Pathology and Asexual Politics

The asexual community has only existed for about ten years, and its existence is due in large part to the growth of the internet.  The center of the community is the Asexual Visibility and Education Network (AVEN, asexuality.org), which defines an asexual as “a person who does not experience sexual attraction.” The site contrasts this with celibacy, which it asserts is a choice, whereas asexuality is a sexual orientation. The main political goals of the asexual community are visibility, acceptance, and understanding. One major means for this involves academic outreach and our representation in academic discourse.


I first discovered the asexual community in fall 2007, my first semester of graduate school.  Even before I eventually decided to identify as asexual, I have wanted to find out as much as I could about the subject.  My own attempts to understand the matter, as well as the realization that I had substantive contributions to make, have led to my involvement in academic outreach. (For instance, I run the site asexualexplorations.net, which “exists to provide promote the academic study of asexuality.”)  I have taken a particular interest in the diagnosis Hypoactive Sexual Desire Disorder (HSDD) in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which led to my involvement in the “AVEN DSM Taskforce,” a group that lobbied the DSM-5 Sexual Dysfunctions Subworkgroup trying to make DSM-5 more asexual-friendly.  I have remained interested even after we completed that project.

Asexuality and the Question of Pathology

After the formation of the asexual community, it was not too long before the community became aware of the fact that in the DSM, there is a disorder about not being interested in sex. (The diagnosis is also in the ICD, but the ICD attracts less controversy). As one of the major political goals of the community is to convince people that there is nothing wrong with not being interested in sex, this diagnosis is not especially helpful for that goal.

In considering what kind of approach the asexual community should take toward the matter, one question that seems like a good starting place is whether asexuality is a sexual dysfunction. I have sometimes seen the question posed as an either/or: Is asexuality a sexual orientation or a sexual dysfunction? Some authors (e.g. Prause & Graham, 2007) have done data collection regarding asexuality and claimed that their results suggest that asexuality is not a sexual dysfunction. Such claims are likely good for our politics, but they make absolutely no sense to me.

There is a considerable literature on defining disorder, a task known to be difficult (many authors think impossible). Most authors, however, agree that at least some amount of value judgment is involved. Often these value judgments are quite uncontrovercial: death, pain, and inability (or greatly increased difficulty) in accomplishing everyday tasks, are fairly universally regarded as negatives that, if possible, should be prevented. For the ones other than death, if they are not prevented, they should be cured if possible, and if not, treated to make the problems more manageable and/or to slow/prevent worsening of the condition. With regard to asexuality, there is the question of what harm it causes. It does not cause death or pain, and it only causes disability if we define it as such. This was, in fact, part of the rationale for including the sexual dysfunctions in DSM-III (Spitzer, Williams, & Skodol, 1980; Spitzer, 1981) without a requirement of distress—the complete sexual response cycle was regarded as normative such that any “inability” to experience such was defined as an impairment in an important area of functioning (c.f. American Psychiatric Association, 1980, p.6).

A core part of people’s intuitions about what is a disorder (including sexual dysfunctions) is that something has gone wrong in the individual. Something is not working how it ought. In my own view, the oughtness inherent in this question means that science cannot answer it (though it can inform an answer.) This view is controversial—some consider function of some part of an organism to be objectively definable (e.g. the heart is for pumping blood.) While I am skeptical,[1] even if we accept that, objectively, the heart is for pumping blood, what is sexual attraction for? What is sex for?  The main answers I’ve seen are a) procreation/finding a partner for such, b) pair-bonding, and c) declaring agnosticism with a skeptical attitude towards those who presume to know [2] My own view, option (c), renders problematic the entire notion of “sexual dysfunction.” A further issue is what I call “the brute fact of the optionality of sex.” Having sex and being interested in sex are optional in a way that eating, breathing, and having a heart that pumps blood are not. It is possible to never have sex and never want sex and it not create any problems in a person’s everyday life. This renders problematic the whole notion of functional oughtness for sexual attraction/interest, making problematic the very notions of “sexual function” and thus “sexual dysfunction.”

As I do not think that asexuality objectively is or is not a sexual dysfunction, the question I think we should be asking is whether regarding it as such makes sense conceptually and pragmatically. Conceptually, I do not think that it does. Pragmatically, we need to be cautious—what effect, if any, this diagnosis has on asexuals is unknown. We simply do not have the data. Posing the question in this way motivates us to ask another essential for asexual politics: how is asexuality different from HSDD? There are two kinds of answers to this question: extensional and valuational/practical. Extensional differences—who fits which group—are often the only ones that come to mind. They are, for instance, the only ones addressed in Bogaert’s (2006) discussion of the matter. This line of thinking seems to stem from treating asexuality and HSDD as somehow “objectively existing” rather than as more nominalist type categories. I am more interested in valuational and practical differences.

One such difference is that HSDD focuses on lack of sexual desire, and asexuality on lack of sexual attraction. HSDD is a more negative valuation of sexual disinterest and asexuality a more neutral/positive one. HSDD was created by physicians (Kaplan, 1977; Leif, 1977) and is diagnosed by clinicians. The conceptualization “asexuality” was created by asexuals, and the designation—an identity—is self-assigned.  Moreover, the conceptualizations HSDD and asexuality will give rise to very different research questions.  However, one important similarity should be noted: lack of interest in sex often causes difficulties in people’s lives that they want help with. [3] Both asexual identity and HSDD are conceptualizations that exist to try to help people deal with these issues.

Asexuality vis-à-vis Pathology

In discussing how asexuality is different from HSDD (i.e. why the DSM does not say asexuality is a disorder), perhaps the most commonly raised point concerns the fact that since DSM-IV (American Psychiatric Association, 1994), for a diagnosis of HSDD to be made, the lack of sexual interest must cause “marked distress or interpersonal difficulty,” although the second half of the disjunction is often ignored. Asexuals are not distressed about it, therefore they do not have this disorder, therefore the DSM does not say that asexuality is a disorder. Some people seem satisfied with this, but others do not. I can think of three reasons that one might not consider this sufficient. First, many people are distressed about their asexuality before identifying as asexual, and there is concern for these people. Second, not every condition that can potentially cause distress or interpersonal difficulty is included in the DSM.  Including some but not others creates a real asymmetry and a sense of negative valuation (even if not a “mental disorder” label) for those that are included. Many in the asexual community are concerned about mental health professionals that will try to “treat” the asexuality of asexuals who are seeking out therapy for some unrelated issue. Third, as long as HSDD remains on the books, there is fear that the pharmaceuticals will someday get the FDA (Food and Drug Administration) to approve a drug for it (that probably will have small, but statistically significant, efficacy), and they will engage in massive “educational campaigns” to create distress about lack of interest in sex (see Anderson, 2005). [4]

A political question that those challenging the pathologization of asexuality must ask is whether to challenge the pathologization of asexuality only or whether to challenge the pathologization of sexual disinterest more generally. This is an important question because asexuals seem to be a small minority of the people not interested in sex [5] This question parallels two general approaches I have seen among those supportive of asexuality. The first is to limit the domain of “sexual dysfunction” and to distance asexuality from it. This approach often involves placing strong emphasis on the requirement of distress (e.g. Brotto, 2010) and claiming that some data supports the view that asexuality is not a sexual dysfunction (e.g. Prause &  Graham, 2007). Also falling in this approach is a suggestion by Brotto (2010), who proposes adding a comment in the DSM that this diagnosis does not apply to asexuals. The second approach is to question the notion that lack of interest in sex is dysfunctional or to question the very notion of sexual dysfunction. To date, the second of these has not been given much voice from within the asexual community, but there are some outside of the asexual community who have been advocating a similar position (e.g. Tiefer, 2004). For those favoring this second option, I recommend three approaches:

(1) Make alliances with people in and supportive of the New View Campaign (newviewcampaign.org), which focuses on sexual problems rather than sexual dysfunctions and rejects any kind of universal sexual norm.

(2) Use asexuality as a wedge for highlighting existing problems with HSDD. This includes the fact that HSDD is such a diverse group, it almost certainly fails Spitzer and Endicott’s (1978) requirement that a disorder be a syndrome rather than a symptom. I know of only a few authors who have even dared to raise this question (e.g. Leiblum & Rosen, 1988), likely because the answer is intuitively obvious and unfavorable for HSDD. However, I would go farther and argue that sometimes lack of interest in sex is a symptom of some disorder, sometimes is “normal variation” and sometimes is an adaptive response to a negative situation (e.g. as a response to relationship problems; see Bancroft, Graham, & McCord, 2001). Another line of argument is to highlight DSM-IV-TR’s (American Psychiatric Association, 2000) absurd suggestion that the difficulty in distinguishing between pathologically low levels of sexual interest and “low normal” levels of sexual interest is the lack of “normative data.”

(3) Do qualitative research on asexuals experiences in therapy (for issues related to or unrelated to their asexuality), on people’s experiences of sex-therapy getting treatment for HSDD, and on the effects of this diagnosis in personal conversations and in educational settings. This research is vitally important for asexual endeavors. It is entirely possible that the situation is not as serious as some may think. In any research project, the results virtually always prove more complicated than whatever hypothesis the researcher first had in mind.

Conclusion

The questions of the relation between asexuality and HSDD are likely to remain important to the asexual community and our allies, and there are multiple approaches that can be taken that are worth exploring. Because of the pragmatic issues involved and the lack of available data, caution is needed, as is research on the effects of this diagnosis. Also, it must be recognized that the situation is complicated by the fact that the DSM-5 Sexual Dysfunctions Subworkgroup is proposing to replace HSDD with Sexual Interest/Aversion Disorder (SIAD), possibly splitting it into one diagnosis for men and other for women, [6] and what these changes would mean for the asexual community are unclear. Further, asexual are not the primary group HSDD/SIAD is intended for. Given that there are many non-asexuals who may qualify for this diagnosis, their good must be considered in whatever strategy is taken. There are no easy answers, but it is important to ask the right questions.

References:

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Anderson, A. (2005). Is Lack of Sexual Desire a Disease? Is Testosterone the Cure? Medscape Ob/Gyn & Women’s Health, 10. Available at: http://www.medscape.com/viewarticle/512218.

Bancfort, J., Graham, C.A., & McCord, C. (2001). Conceptualizing women’s sexual problems. Journal of Sex and Marital Therapy, 27 (2), 95-103.

Bogaert A. F. (2006). Toward a Conceptual Understanding of Asexuality. Review of General Psychology, 10, 241-250.

Brotto, L. A. (2010). The DSM diagnostic criteria for Sexual Aversion Disorder Archives of Sexual Behavior, 39, 271-277.

Kaplan, H.S. (1977). Hypoactive sexual desire. Journal of Sex & Marital Therapy, 3 (1), 3-9.

Leiblum, S.R., Rosen, R.C. (1988) Introduction: Changing perspective on sexual desire. in Leiblum, S.R., Rosen, R.C (eds). Sexual Desire Disorders. pp. 1-15.

Lief, H. (1977). Inhibited sexual desire. Medical Aspects of Human Sexuality, 7, 94-95.

Prause, N & Graham, C. A. (2007) Asexuality: clarification and classification. Archives of Sexual Behavior, 36, 341-35.

Spitzer, R. L. (1981). The diagnostic status of homosexuality in DSM-III: A reformulation of the issues. American Journal of Psychiatry, 138, 210-215.

Spitzer, R. L., & Endicott, J. (1978). Medical and mental disorder: Proposed definition and criteria. In R. L. Spitzer & D. F. Klein (Eds.), Critical issues in psychiatric diagnosis (pp. 15-39). New York, NY: Raven Press.

Spitzer, R. L., Williams, J. B. W., and Skodol, A. E. (1980) DSM-III: The major achievements and an overview. American Journal of Psychiatry, 137, 151-164.

Tiefer, L. (2004). Sex is not a natural act & other essays (2nd ed.). Boulder, CO: Westview Press.

[1] I doubt it is possible to go from “in living organisms the heart pumps blood; if the heart does not pump blood the organism dies” to “the heart is for pumping blood” without regarding being alive as normative.)

[2] The difference between (a) and (b) can be seen with homosexuality, which is a dysfunction according to the former, but not the latter.

[3] If asexuality never caused anyone any difficulties, there would be need to discuss these issues, nothing for people to try to figure out, no political goals to accomplish, and thus no asexual community.  Likewise, HSDD/ISD were first regarded as disorder in part because of people presenting to clinicians with this issue.

[4] In the US, pharmaceuticals can advertize directly to the general public.

[5] The impression is that most asexuals’ have always not been interested in sex, whereas most people with HSDD have not, although I am not aware of any data confirming these impressions.

[6]http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=432

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=434


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