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

Specifiers
(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?

Conclusion
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.