asexuality as (psycho)pathological?

I don’t mean this as a rhetorical question, nor do I mean to suggest we accept without comment HSDD. Intuitively, I want to say, “That's different.” For some things, it feels appropriate to classify them as pathological; for many, this will be very uncontroversial (like liver cancer.) There seems to be something different about calling asexuality disordered than does make is problematic when, for many of these others, calling them pathological does not seem problematic. The question is, “What is the difference? How is it different?” And not just, "How is it different from liver cancer?" But "How is it different from other things of much less severity that we readily regard as pathological?"

I'm not going to try to answer the question now, but hope to start to do so over the next few months. I attempted this in a series over the summer, but, as my most recent blog summary notes, I got through all of two posts before hitting a serious case of writer's block. I've done more reading and thinking, and I think I'm ready to attempt it again.

Friday, December 11, 2009

DSM-V anticipated date of publication moved back a year

For some time, there have been serious criticism of the DSM-V process, including criticism that the process is not transparent enough and that there is no way they can finish by May 2012. Yesterday, an article about the matter, to appear in New Scientist on Saturday, was published website: Pscyhiatry's Civil War. Published along side it was a scathing editorial titled Time's up for psychiatry's bible.

Within hours of it appearing online, the American Psychiatric Association issues a press release: DSM-5 Publication Date Moved to May 2013

The press release also indicated that, according the the chair of the DSM-V task-force,
draft changes to the DSM will be posted on the DSM-5 Web site in January 2010. Comments will be accepted for two months and reviewed by the relevant DSM-5 Work Groups in each diagnostic category. Field trials for testing proposed changes will be conducted in three phases.

This seems to be a positive development. For some interesting commentary on the matter, see New Scientist expose of psychiatry’s "civil war" on the blog, In the news, which is where I first learned about the articles and the press release.

Wednesday, December 2, 2009

More News on Paraphilic Coercive Disorder

A few months ago, I wrote a couple of posts here and here on a diagnosis proposed for DSM-V: Paraphilic Coercive Disorder (PCD), and I wrote about a profoundly troubling report on the matter by an advisor to the Paraphilias Subworkgroup for DSM-V (who, for some unknown reason, called it Coercive Paraphilic Disorder. If you google each of the names in quotes, you'll see the difference.) That report argued against including the diagnosis (a conclusion I agree with), but gave just about the scariest argument publishable in defense of that conclusion.

Since then, there have been three additional reports published by advisors to the paraphilias subworkgroup, two of which are on PCD (other groups only publish reports by workgroup members.) In my previous post I gave two possible explanations for the really scary report: either it is a diversionary tactic or they’re wanting to give the worst possible argument against the diagnosis in order to gain support for it.

The second of the reports on PCD seemed quite promising—the author gave some very sensible arguments against including it (basically, that it has dubious scientific support and would have rather undesirable consequences in terms of research on understanding the causes of rape [by causing researchers to focus on the wrong questions] and in terms of misapplication with respect to laws permitting the “civil commitment” of sex-offenders [i]after[/i] they finish their sentences. These laws, which a number of US states have, are, in my view, are of very questionable constitutionality: they essentially take away procedural due process rights and violate the US Constitution’s ex post facto and double jeopardy clauses, though the Supreme Court has [wrongly, I think] rejected these arguments to date.)

A third report has recently been published arguing in favor of adding the diagnosis. Having read it, it feels as though it would be very persuasive if I didn’t know anything about the matter (or know to be very skeptical of certain lines of research that he cites.) Based on this third report, I am fairly strongly inclined to think that the Paraphilias Subworkgroup members really do want to add this diagnosis in DSM-V. There is a very telling piece of evidence if you read the acknowledgements at the end of these reports:

First report, argues against PCD:
Thanks are due to Rick Beninger, Joe Camilleri, Grant Harris, Martin Lalumie`re, and Marnie Rice for their comments on an earlier version of this manuscript. The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

Second report, argues against PCD:
I would like to thank Jane Harries, Matthew King, Elizabeth Saunders, and Judith Sims-Knight for their insightful comments and suggestions on an earlier version of this article. The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

Third report, arguing in favor of including PCD:

The author is an Advisor to the DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). I wish to thank members of the subworkgroup for their discussion of an earlier version of this paper and their role in refining and developing the diagnostic options that are discussed. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association. (emphasis mine)

And, just for additional contrast, another report by an advisor to the paraphilias subworkgroup (on a different matter):
The author is an advisor to the Paraphilias subworkgroup of the DSM-V Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). This article is a revised version of a commentary submitted on July 17, 2009 to the Workgroup. I would like to thank Jobina Li for help with the references. The views expressed are those of the author and not necessarily those of Public Safety Canada.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

Which of these things is not like the others?

In case you hadn’t guessed from the section I bolded, only one of these authors mentions having ever discussed their report with members of the Paraphilias Subworkgroup. Now, my understanding was that the whole point of having official advisors is for them to, you know, advise? By, like, talking with the workgroup members? In just about every other report I’ve read so far, authors acknowledge the helpful input from other workgroup members. (The exceptions are those by Ray Blanchard who finished his reports of pedophilia and “transvestic fetishism” not long after the workgroups were formed; in the former, he thanked two people for comments about a single point, and in the latter, he thanked several people for “their stimulating conversations, over many years.”)

Now, I may be reading a little too much into the fact that only one of their advisors acknowledges ever speaking with the people they’re advising about the matter on which they are advising them. (Though I assume that they’ve probably all met before, as it isn’t that big of a field.) Still, it does seem suggestive.

And I really don’t like what it suggests. In the second report on PCD published online, Raymond Knight sums up the reasons:

First, identifying and reifying a taxon implies a research strategy that emphasizes extreme group designs that attempt to distinguish the putative taxon from other discrete groups of rapists that have been formed for comparison purposes [reference]… Searching for the identifying characteristics of a non-existent taxon will delay the task of discerning the underlying dimensions of rape and explicating their etiology and life course.

Second, the criteria for civil commitment depend on some form of mental disorder to legitimize the process and keep it from becoming unconstitutional preventive detention [references]. Moreover, it is required that it be demonstrated that the mental disorder is a likely source of the offender’s sexual offending. In commitment proceedings for rapists Paraphilia NOS, nonconsent has frequently served the role of a sexual aggression inducing mental disorder, despite the lack of specific criteria for its implementation and the absence of evidence of its reliability and validity [reference]. The inclusion of PCD would inappropriately legitimize this ‘‘disorder’’ and grant it the imprimatur of the DSM, which is almost universally cited by expert witnesses in civil commitment proceedings. The present review indicates that the diagnosis has little empirical support, and it would be a travesty to grant it a status that would perpetuate its misuse.

Tuesday, December 1, 2009

More news on the DSM: Women who want to want

Women who want to want, an article published his past weekend in the New York Times Maganize, discusses the future of the diagnosis female Hypoactive Sexual Desire Disorder (HSDD) in the DSM-V, focusing on Lori Brotto, the member of the sexual of DSM-V subworkgroup for Sexual Dysfunctions who wrote the report on female HSDD (which I have discussed here). (She has also been involved in research on asexuality.)

It was an interesting article that I would definitely encouraged readers to take a look at. Here's my favorite part:
Brotto knows too that there are sexologists who maintain that desire by any definition — whether the sheer lust Basson minimizes or the responsive variety she trumpets — is almost entirely a cultural invention rather than a biological reality; that it has been made to seem essential by the sex scenes in movies and the advice columns in magazines; and that it is best deleted from the D.S.M. Leonore Tiefer, a professor in the psychiatry department at New York University and the author of a collection of essays titled “Sex Is Not a Natural Act,” argues that the contrivance is compounded by the pharmaceutical industry, which offers research money to sexologists who find ways, no matter if unconsciously, to inflate hugely the numbers of women suffering from an already-fictive condition — a disorder that the drug companies intend to cure. High numbers help to increase awareness, which stokes demand. To what extent this theory represents truth, as opposed to being merely plausible, is hard to sort out.

I wouldn't exactly endorse the claim that lust is a cultural invention without qualification--like many claims about this or that being "social constructs" (whatever that means), the statement seems to conflate "the sheer biological/psychological fact of the experience of lust" one the one hand, and "the conceptualization of lust and corresponding beliefs" on the other. (The former, presumably is rather biologically rooted; the later much less so, except to the extent to which all human conceptualizations of anything are rooted in general abilities of reasoning, conceptualization, thinking etc. based on how human brains work.)

Other than that, I'm generally inclined to agree. (Although, the facts are somewhat more complicated in the sense that the medicalization of low sexual desire considerably preceded the release of Viagra, which is when, according to Tiefer's analysis, the pharmacuticals realized just how much money they could make were they ever to invent "the pink pill.")

Sunday, November 15, 2009

Socially, is asexuality a sexual orientation?

Because school has been keeping my very busy of late, I haven't been able to write as much as I had been before, but over the course of this semester I've (slowly) been attempting to address the question of whether asexuality is a sexual orientation. First, I observed that "sexual orientation" is polysemous (one word has a number of distinct, but closely related meanings), and have so far discussed asexuality in terms of scientific definitions and in terms of legal definitions. The third type of "definition" I wanted to address is that of social definition.

Here, I use quotation marks because I don't think that definitions are really appropriate for most human concepts--the categories we use work well enough for daily life but typically lack precision and defy definition. Areas such a science (where operational definitions are essential), law (where definitions are crucial), and mathematics (where precise definitions are actually possible) seem to be the exceptions, not the rule. Definitions are, at best, useful rubrics, signposts helping beginners to understand, roughly, what something means; and they may be helpful in thinking clearly about some issue and they can be ideological battlegrounds.

For "sexual orientation" as a social concept, I will avoid definitions for another reason: lots of people have very different ideas about what sexual orientation is and few use precise definitions. And most who use definitions only do so to try to explain some idea they already had.

So, with our vague and undefined notion of "sexual orientation" as it exists in various people's understanding, is asexuality a sexual orientation? Well, it depends on who you ask. Some people say it is. Some people say it isn't. Most people have no idea what asexuality is and have probably never considered the matter. Most who have considered the matter have probably not considered it at length.

Nevertheless, current ideas about sexual orientation are generally that most people are straight and some people are gay (and, if pressed, I imagine that most people acknowledge that some people are bi. Taking this as a general starting place (because it is a general starting place for most people), there seem to be basically three options for conceptualizing asexuality:

1) Asexuality is a sexual orientation.
2) Asexuality is a lack of sexual orientation.
3) "Asexuality" is a sexual dysfunction.

I think that it is very difficult to figure out what empirical differences there are between these. It is, in my view, principally a value judgment, and the main basis on which decisions will be made regards what people feel makes most sense, and what people feel will be most helpful for such individuals. Thus, it seems that perhaps we should rephrase the question: Rather than asking the question in the title of this post, perhaps we should ask, "Socially, should asexuality be considered a sexual orientation?"

Now, in media presentations of asexuality (and in academic ones) there is a rather interesting phenomenon that I've never seen explicitly discussed, though I imagine many engaging in it are well aware of what they're doing. The question of whether it would be most beneficial to asexuals if, socially, asexuality were considered a sexual orientation is a matter separate from the scientific issues involved in deciding whether it makes sense scientifically to regard asexuality as a sexual orientation. There is no a priori reason why the two questions must have the same answer.

In media presentations, there are often academics--taking various positions--using their perceived status as experts to advance their own positions on whether asexuality is a sexual orientation. Of course, many of these people may well be experts in some areas of human sexuality, but some of them have never actually studied asexuality but don't feel that this disqualifies them from using their expert position to advance their own ideology. (And those who have studied asexuality, tend to be supportive of the position that asexuality is a sexual orientation, but also tend to make very guarded claims, noting that very little is known at this point.)

Still, because of the respect granted to science in society at large (though, this is often not nearly as much respect as scientists would like), it is recognized that if scientific evidence can be given which is used to justify the claim that asexuality is a sexual orientation, this is felt to add legitimacy to accepting asexuality as a sexual orientation in terms of vaguely defined understood social categories. To a large extent, regarding asexuality as a sexual orientation (scientifically) adds legitimacy to regarding asexuality as a sexual orientation (social "definition") precisely because people rarely stop to think about how these are different matters.

To a large degree, it is because people think of the question in terms of "Is asexuality a sexual orientation?" rather than "Should asexuality be regarded as a sexual orientation?"

Thursday, October 22, 2009


Have you ever wondered why I blog under the name that I do? Have you ever asked yourself, “Who is this pretzelboy, this rolled and salted dough named blogger, this international man of asexuality?”

If you have—or even more likely, if you haven’t—I thought I would diverge from the more serious topics I’ve tackled of late and answer this question, sharing some lesser-known facts about myself and attempting to make it tangentially related to asexuality.

The highschool I attended, a private school with grades 7-12, had every year an event called “Spirit Week” wherein we would show our school spirit and participate in lots of random games, activities, etc., involving numerous competitions between classes, many of which were held at an assembly comprising the last 50 minutes or so of each school day for that week. My freshman year, we had a “Stupid Talent Contest” in which each class, having about 100 members, had to select one member to represent it and display their stupid talent.

I, being extraordinarily stupid-talented, volunteered to represent my class, a volunteering rapidly accepted as, evidently, they had already been considering asking me. Whether to view this as a compliment or an insult, I do not know, but either way, to make my stupid talent more superlatively so, I opted to combine two of my peculiar abilities into one act: my greater-than-normal flexibility and my ability to memorize stuff. So, on the day of the contest, I got up before the school and, on the gym floor, put both of my feet behind my head and recited, from memory, 95 decimal places of pi. Sadly, I had said I would recite 135, but my mind blanked and I had given a printout to the judges. Alas! I only got second place—beaten by the senior who put floss up is nose and out of his mouth!

As pi-memorization goes, it was nothing especially amazing—I had learned maybe 150 decimal places at my best. If you ask me now, I could do much less. The first 60 decimal places were memorized first and, for the cognitive psych folks out there, seem to have shifted from declarative to procedural memory. (Now, it just sort of comes out and I have little idea what I’m saying; it comes to me with such rapidity that even having to articulate it slows me down. Of all the useless things to be able to do…)

As for the name pretzelboy, I’m sure you can imagine why this nickname was given to me by my peers. A couple years later, during my junior year of highschool, I discovered that I could kick my left leg over my head and get it to latch around my neck and stay; I could then hop around for a little while like this, which proved to be a source of amusement among my peers and came to be known as “the leg thing.” As in, “Do the leg thing!” A frequent request while I was in college.

Now, many asexuals complain of the very limited range of responses people give to asexuality. They find it frustrating to get the same questions over and over and over again. With the leg thing, it was very much the same: basically, people asked one of two questions. “Does it hurt?” (No) “How did you learn that you can do that?” (Make up some crap because the actual answer was long, complicated, and not especially exciting.)

Since my senior year of college, I haven’t been able to do the leg thing except once while alone a few years back, and then only after stretching first. It seems that what happened was that I had started to get slightly less flexible, causing my leg to not quite go far enough on many of my attempts. And while being able to repeatedly kick myself in the back of the head while trying to do the leg thing may be an impressive feat in itself, it wasn’t one I wanted to show off too often. And now, if I try to put both feet behind my head, it hurts my back.

So there you have it: the origin of my blogger name Pretzelboy. It’s quite a lot more interesting than the origin of my blog name, which comes from a college algebra text book

Saturday, October 10, 2009

Is asexuality a sexual orientation? Legal definitions

In my several posts, I've largely dealt with issues pertaining to the upcoming DSM-V, which sometimes dealt with asexuality and sometimes didn't. I now return you to your regular asexual programming, continuing a series on whether asexuality is a sexual orientation.

In the start of that series, I made the claim that sexual orientation has at least three separate meanings: sexual orientation as a scientific concept, as a legal concept, and as a social concept. In answering whether asexuality is/should be a sexual orientation, the answer may or may not be the same in each.

I gave a bare outline of the scientific issues here, and I now turn to sexual orientation as a legal concept. For some reason, I had decided to start with this because the issues seemed the most straightforward of the three meanings of sexual orientation I wanted to consider (which I knew to be a foodhardy assumption where the law is concerned.) After I started to write about it, I become less certain and asked a friend in law school for clarification on one point, and then other things came up and the post got delayed about a month.

Is asexuality (legally) a sexual orientation? It depends where you live. In the state of New York, yes. (See the definition of "sexual orientation" in SONDA) Elsewhere, the answer is either no or maybe. (I haven't been able to find anyone else that includes asexuality in the definition of "sexual orientation" in non-discrimination bills, but that's just with Google, which is not be the most thorough analysis of the matter.) The legislation where (the definition of) sexual orientation is most significant is hate-crimes legislation and non-discrimination legislation for employment and/or housing.

(Aside: I'm excluding same-sex marriage/marriage equality because the definition of sexual orientation is sort-of irrelevant for the laws themselves--what matters there is the sex/gender of the people wanting to get married, not their sexual orientation. I use "sex/gender" because the legal gender of transgender and intersex people depends on a number of factors, including the jurisdiction they live in. I say "sort-of irrelevant" because sexual orientation does play an important role in judicial questions--in the US at least--of whether prohibitions against same sex/gender marriage violate either federal or state constitutions, especially with respect to equal protection rights. End aside.)

In places that include sexual orientation in hate crime or non-discrimination legislation, is asexuality a sexual orientation? Because many bills define sexual orientation by giving a list, if asexuality is included in the list, it's a sexual orientation according to that law. If it's not included in the list, the matter is less certain. Because sexual orientation is typically defined by a list, if asexuality is not specifically enumerated, this may mean that, according to that law, asexuality is not a sexual orientation. Or it might mean that that law takes no stance on the issue one way or the other. And unless this question arises in an actual case before some court, there's not going to be an answer. Even then, there would only be an answer for that particular law. (As possible evidence that lack of inclusion does not necessarily mean exclusion, the Illinois Human Rights Act, for example, explicitly excludes one group not enumerated in the definition of sexual orientation.)

My friend in law school has pointed out that in addressing the issue of asexuality, an important source of evidence would be legislative deliberations concerning the law in question. If the issue of asexuality came up and they decided not to include it, then it's probably not a sexual orientation according to that law. If the matter never came up in discussion, the matter is less clear. In that case, perhaps expert testimony arguing that asexuality is a sexual orientation might be relevant.

There does seem to be some evidence that the issue of asexuality has come up. Asexuality was listed as a sexual orientation in a book arguing for sexual orientation as a human right published in the 90's (Sexual Orientation: A human right, and it was included in a New York Statute passed in 2002. It is likely that one of both of these were considered in passing non-discrimination or hatecrimes laws. Also, there is evidence suggesting that asexuality was intentionally excluded from a recently passed Ohio statue banning discrimination in employment or housing on the basis of sexual orientation. There, Sexual orientation is defined as, " actual or perceived, heterosexuality, homosexuality, or bisexuality." In a version of the bill proposed last year (that, I believe, never got voted on) sexual orientation was defined as, "heterosexuality, homosexuality, bisexuality, asexuality, or transgenderism, whether actual or perceived,"

Another question that seems like it might be relevant is that if sexual orientation is defined as "heterosexual, homosexual or bisexual" and asexuals aren't any of these, does that make asexuality a lack of sexual orientation? And if it is a lack of a sexual orientation, then this may imply recognition of it as a sexual orientation category, which may be relevant.

This raises what is perhaps the biggest question regarding whether asexuality is a sexual orientation: Is asexuality a sexual orientation or is it a lack of a sexual orientation? It's a question I've seen raised by a number of different people in a number of different contexts.

In some sense, the question of whether asexuality is legally a sexual orientation may be pointless intellectual exercise. There have been lots of people discriminated against for being LGB and there have been lots of people discriminated against for being T (who may or may not be protected by the same laws.) Even after participating in the asexual community for two years, I've never heard of a single case of an asexual being discriminated against in employment or housing for being asexual. I've never heard of any asexuals who were the victims of hate crimes for being asexual. My suspicion is that if some asexual was the victim of either a hate crime or sexual orientation based discrimination, it's a lot more likely that it would be the result of homophobia than "aphobia." (Many asexuals are suspected of being gay on the basis of their not being straight, and there are a number of asexuals who also identify within one of the LGBT categories.)

Asexuals real issues to deal with: struggling against feelings of alienation, wondering if they're "the only one," facing misunderstanding and disbelief. But outright discrimination doesn't seem to be much of an issue for us, so whether asexuality is legally regarded as a sexual orientation is probably not all that important of an issue. On the other hand, I'm inclined to think that regarding asexuality as a sexual orientation for the purposes of on-the-job ethics training wouldn't be such a bad thing in terms of increasing sensitivity towards asexual employees.

Tuesday, September 29, 2009

Proposed changes to HSDD

In my last post, I informed readers that the report of the Sexual and Gender Identity Disorders Workgroup for DSM-V for female HSDD has been published, and I said that I would summarize it and give a little commentary.

First, there are documents that I will be discussing: the report of female HSDD and the report of Female Sexual Arousal Disorder (FSAD). Mostly, I'll talk about the first one, but the current proposal involves merging them, so I'll refer to the other one a few times as well.

Brotto, L.A. (in press) The DSM Diagnostic Criteria for Hypoactive Sexual Desire Disorder in Women. Archives of Sexual Behavior DOI 10.1007/s10508-009-9543-1

Graham, C. A. (in press) The DSM Diagnostic Criteria for Female Sexual Arousal Disorder Archives of Sexual Behavior DOI 10.1007/s10508-009-9535-1

I would strongly encourage readers with sufficient library access to simply read at least these, especially the first (as it deals more with issues of direct concern to the asexual community.) I'll summarize the main issues that I think will be of interest to members of the asexual community.

The part of Brotto's paper where asexuality is directly addressed is the section on whether the distress criterion should be kept. There have been serious proposals to remove it, and she briefly mentions some of these--premature ejaculation and Female Orgasmic Disorder--noting that it seems illogical to say that a woman who cannot orgasm does not have this simply because she is not distressed by it. She notes, however, that according to the New View, labeling this as a disorder in the absence of distress "assumes that orgasm is a normal/natural state and that its absence denotes pathology."

Regarding low desire, she claims, the matter is less clear; to support this, she notes that "there is a small but growing body of literature on the
phenomenon of human asexuality [citations] defined as lifelong lack of
sexual attraction." People have described asexuality as a sexual identity rather than as a sexual dysfunction because of the "finding that the only distress
experienced by asexual persons is in reaction to sociocultural pressures to be sexual, and pathologizing those who do not wish to be sexual."

She continues,
The removal of distress from the criteria for HSDD may lead to the unfortunate labeling of asexuals as having a sexual dysfunction and there is strong opposition to this view among the asexual community [citation]. Although research on asexuality is still in its infancy, there is also insufficient evidence to suggest that asexuality is a sexual dysfunction of low desire. I would forward that the DSM-V consider making this point in the text or adding it to the list of exclusion diagnoses.
She also notes that in studies on the prevalence of low sexual desire and associated distress, there are more who aren't distressed about their low sexual desire than there are who are distressed about it.

Also, of interest is a suggestion that was made by, I think, by L. Tiefer, who is a DSM-V advisor*. The proposal is to replace HSDD, FSAD, and Female Orgamic Disorder with a disorder based on distress about these. (After all, it is distress that causes people see clinicians). A proposed name is "Sexual Response Distress." The idea is only discussed briefly, but Brotto states, "This intriguing idea deserves consideration." I would agree with that judgment.

Proposed changes
The report recommends that the requirement of the absence of fantasies be deleted. It recommends that the "hypoactive" part be deleted from the name, and that the diagnoses HSDD and FSAD be combined into a single diagnosis. Two names are proposed: "Sexual Interest/Arousal Disorder" and "Sexual Arousability Disorder."

I'll quote the language for the proposed diagnostic criteria:
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 nongenital physical changes during sexual activity (on at least 75% or more of sexual encounters)
B. The disturbance causes clinically significant distress or impairment

(1) Lifelong 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/medications)

Not surprisingly, this proposed diagnosis is almost identical with the diagnosis proposed in Graham's report on FSAD. The differences between them are of interest: there are only two. Graham has one proposed only one name (Sexual Interest/Arousal Disorder), and, in her proposal, criterion A requires 3 out of 5 indicators, rather than 4 out of 6, as in Brotto's proposal. (Graham's does not include Brotto's #5.) There are a number of possible reasons for these differences (e.g. disagreement among the authors, one report being finished some time after the other, wanting to propose multiple versions to stakeholders, etc.) So I will not speculate on the matter.

Thoughts and comments
My guess is that most people in the field will regard these proposed criteria as a considerable improvement over the current diagnosis. It's not clear what comments about asexuality might be made in the text of the DSM-V or how relevant clinicians and researchers would react to such a change. (I assume that no decisions on the matter have been made.)

There are some points in the proposed definition for Sexual Interest/Arousal Disorder (which I'll call SIAD) that seem to lack as much clarity as might be desirable--though these are mostly things that could be dealt with in the supporting text for DSM-V.

There is one issue whose omission seemed to stand out in the Female HSDD report. There is no justification given for including the specifiers "Lifelong or acquired" and "Generalized or situational." The specifiers themselves are nothing new. They were included (under various names) in the original proposals for HSDD/ISD in 1977; they were included in the introduction to the sexual dysfunctions in DSM-III, and they were added as subtypes in the diagnostic criteria for HSDD in DSM-IV.

Brief mention of them is made in Graham's report.
The first two of these subtypes, ‘‘lifelong’’ vs. ‘‘acquired’’ and ‘‘generalized’’ vs. ‘‘situational,’’ seem potentially useful for clinical purposes, although it is worth noting that, in epidemiological research, these distinctions have very rarely been made. The recommendation made here would be to retain these distinctions, although rather than include these as ‘‘subtypes’’ they could instead be incorporated as specifiers.

This strikes me as odd. One of the two subtyping** systems is seen as useful, so both recommended to be included. But they're degraded to the status of specifiers because of lack of empirical evidence. If there is a meaningful difference between generalized and situational low sexual desire in women, it seriously draws into question certain parts of the proposed diagnostic criteria. Namely, indicators (2) and (5):
(2) Absent/reduced sexual/erotic thoughts or fantasies
(5) Desire is not triggered by any sexual/erotic stimulus (e.g., written, verbal, visual, etc.)

Indicator (2) would only be an indicator for "generalized" SIAD, but not for "situational." In (5), it is not clear if "desire" includes solitary desire or is limited to to dyadic desire. If the "generalized" vs. "situational" distinction is meaningful for (at least some?) women, this distinction is crucial. And if it's not, why is the "generalized vs. situational" distinction being retained?

It remains to be seen what commentary will be published in response to this proposed diagnosis, and it remains to be seen what the proposed diagnosis for male HSDD will look like (or whatever might be proposed to replace it.) Personally, I'm a fan of deleting HSDD, FSAD, and Female Orgasmic Disorder and replacing them with Sexual Response Distress.

*In addition to members of each workgroup, the DSM-V Taskforce nominates people to serve in advisory roles. According to the April 2009 report from the Sexual and Gender Identity Disorders Workgroup, "Each sub-work group is providing internal feedback for the literature reviews and the next step will be to obtain feedback from advisors who have been nominated to comment on specific literature/diagnostic reviews." Google didn't provide me with any information on who any of these people are, but names are given in the Acknowledgments of each paper I've cited. Each lists five people, four of whom are on both lists.

**On p. 1 of DSM-IV-TR there is an explanation of the distinction between specifiers and subtypes. Essentially, subtypes should create a partition on the set but specifiers don't have to. The goal is to create more homogeneous sub-populations.

Sunday, September 27, 2009

More news

The report of the Sexual and Gender Identity Workgroup for DSM-V for HSDD in women has now been published online. (Current thinking seems to be to divide sexual dysfunctions in women and sexual dysfunction in men into different categories.)

The DSM Diagnostic Criteria for Hypoactive Sexual Desire Disorder in Women.

So far, I've only gotten to skim it so far. I'll make another post on it after I've gotten a chance to read through it in full, but I figured that readers would be interested to know about this.

Also, the articles for Female Sexual Arousal Disorder and Paraphilia NOS have been published as well.

Edit: The current proposal is to merge (female) Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder, and to give them a new name. The main reasons are, more or less, that a) there is enormous overlap between these two diagnoses and b) many women have difficulty distinguishing sexual desire and sexual arousal, to the point that it's not even clear that they're different (if subjective sense of arousal is what is being considered.)

Before I make comments, I will need to read both articles.

Monday, September 21, 2009

News about the sexual dysfunctions in DSM-V

About a month ago, I made a post called DSM-V News (or lack thereof) in which I informed readers about happenings with DSM-V and lamented the lack of publicly accessible information about the current thinking of the Sexual Dysfunctions Subworkgroup. It seems that I was a bit premature in making this claim.

Reports written by the members of the Sexual and Gender Identity Disorders Workgroup for DSM-V are currently in the process of being published (though they were written a while back.)

These reports are currently in the process of being published. So far, the introduction to these has been published online, and so have the reports for Pedophilia and Transvestic Fetishism.

Most of the reports will be published in a special issue of Archives of Sexual Behavior. Zucker, the head of the workgroup (and editor of that journal), states that in that issue:
[There are] a total of 16 reviews written by our Work Group. Reviews by Taylor Segraves on the male sexual dysfunctions will be published in the Journal of Sexual Medicine. Most of the reviews focus on a critical appraisal of the relevant diagnoses that appeared in the DSM-IV (or earlier), with proposed suggestions for reformand revision.There is also one review that considers the addition of a new diagnosis (Hypersexuality) and two reviews on gender identity disorder consider conceptual and sociopolitical/historical parameters. Each review was subject to internal feedback by the Work Group and, in some cases, from feedback by advisors. It should be made clear that the recommendations and options embedded in these reviews are just that.
I'm not really sure why the male sexual dysfunctions will be published elsewhere.

UIUC doesn't subscribe to the Journal of Sexual Medicine. I can still get articles for free, but I have to make some librarian somewhere scan things so I can get emailed a copy, so it's a lot more cumbersome (because it takes longer and I know I'm creating extra work for someone somewhere.) And those aren't searchable. (Technology has made me spoiled!) WorldCat tells me of 24 libraries worldwide have copies of this publication, compared to 620 that have Archives of Sexual Behavior.

These reports were written a while ago (some this year, most last year), so they do not necessarily represent the most up-to-date thinking of the DSM people. But these do represent an important part in making public information regarding the workgroup's thoughts and proposals, and they are an important contribution to the historical record.

As more of these are published, I may have more to say on the topic, depending on what I think would be of interest to readers. The publication of these doesn't completely contradict my earlier claim that there is a lack of public information about the Workgroup's current thinking: these reports generally indicate people's thinking 6 months to a year ago, in some cases, a fair portion of the various workgroups' discussion of these issues. But there is no question that this is a definite step in the right direction in terms of adding transparence to the DSM-V process.

Friday, September 18, 2009

Scientifically, is asexuality a sexual orientation?

I have argued that “sexual orientation” has a number of related by slightly different meanings: sexual orientation as a legal category, as a social category, and as a scientific category. Depending on which meaning of “sexual orientation” we’re dealing with, the issues involved in determining/deciding if asexuality is a sexual orientation or not are somewhat different. In this post and the next, I intend to address it as a scientific category.

Given the current state of research on asexuality--and the research on sexual orientation more generally--I do not think it is remotely possible to answer the question of whether asexuality is a sexual orientation in anything but the most tentative way. Asexuality has received very little research, so there is very little data to work with. Sexual orientation more generally has received quite a bit more research, but things are very uncertain there as well.

Regarding “sexual orientation” more broadly, there are a number of open questions. To restate a few from my last post: What is “sexual orientation” is measuring? How should it be operationally defined? Is sexual orientation in men the same thing as sexual orientation in women? Should sexual orientation include all of the factors involved in a person’s pattern of sexual attraction (e.g. personality features, physical features, etc.) or be limited to the part gender plays in their sexual attraction? Is "sexual attraction" more about a person's patterns of sexual attraction or about patterns of sexual arousal? Is all sexual attraction part of sexual orientation, or does some sexual attraction stem from some other cause? What is "sexual attraction" anyway? Are heterosexuality, homosexuality, and bisexuality each somehow unified groups in some scientifically important way or are they just conglomerations of merely superficially similar features lumped together? How useful a concept is "sexual orientation"? There are opinions on these questions but not much consensus.

And if it's not clear what "sexual orientation" is, then that makes answer the question of whether asexuality is one or not even more difficult.

One question of fundamental importance is "Scientifcially, how useful of a category is asexuality?" Thinking about this problem, along with think about Nelson Goodman’s New Riddle of Induction, which I learned about at around the same time, has gotten me thinking a lot about categories. Ultmiately, what seems to make a category useful is that identification of someone or something as a member of some category liscenses (probabilistic) inference about them/it with respect to properties other than that which defines them as a member of that category. Thus, if I know someone is from Korea, they probably speak Korean, they probably have a certain ammount of knowledge about Korean, etc. In meeting people for the first time, identifing such categories can be very important for ascertaining what knowledge/beliefs are liekly to be mutual and waht aren't. (If I'm talking to a linguist, I can assume certain knowledge about linguistics that I cannot assume for others.) Likewise, if I see an apple, I can infer it's probably good to eat (unless it looks like it rotting or something) but if I see a table, it's probably not good to eat.

With something like asexuality, there seem to be three possible types of correlates of interest: causes, effects, and other. To illustrate these, let’s use biological sex. There is a strong correlation between having two X chromosones and being anatomically female. Now, it’s certainly not 100% (there are a number of intersex conditions that make exceptions; also there is SRS), but it’s a pretty strong correlation. This enables people to understand and research causal mechanisms involved. Another way of thinking about the category deals with effects. If we take the (extensionally somewhat different category though largely overlapping) category of women, we can think about effects: what are the effects of being a woman in some particular cultural context? Here, it’s usually not going to be effects that happen to every single woman that are of concern: rather, it’s going to be tendencies and likelihoods people are interested in, or issues that are more often of concern for women than non-women, etc. The third type are going to be things that happen to be correlated but no one really knows why. Typically, there are some of the most common found in research, and people are interested in trying to figure out what causal mechanisms might be invovlved in creating some difference.

With respect to asexuality, I think we have these three things involved. How scientifically useful the category is, I think, depends on how strong the causal and/or effectual correlations turn out to be. This raises an interesting point: causally, what we call asexuality may well be (in my view, almost certainly is) a whole bunch of things just sort of lumped together into one category. However, the social consequences (effects) of lack of sexual attraction (whatever “causes” might be involved) seem to be similar despite this. To a large extent, it is the similarities, overlaps, and criss-crossing of shared experiences that has led to the creation of this identity category in the first place. And once the category is created, a community of discourse and an identity is created. This results in common vocabulary and concepts that people use to understand themselves and to communicate. (If I'm talking to other asexuals, I can generally assume knowledge of certain words that most people probably won't know. I can make jokes based on shared sorts of experiences, etc.)

What this means for scientific theories of asexuality is simply that the usefulness of the category “asexual” is dependent on what we’re trying to understand (which is true of pretty much all of our other categories anyway.) Ultimately, it’s the cause-based-categories and the effect-based-categories that are the most important and the most interesting—if the goal is to understand how stuff works. But, where humans are concerned, establishing cause and effect are extraordinarily difficult.

And here’s another thing: suppose that we were able to figure out what causes asexuality/asexualities. Would this create the danger that those caused-based-categories are seen as somehow “real” asexuality, and anyone who didn’t fit those, their asexuality is somehow less real? Even if, at the level of experience, what they’re feeling is very similar to those proclaimed to be “real asexuals,” even if the social effects are very much the same? There is no a priori reason to expect cause-based-categories to exactly coincide with effect-based-categories. I don't know the answer to this, but it is a matter worth considering.

Saturday, September 5, 2009

Is asexuality a sexual orientation?

In a recent podcast over at A-Life, they asked the question of whether asexuality is a sexual orientation and made a poll about it on AVEN. Another way of posing the question, with somewhat different meaning, would be, “Should asexuality be considered a sexual orientation?” Either way it's posed, it’s a more complicated matter than most people probably recognize.

The first problem in answering the question is that the term “sexual orientation” has a number of closely related but distinct meanings. At least three come to mind: sexual orientation as a scientific concept, sexual orientation as a legal concept, and sexual orientation as social concept.

Sexual orientation as a scientific concept
As I understand the current research, what “sexual orientation” is measuring and how useful a concept it is remain open questions. What is sexual orientation a measure of? How should it be operationally defined? Is sexual orientation in men the same thing as sexual orientation in women? Should sexual orientation include all of the factors involved in a person’s pattern of sexual attraction (e.g. personality features, physical features, etc.) or be limited to the part gender plays in their sexual attraction? Is "sexual attraction" more about a person's patterns of sexual attraction or about patterns of sexual arousal? Are heterosexuality, homosexuality, and bisexuality each somehow unified groups in some scientifically important way or are they just conglomerations of merely superficially similar features lumped together? These remain open questions, and they probably will for some time.

Sexual orientation as a legal concept:
In anti-discrimination legislation, often involving employment and housing, the difficult scientific question are simply irrelevant. In the Employment Non-Discrimination Act (ENDA), currently under consideration in the US House of Representaitives, it defines sexual orientation as follows: "The term `sexual orientation' means homosexuality, heterosexuality, or bisexuality." What the prohibits is as follows:
(a) Employer Practices- It shall be an unlawful employment practice for an employer--

(1) to fail or refuse to hire or to discharge any individual, or otherwise discriminate against any individual with respect to the compensation, terms, conditions, or privileges of employment of the individual, because of such individual's actual or perceived sexual orientation or gender identity; or

(2) to limit, segregate, or classify the employees or applicants for employment of the employer in any way that would deprive or tend to deprive any individual of employment or otherwise adversely affect the status of the individual as an employee, because of such individual's actual or perceived sexual orientation or gender identity.
It's very important that it says "actual or percieved" sexual orientation or gender identity.

Suppose that a law said that it is illegal to discriminate against someone on the basis of their sexual orientation (without saying anything about “actual or perceived”); this would create the potential for a very undesirable loophole: it might be legal to discriminate against someone on the basis of believing that they’re belong to one of the LGBT categories as long as they aren’t actually LGBT. Consider the following hypothetical example. Employee X and employee Y work at the same company, and Y particularly dislikes X. Now, X is a heterosexual male, but he’s single and doesn’t date much. Y, knowing their boss to be particularly homophobic, spreads a rumor around the workplace that X is gay. On the basis of this rumor, the boss fires X. If the law says that you can’t discriminate against someone on the basis of their sexual orientation, the boss has probably not violated it. X is heterosexual and was not discriminated against on the basis of his sexual orientation. Moreover, this loophole could then create a situation where the employer could try to argue that the employee who was fired on the belief that they are LGBT isn’t actually LGBT. To counter this, people would have to try to prove in court what their sexual oriention or gender identity actually is, which could require putting in the public record very personal information, and the very idea that this is something people might have to try to “prove” in court would be exasperating to many. Both of these would be highly undesirable situations. I assume it is to avoid them that the law says, “actual or perceived.” That means, discriminating against people (in employment, and possibly housing, depending on the law) on the basis of a belief about their sexual orientation is wrong, regardless of whether that belief turns out to be correct or not.

In sexual orientation as a scientific concept, questions of operational definitions in research (how to measure what a person’s sexual orientation is) are extraordinarily important. In sexual orientation as a legal concept, not do operational definitions not matter, in many cases, what a person’s sexual orientation actually is does not matter.

Sexual orientation as a social concept
This is probably the most important part of the idea of sexual orientation; it’s also the hardest to define or explain. Basically, I’m including here popular ideas about sexual orientation, knowing that there is a diverse range. In terms of sexual orientation as a social category, the scientific questions above aren’t that important, although what people think the science often is important in how people think about the matter. Legal issues are also rather far from most people’s minds. But I think it is clear that the general idea(s) about what sexual orientation is that are floating around the general population are quite a bit different than the other two types. And it’s primarily these that inform how people use “sexual orientation” to think about themselves and others.

When looking at things this way, I think it becomes clear why asking whether asexuality is a sexual orientation becomes a more complicated question than it might seem at first: Which definition of “sexual orientation” do we have in mind? The isues involved in each case are not identical.

Wednesday, August 26, 2009

DSM-V News (or lack thereof)

A while ago, I wrote about the history of the diagnosis Hypoactive Sexual Desire Disorder and the involvement of the asexual community in trying to get the DSM-V to be more ace-friendly. I thought that I would highlight some of the more recent news with respect to the DSM-V that readers may be interested in.

To avoid having to write too much, I’m going to write relatively little and link a lot.

For some basic background, the American Psychiatric Association has a brief summary of the history of work so far and future plans: DSM-V: The Future Manual.

There are two main issues that I want to highlight: some sizable controversies over the DSM-V process and happenings with the Sexual and Gender Identity Disorders Workgroup. (The link is to a list of members with information about each.)

Robert Spitzer, chairman of the DSM-III and DSM-III-R taskforces, wrote a letter published in "Psychiatric News" in July 2008 called DSM-V: Open and transparent? in which he strongly criticized a policy in which all members of workgroups for DSM-V have to sign a confidentiality agreement which reads,
"I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way... any Confidential Information. I understand that 'Confidential Information' includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group."

A Response was published in the same issue.

More recently, another controversy has flared up in which a commentary by Allen Frances, chair of the DSM-IV taskforce, was published in the "Psychiatric Times" in July of this year: A warning sign on the road to DSM-V: Beware of its unintended consequences. Like Spitzer’s letter to the editor, the main criticisms deal with lack of transparency, lack of openness, and shortage of opportunity to get feedback. In a move that makes you go “Holy shit!!!” the DSM-V task force wrote a response in which they actually implied that his commentary was written out of financial motivation. That merited a response from Robert Spitzer (APA and DSM-V: Empty Promises) and, a few weeks later, a response from Frances. (Frances responds to APA: “Important Questions Need Answering) There have been a number of other brief commentaries that have resulted in the Psychiatric Times. (They have a number of articles linked under “DSM-V” and “Featured Articles.”)

One of the big criticisms is that no one really knows what the specific proposals that the workgroups are thinking about, leaning towards, etc. are, and there is fear that things will come as a big surprise at the end, after minds are made up, and without opportunity for feedback from those with a vested interest in the outcome. This criticism isn't entirely accurate, as has been pointed out in the responses to these criticsms: A number of members of the various workgroups present various proposals at conferences. On occasion, they may even post these online.

Turning attention to the Sexual and Gender Identity Disorders workgroup, this workgroup is subdivided into three sub-workgroups, based on the current three-way division of that chapter of the DSM. These sections are called Gender Identity Disorder, Paraphilias, and Sexual Dysfunctions.

As for the committee as a whole, they two progress reports have been posted online. One is from November 2008 and the more recent is from April 2009.

The question of how transparent the process is and how open to expert feedback they are seems to depend considerably on the individual subcommittee. The paraphilias people have presented the proposals they are considering at a number of conferences. Ray Blanchard gave presentations at the Society for Sex Therapy and Research annual meeting and at the WAS World Congress for Sexual Health about some of his suggested proposals, and these are posted on his webpage. (DSM talk at SSTAR, DSM talk at WAS.) There will be symposium on the matter at Association for the Treatment of Sexual Abusers’s annual conference. (This symposium will be on October 1.) They already have a document posted (Paraphilic Disorders and DSM-V: Considerations for Revision of Diagnostic Criteria) in which each member of that subcommittee has written a section about some of the changes they are considering.

Regardless of what one might think of any of their particular proposals, it gives a good idea of where they are in their considerations, and it enables people to provide feedback on those proposals. The other two subcommittees seem less transparent.

Regarding the diagnosis Gender Identity Disorder, a lot has been written, and here’s pretty much all I’ve been able to find out about the thinking of that subgroup, quoted from an article in MedPages Today about the APA’s annual meeting in May. (APA: Major Changes Loom for Bible of Mental Health
As described by its chairwoman, Peggy Cohen-Kettinis, Ph.D., of VU University in Amsterdam, the group is facing three main options: keep gender identity disorder approximately as it is, jettison it entirely, or change the name and diagnostic criteria.
Dr. Cohen-Kettinis said the group was nearing a decision, but both she and fellow group member Jack Drescher, M.D., a New York-based psychiatrist and prolific author on sexuality and gender, were noncommittal on which way the group was leaning.

As for the Sexual Dysfunctions, these seems to be less information than would be desired. The above cited progress report for April 2008 given information about who on the workgroup will present when at what conferences.

That sub-workgroup has four people. The chair is Taylor Segraves, who has been on the same subcommittee on the past few versions of the DSM. The other members of Irving Binik, Cynthia Graham, and Lori Brotto. At the already mentioned SSTR conference, there was a symposium for "Provisional Report by the DSM-V Workgroup on Sexual and Gender Identity Disorders." Information about the talks is found in the conference program, to which the following page numbers refer. Three of the members of the Sexual Dysfunctions subcommittee gave presentations (Segraves, Binink, and Brotto.) Segraves (pp. 40-41) discussed proposed changes to the diagnoses he was assigned (by himself?) to review: Premature ejaculation and male orgasmic disorder. Binik (pp. 44-45) discusses dyspareunia and vaginismus, which I assume are the diagnoses he has been assigned to write literature reviews for (given his area of research on the topic of his talk.) Brotto discusses reconceptualization of what are now hypoactive sexual desire disorder (for women) and Sexual arousal disorder (for women), though the abstract does not give much information on what specific changes are being suggested for DSM-V.

The other other talk listed on the April progress report was just recently given by Binik (Conference program p. 8). If I understand things correctly, this leaves only a vague idea for proposals for the future of (female) sexual arousal disorder and (female) hypoactive sexual desire disorder, and virtually no indication of what proposals they are considering for (male) hypoactive sexual desire disorder, sexual aversion disorder, and (male) sexual arousal disorder with the exception of what can be known from prior publications by members of the subworkgroup. (I use parentheses because the current system generally lumps male and female problems into the same category, following Kaplan's modification of Masters and Johnson's model for the sexual response cycle, which emphasized gender similarities and minimized gender differences.)

Particularly troubling, is that I can find nothing on what changes (if any) are currently being considered regarding the "clinical significance criterion" that is currently in each diagnosis. (That's the part that says something must cause "marked distress or interpersonal difficulty" to constitute a disorder.) These were added in a rather ad hoc fashion in DSM-IV and been a source of a fair amount of controversy. Yet I can find out nothing about what changes are under consideration regarding these.

What I've written and linked here is pretty much everything I've been able to find out online about the goings on, although there are some publications by subworkgroup members from before they were appointed to work on DSM.

Edit: My comments here have proved to be somewhat premature, especially regarding the lack of publicly accessible information about the thinking of the Sexual Dysfunctions Workgroup. For more information see News about the Sexual Dysfunction in DSM-V and more news.

Saturday, August 15, 2009

Blog summary

At the end of last year, I finished a rather lengthy series, and since then, my blog has kind of been all over the place. I just finished a series on criticisms of asexuality, but I had related posts before starting that series, so I figured I would do a topical summary of posts this year, excluding news updates (i.e. announcements about my website, updates to that site, and new academic publications about asexuality, etc.)


I started the year with attempts at some humorous posts:
Lexicon Fail

Analogy Fail

Asexual Wikipedia Fight Reproduces by Itself
About a month later, I had a follow up:

Wikipedia update

Random topics

Are asexuals non-religious?: I examine the belief in the asexual community that asexuals are more likely to not be religious.

Pronouns and gender-part I. I had intended to write a part II, but lack of motivation and writers block set in.

In defense of the prop 8 ruling but not defending prop 8. There I deviated from my usual topic of asexuality because I sensed a lot of anger and a lot of misinformation and misunderstanding surrounding that court case. I tried to help readers understand the issues.

Hypoactive Sexual Desire Disorder

Hypoactive Sexual Desire Disorder and the Asexual Community: A History. This was an expanded version (with citations) of an article appearing in AVENues at the same time. It was written as a stand alone article, but a few months later, I decided to start a series on the subject.

Is asexuality as sexual dysfunction? This was intended as an introduction.

Challenging HSDD. I used a publication challenging HSDD as a springboard for discussion.

Then a nasty case of writer's block set in, and I found myself unable to continue the series.



Back in January, I coined this term to refer to standard responses to anti-asexual comments. My goal was to help people be more understanding of where such claimants are coming from.

I then took up this topic again in June when I couldn't continue my HSDD series. After an introductory post, I consider a number of standard responses asexuals get when coming out. I am critical of both the anti-asexual nature of the response and the typical asexual replies. The exception is "sexual repression," which is a concept that I think needs to die. Here my response is probably stronger that the typical asexual response. I finished the series with the only criticism of asexuality that genuinely bothers me, even though it's a criticism that I rarely hear.

Whence comest thou, O asexohater?

You're not asexual. You're just a late bloomer.

Am I sexually repressed?

Accusing others of sexual repression

You're not asexual. You just haven't met the right person yet.

Have you considered the possibility that you might be...(hushed voice)

You're not asexual. You're just not willing to accept your true sexuality.

If someone who isn't really asexual identifies as asexual, so what?

How can you know you're asexual if you've never had sex?

The only criticism of asexuality that actually bothers me

Wednesday, August 12, 2009

The only criticism of asexuality that actually bothers me

In the past several posts, I've been looking at various criticisms of asexuality. My responses to them don't really fit with standard line identity politics, but none of those criticisms really bother me. In the case of sexual repression, I think it's a term we need to abandon. In the other cases, my responses have been that often the criticism isn't true, and even when it might be, it's probably not helpful. But there is one criticism of asexuality that has long troubled me though I have rarely seen it expressed--once in a thread I started on Apositive and a handful of other places.

Roughly speaking, criticisms of asexuality come in two varieties: "criticisms from above" and "criticism from below." The criticisms from above have three main varieties.

1) "You really are super interested in sex, but you just don't know it/won't admit it." (e.g. You're not asexual, you're gay/a lesbian but won't admit it. You just aren't willing to accept your "true sexuality." You're just immature and afraid of sex. etc.)

2) "You aren't interested in sex now, but you will be, just you wait." (You're a late bloomer. You just haven't met the right person yet. etc.)

3) "You should be super interested in sex, but there must be something wrong with you prevening it." (You're sexually repressed. You must have been abused as a child. Or some other item from a long list of supposed-causes of low sexual desire may be given, even though the vast majority of these have no empirical support or scientific evidence.)

The only potential criticism of asexuality that actually bothers me is the "criticism from below" although I rarely see it expressed. I suppose that's because people actually have to understand asexuality and be generally accepting of it to be aware of this problem.

Roughly, here's the idea: let's suppose that people's (lifetime) interest in sex ranges from 1-99 with the median being 50. I realize this is a gross oversimplification, but I think it works to illustrate my point. Let's arbitraily say that "real asexuals" are people around 1-2 and "gray-A's" being maybe 3-5.

Most of us have absolutely no idea what other people are actually like sexually. We have no idea what 50 is like and no idea what 10-20 is like. Rather, we are bombarded with images and messages about sexuality in movies, on TV, in magazines, and on the radio that give us wildely over-inflated ideas of what "sexually normal" is. People get ideas about "normal sexuality" from their peers. But not just from any peers--they get these ideas from their peers who talk the most about sex. And it's probably the people most interested in sex who talk the most about sex. Not only that, but sexuality--especially heterosexuality--is a major part of preformance of gender roles. Consequently, to fit in, a lot of people probably exagerate their own sexual interest to where they feel it should be, or to where they can brag.

The result is wildly unrealistic ideas about just how interested in sex most people are. Problems are compounded by so-called "comprehensive sex education." In my experirience, these materials are written by and for people with higher interest in sex with minimal concern for being sensitive to those who aren't all that interested in sex, with minimal sensitivity to the feelings of wierdness caused by people not being as interested in sex as they feel they should be, with no attempt to explain the lower range of sexual interest in order to normalize it. I'm sure this impression is not fully representative, but it is the experience I've had with "comprehensive sex education" so I imagine it at least isn't that uncommon. This is the experience I've had both with a well-respected textbook I read parts of when confused about my sexuality (and found out the expert opinion is that I don't exist) and from a university Human Sexuality course I took. (I realize I'm stepping on toes here, and I'll just say that I used to support comprehensive sex education until I actually saw it in practice. I still believe that it is very important to have quality sex-education. Part of the problem seems to be that comprehensive sex education is so embattled just to exist that it doesn't have the necessary internal criticism necessary for an educational enterprise to thrive.)

Here's an example: I was long confused about not understanding what it's like to think someone is "hot." I didn't even have much of a sense for "pretty" until I was in my 20's, so I was really confused about conversations about the matter, and I was even more confused about how there was no recognition that people like me even exist. I read through a section of a textbook (Our Sexuality) about the role of different senses in sexual arousal, and they said it is important, and failed to mention that visual stimuli are not an important part of sexual excitement for everyone. I tried a number of searches on google, and all confirmed my fear: I don't exist. Since identifying as asexual, I've found that a number of other people (who aren't asexual) don't get hotness either, and they often expericne a good bit of confusion over the matter. Had I known about this when I was younger, I might not have felt nearly as much of the sense of wierdness that led me to identify as asexual.

When people try to decide if they're asexual or not, they rely on a negatively defined concept. Asexuals are people who don't experience sexual attraction. What "sexual attraction" is believed to be, is going to be based on what they think "sexual people" are feeling. But "sexual people" is often going to be based on these unrealistic images of "sexually normal" that treats "sexual people" as 50-80, rather than including the lots of people in the bottom quarter or bottom third.

When people become confused about their sexual feelings, about why they aren't feeling certain things, why they aren't as obcessed about sex as their peers, and they identify as asexual, they feel a sense of acceptance, a sense of belonging, a sense that there are others like themselves. My fear is that there is often a temptation to use this identity normatively--having decided they are asexual, someone feels a need to "be asexual." Recognizing feelings that suggest that perhaps they aren't may be frightening because that sense of belonging may be lost, and if there isn't something to replace it with, if there isn't some other source of validation of their relatively low interest in sex, it can lead to futher feelings of isolation or fears of future feelings alienation.

The "criticism from below" is that perhaps many people in the 5-15 range who aren't "really asexual", who experience a little sexual attraction--at least in some contexts--who would like sex, some of these people may identify as asexual, may use that identity prescrptively and decie that they'll never want to have sex and that they won't like sex. I wonder if this may in some sense limit what they permit themselves to experience and what they permit themselves to feel.

As long as asexuality is used as an identity for people to figure themselves out and communicate themselves to others, and as long as people are willing to reconsider that identity should they find reason to, I don't think this "criticism from below" applies. But still, I think the temptation is there to use the identity prescriptively.

Saturday, August 1, 2009

How can you know you're asexual if you've never had sex?

A number of people identifying as asexual have never had sex and sometimes are met with this criticism: Maybe they hear, "How can you know you're asexual if you've never had sex?" This is, in fact, the only of the typical asexodoubting questions people get when telling others they're asexual that I have personally received. There are also variations on it skeptical of asexuality in general rather than merely skeptical of that individual's asexuality: "I'm sure you would like sex if you tried it." Or if the person has had sex, "Maybe you just didn't have sex with the right person."

And there are asexual responses. In the first few months I was on AVEN, the impression that I got was that the most common sort of response to this was either that people generally know that they want sex before they have sex or that even if someone has never had sex, they can know that they're not interested. This seems plausible enough. But I also got the impression that some people believed that even without having sex, they could know that they didn't like it. Sometimes analogies to food are given: people claim to know that they won't like this or that food before they try it. This bothered me.

Our imaginations are notoriously unreliable for predicting what something is going to be like, what something is going to feel like, whether we're going to like something or not. Of course, sometimes our imagination is right, but it's wrong often enough that we shouldn't take it to be too strong of a predictor. I don't see any reason why sex should be any different. In fact, there are plenty of people who, when imagining some particular sexual act, find it rather repulsive, but they come to like it after trying it a few times.

But this meant that I believed that people in the asexual community generally can't know if they would like sex or not without having ever had it. I felt that this opinion was subversive with respect to the standard asexual line, so I decided that I should just keep my opinion to myself.

However, a few months ago on Apositive, Ghosts started a thread on this subject (Don't knock it till you try it!), where I found out that my "subversive opinion" was actually one that a number of other people held. To a large extent, this is why I'm writing this series on many of the standard criticisms of asexuality: I have somewhat mixed feelings about the standard asexual responses. I really don't like to be subversive, so I tend to try to keep any opinion that challenges the system to myself except when I particularly dislike the system. In this case, I was afraid of somehow subverting asexual identity. However, I've been coming to recognize that many of these "subversive opinions" are ones that quite a number of other people hold too, but might not always readily express on AVEN.

With respect to the asexodoubting response in this post, my thoughts are similar to those about being a late bloomer or not having met the right person yet: even when it's true that the individual in question might like sex if they tried it (in the right circumstances), telling them that they can't know if they're asexual or not if they haven't had sex simply isn't helpful, especially as a response to someone revealing their asexual identity.

People should never be made to feel that they need to have sex to feel normal. Ever. If they don't want to have sex, they don't have to have sex.

Also, asexuality isn't about not liking sex; it's about not experiencing sexual attraction. People may not be able to know if they like sex or not without trying it, but they can know if they experience sexual attraction or not. And with sex, sexual desire seems to be a big part of what makes it fun for most people. And people know if they experience sexual desire. Also, as noted by Ily on the Apositive thread, some people don't like to be touched. As sex involves quite a lot of touching, such individuals can have a pretty good idea that they wouldn't like sex.

Thursday, July 30, 2009

Another publication on asexuality

A few months ago, I had a post in which I informed readers of a letter to the editor I wrote ("Methodological Issues for Studying Asexuality") that was published in one of the sexuality journals.

A response has recently been published (online) in the same journal.

Brotto, L. A., Yule, M. A. Reply to Hinderliter Archives of Sexual Behavior.

Thursday, July 23, 2009

If someone who isn't "really asexual" identifies as asexual, so what?

One criticism of asexuality, or a claim sometimes used to dismiss asexual identities, is that those claiming to be asexual aren't really asexual; they're just not willing to accept their true sexuality.

In my last post, (which, if you haven't read, you should read before continuing), I noted that there are, in the asexual community, generally three beliefs people can have regarding this criticism.

(A) It's wrong. Asexuals are asexual, not people who are afraid of their sexuality.
(B) It's wrong in a number of cases (some people really are asexual), but it is right in many cases; this is a real problem.
(C) It's wrong in a number of cases, and even when it's true, so what?

While some might deny that the criticism has any substance, as in A, I think that most people who have been around the asexual community a while will acknowledge that there certainly are some people identifying as asexual (or asking "Am I asexual?") who are clearly "not asexual." Rather, they're afraid of sex, or are immature, or have anti-sexual views, or are otherwise not willing to accept their own sexuality. Yet, as common as I suspect views B and C to be, I don't see them expressed very often, and when they are, it's usually not on AVEN. (Both views are represented, for example, on Apositive in the thread Legitimacy and Blurry Lines.)

There are two primary reasons that I support C. First, I imagine that most of the people identifying as asexual because they're not prepared to accept their own sexuality are fairly young--teenagers and some people in their early 20's. Especially for teenagers, here's what I imagine to be the result of them mislabeling themselves as asexual: delaying onset of sexual activity by a few years until they're more mature, better understand their own feelings, and are more accepting of their own sexuality.

Oh the horror! The only think I can't figure out is why, exactly, we're supposed to think this is a bad thing.

The second reason that I'm not convinced that temporary "mis"-identification as asexual isn't necessarily a bad thing is that such identification can help to provide people a safe-space to think about their own feelings. The assumption underlying the belief that "mis"-identification as asexual is bad seems to be either that a) this will cause the person to be smug in their sexless life rather than actually dealing with the issues that need to be dealt with, or b) OMG, sex is like, totally, the best thing EVER, and like, (mis?)labeling your self as asexual is going to make you, like, miss out or something. The second of these strikes me as pretty absurd: sex is not like-OMG-totally-the-best-thing-ever for everyone, including many sexual people who may like it but can also be perfectly content without it for long periods of time or who may only like it in a very restricted set of circumstances. This assumption seems to stem from the fact that there are people who have difficulty understanding that just because they really, really like something and make it a really important part of their lives doesn't mean that everyone does. Or should.

And then there is the other possible assumption: that "mis"-identifying as asexual helps people feel smug so that they decide not to deal with some issues that they have. I suppose this may well be true in some cases, but the exact opposite is true in others: for some people temporarily identifying as asexual can help provide them with a safe space in which to deal with those issues, a place where are are neither pressured to be sexual nor to be asexual, a place to read about others' experiences and feelings and to think about their own feelings and experienced. As the Venus of Willendork writes:
For many, asexuality is not a safe space. It’s an identity, – and one that sometimes brings misunderstanding, pain, and rejection, even ridicule or betrayal. For others, it’s the exact security necessary to begin the difficult process of unpacking one’s past...I know that exploring difficult issues and working to heal them requires the secure environment where one can do so “safely” and with support. Being badgered into sexuality has done nothing for me. Being allowed to identify as asexual has allowed me to address the possibility that I am not.
And sometimes, even when people have issue to deal with, they're not always ready to deal with them.

I think it is precisely because of this point that many who believe either B or C tend to keep these opinions to themselves. Even when it is obvious that some person isn't "really asexual" but is just identifying as asexual to hide from their own insecurities or to justify their anti-sexual views, telling them as much isn't helpful. Everyone who identifies as asexual has a reason for doing so, regardless of whether you or I or anyone else thinks that it's a good reason or not. Telling them that they aren't asexual, or even strongly suggesting the possibility, will likely be perceived as an attack on a part of their identity. (If someone thinks that the asexual claimant is really asexual, they're probably not going to ask, "Have you considered the possibility that you're not really asexual but that you're just [fill in the blank]?" And the recipient of the question, simply by being asked it, becomes aware that their interlocutor doesn't really believe that they're asexual.) When people feel that part of their identity is being attacked, they often get defensive. And being defensive is not when we are the most inclined to do the introspection and self-reflection necessary to deal with the issue that needs dealing with.

My own view is that if people identify as asexual because of very negative views of sexuality, trying to help them see how sex can be a positive thing in some contexts (at least for other people) is probably more useful (and more likely to have some measure of success) than trying to convince them that they're not asexual. Of course, it's fully possible that some asexuals (especially younger ones) may end up having rather negative views of sexuality. There is a lot of really awful shit that goes on where sex is concerned, and there are a lot of profoundly negative personal of social consequences of how sex can be--and often is--used. Of course, in some contexts, sex can also be a very positive experience as well. For people who have no positive personal experience with sex and no sexual desire, it seems likely enough they some of them may tend to see more of the negative aspects and use this to reinforce anti-sexual views, while ignoring the positive aspects of sex and sexuality.

So my point is this: even if some people who aren't "really asexual" identify as asexual, so what? Why is that such a bad thing? And even if it sometimes is a problem, is telling them that they're not really asexual going to be helpful? Who is telling non-asexuals that people identifying as asexual aren't really asexual going to help? Probably not the people currently identifying or thinking about identifying as asexual.

Saturday, July 11, 2009

You're not asexual: You're just not willing to accept your true sexuality.

Although the not-accept-true-sexuality response to asexuality doesn't seem to be as common as the (maybe)you're-gay response, it is a more generalized version of it. Instead of asserting someone is (or might be) claiming asexuality because of a refusal to acknowledge their homosexuality, this response suggests someone is claiming asexuality because of a refusal to acknowledge their sexuality, whether that is a socially stigmatized sexuality, the most vanilla heterosexuality imaginable, or anything in-between.

Before Clay Aiken came out as gay, there was speculation that he may be asexual, though he never himself claimed this. In an ABC News article, Could 'American Idol' Star Clay Aiken be Asexual?, they quoted a sex-educator who affirmed the legitimacy of asexuality but pointed out that Aiken's comments could not be taken to mean he was asexual. They also quoted a sex-therapist with less positive things to say.
Using asexuality as an excuse, according to Ian Kerner, sex therapist and author of "Sex Detox," is also common for people who have had negative sexual experiences earlier in life or are trying to hide their true sexuality.

"There are many people who are confused about their sexuality or their sexuality is in stark contrast to their social and cultural values," said Kerner. "So they think it's easier to be asexual than to acknowledge their unique sexuality and identity."

Of course, there are a number of points on which this can be criticized: the sex-therapist probably knows virtually about asexuality as the term is understood in the asexual community. However, rather than admitting his ignorance on the subject, he equivocates on the meaning of asexual to feign expertise and to speak with seeming authority on the matter. And then there's the fact that people leading non-sexual lives who decide to go see a sex-therapist about it are probably not representative of people leading non-sexual lives in general. And then there's the fact that the things he associates with non-sexuality are pretty standard ones that sex-therapists have been claiming for decades. However, I've never seen anyone do so with a citation. Even in books on sex-therapy. It seems that a lot of it comes from people being told to look for these things in sexual disinterested people (but not necessarily ask about in other cases), so when they find them in some such people, this belief is reinforced. This is called confirmation bias. Hypothetically, the remedy for this would be actual scientific data, but that data just doesn't exist.


In the asexual community, there seem to be three main classes of beliefs regarding the not-accept-true sexuality response.

(A) It's WRONG, WRONG, WRONG: Asexuals are asexual! They are NOT people who are afraid of their sexuality!
(B) It's wrong in a number of cases (certainly some people really don't experience sexual attraction), but the criticism is right in many cases; this is a real problem. The result is a mixed view towards asexual identity.
(C) It's wrong in a number of cases, and even when it's true, so what? What's wrong with someone temporarily using asexuality to hide from issues they aren't ready to deal with?

Corresponding to these beliefs, there are, potentially, three kinds of replies from within the asexual community to the not-accept-true-sexuality response. To make sense of this, it is important to note that there are really two parts to the not-accept-true-sexuality response:

(1) People calling themselves asexual are really just unwilling to admit their true sexuality.
(2) This is a bad thing.

The three reply-types are:

(A'). The claim in (1) is wrong: Asexuals are not people unwilling to accept their "true sexuality."
(B'). The claim in (1) is clarified and the one in (2) is accepted: Some people really are asexual (and should be accepted as such), but many people identifying as asexual really are just afraid to accept their sexuality; this is a real problem.
(C') The claim in (1) is clarified and the one in (2) is rejected: Some people identifying as asexual really are asexual, and even if some are "just" unwilling to accept their sexuality, so what? That might not be a bad thing.

Furthermore, responses of these three types can function at the individual level (focusing on one's own experience) or the general level (it's not a valid criticism of asexuality more generally.) I'll refer to these A'-personal, A'-general, B'-personal, etc. For example, the blogger Naturally Curvy, in her Introduction to Asexuality uses A'-personal: she emphasizes that she is sexually experienced (it's not for a lack of trying to be sexual or trying sexual activities), and she mentions multiple non-standard sexualities that she tried on (and couldn't get them to fit) before identifying as asexual. The blogger The Venus of Willendork, in the post Hide and Seek, uses C'-personal, and then uses this as a springboard for C'-general: she explains why she thinks it would be perfectly reasonable for someone in her position to identify as asexual (even though she doesn't identify as asexual anymore), and then discusses how using a temporary asexual identity may be helpful to provide a safe space for people trying to figure things out.

Now, it is worth noting that while the beliefs A, B, and C correspond to the responses A', B', and C' respectively, believing in one of the former does not have to mean that someone employs the corresponding response, and using one of these responses does not necessarily mean that someone holds the corresponding belief. For example, someone who believes B or C cannot (honestly) use A'-general, but they could very reasonably use A'-personal. Moreover, beliefs often do not result in expressing those beliefs. Sometimes we have no occasion to express some opinion, and sometimes we feel the need to keep an opinion to ourselves. I rarely see opinions B and C expressed, and when they are, it's usually privately, or, if publicly, on Apositive or a blog (i.e. not on AVEN.) People are either afraid of being attacked or afraid of being subversive. This is especially the case with B: people recognize the importance of asexual identity for some people and do not want to give fodder to those eager to delegitimate asexuality.

In my next post, I intend to defend option C: even if some people identifying as asexual, aren't "really" asexual, so what?