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 I understand that 'Confidential Information' includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other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.