Female Sexual Interest/Arousal Disorder & Male Hypoactive Sexual Desire Disorder in the DSM-5

Transcript

Courtney: Hello everyone and welcome back. My name is Courtney. I’m here with my spouse Royce. Together we are the Ace Couple and we are continuing our series about asexual medicalization. two weeks ago we did a wide look at a vast history of asexual medicalization. Last week we talked about the recent iteration of the ICD specifically pertaining to their diagnosis of hypoactive sexual desire dysfunction.

Courtney: And today we are diving into the DSM-five. If you will recall from two weeks ago, the hypoactive sexual desire dysfunction diagnosis, HSDD, was in an earlier edition of the DSM. The DSM-five sort of took that existing framework and has split it into two different diagnoses that I want to look at today.

Courtney: The first being female sexual interest slash arousal disorder, and the second being male hypoactive sexual desire disorder.

Royce: Anywhere in the DSM-five does it try to classify hyperactive? Because generally in any sort of medical situation where you have a hypo, you also have a hyper.

Royce: There’s, if there’s a low, there’s also a high that is being watched for.

Courtney: Why, I am so glad you asked, because of course the word hyperactive appears in the DSM. Pertaining to a variety of other diagnoses, specifically it’s mentioned under like ADHD as an example that most of you I’m sure have heard of. But under the entire section of sexual dysfunctions, no, there’s no hyperactive sexual dysfunction in this manual. Which is, from an anecdotal standpoint, extremely fascinating to me because I do know several aces who for a very long time did not realize they were asexual because of whatever their respective psychiatric diagnosis is. I’ve I’ve heard this from people with a few different labels and identities and whatnot, where periods of time where they do get sort of hyperactive sexually tends to correspond with negative mental health outcomes. Whether that be a type of mania, a type of, you know, alcohol dependency.

Courtney: I’ve heard this from a variety of aces who said, actually, during times where I feel hyperactive sexually, that is a symptom. My baseline, my healthiest level is little to no sexual attraction or desire. But if you’ll recall this sort of history pertaining to this evolution of diagnoses, it very much started with sex therapists who tried to expound upon preexisting ideas about, you know, to use their word, dysfunctions that could occur at various points within sexual activity and sexual engagement.

Courtney: And they thought, well, we’re missing something here. There’s the very first stage, and that is interest in the thing itself. It is the desire, it is the attraction. Because in their minds, which to me makes all of these diagnoses discreditable, is that the very foundational framework of these is if you do not have that sexual interest, or you don’t have enough of it, or as much as we think you should have, that is a problem. And obviously designating how much attraction or interest or desire is appropriate and healthy is going to be a net negative for all of society, and a variety of people can be harmed by this existing framework, but it is disproportionately going to impact the asexual community. And so if we look at it specifically from that viewpoint of our community, it’s almost even more egregious that they took an already bogus blanket diagnosis like HSDD and split it into male and female.

Courtney: And change the verbiage around female to be sexual interest slash arousal, because as we know, the asexual community has a much higher percentage of folks identifying as nonbinary. So just to give us a primer for these two diagnoses, I’m gonna go ahead and pull from the desk reference to the diagnostic criteria from DSM-five, because this is the shortened, edited-down version of the full diagnostic manual. And although there are asexual activists who, thanks to their work, did get a little nod to asexuality added in the DSM, it is absent from this DSM-five reference. So anybody who has the shortened, easier to store, easier to carry, easier to put on your desk version of this, there is absolutely no mention of asexuality. So let us begin with female sexual interest slash arousal disorder.

Courtney: I already think that is an absurd title. Because we in the ace community spend so much time thinking about what is attraction, what is interest, what is arousal, and how many of these things do I feel, and do I feel them in a comparable way to a general allosexual population, or in what ways does it differ. So there are many arguments to be made that interest and arousal themselves are not always synonymous.

Royce: Outside of the realm of psychology, there’s also a long history of bad research and medical or scientific theories about female arousal in the first place.

Courtney: Yes. And mind you, the earlier iteration of this being HSDD and the title it went by before that were all basically put in here with no comprehensive studies. And in fact, there were people who took a second look at this saying, “Do we actually have enough uh evidence to keep this in here?” But because they could not produce enough studies to refute these, it had to stay in. Because not only is our fundamental understanding of these things evolving over time, but our scientific standards have also changed throughout this process. And as this diagnosis proves, that shift in standard made it very difficult to remove things that were put in before we had these requirements.

Courtney: So how does the DSM-five define female sexual interest slash arousal disorder? A lack of or significantly reduced sexual interest slash arousal as manifested by at least three of the following. So again, we have lack of sexual interest or not enough sexual interest.

Courtney: They give six examples. One being absent slash reduced interest in sexual activity. two, absent slash reduced sexual slash erotic thoughts or fantasies. three, no slash reduced initiation of sexual activity and typically unreceptive to a partner’s attempt to initiate. four, absent slash reduced sexual excitement slash pleasure during sexual activity in almost all or all sexual encounters. five, absent slash reduced sexual interest slash arousal in response to any internal or external sexual slash erotic cues. Example, written, verbal, visual.

Courtney: Or six, absent slash reduced genital or non-genital sensations during sexual activity in almost all or all sexual encounters. A majority of asexual people I know hit at least three of these six.

Courtney: I would love to be a fly on the wall when they were deciding on the verbiage for this, because there’s a lot of slashes in there. Interest slash arousal, sexual slash erotic, absent slash reduced.

Courtney: It’s almost as if they themselves could not settle on a definition of the words or the right word to use, so they just used both. Or they acknowledge that they can be two different things and are like, “Well, either is a problem. Both is all a problem, because at the end of the day, this person is not experiencing the correct sexual interest. Therefore, we must come up with a diagnosis to slap on this person.” So, if an individual has at least three of these six, which in my experience, a high percentage of aces would hit.

Courtney: Then we go on to B, the symptoms in criterion A have persisted for a minimum duration of approximately six months. C, the symptoms in criterion a cause clinically significant distress in the individual. And D, the sexual dysfunction is not better explained by a non-sexual mental disorder or as a consequence of severe relationship distress like partner violence, or other significant stressors, and is not attributable to the effects of a substance slash medication or another medical condition. So we talked quite a bit last week, and I’ll make the same argument here about significant distress in the individual. A lot of distress that folks belonging to any minority sexual identity often comes from Lack of support from family, friends, partners, society on the whole, overt bigotry, an increased risk of domestic partner violence, an increased risk of being offered or undergoing conversion therapy.

Courtney: And really ask yourself, really, really ask yourself, anytime you encounter something like this that you go, “Oh, that seems a little strange, that seems a little unnecessary,” Truly ask who could stand to benefit from a framework like this. So let’s say there is an individual who has not yet gained the vocabulary to understand or explain themselves as an asexual person.

Courtney: They meet three or more of these very common ace experiences. Number one, just being absent or reduced interest in sexual activity. Absent or reduced sexual or erotic thoughts or fantasies.

Courtney: And they are distressed by this because they live in an allocentric world that is enforcing compulsory sexuality on them. They are told if you do not have a healthy, quote, heavy, quote, flourishing sex life, you aren’t going to be able to maintain a romantic relationship. And a romantic relationship is the only way you can be successful in life and you can be happy. long-term.

Courtney: Yeah, someone like this might be clinically significantly distressed. And so a, you know, medical professional does their due diligence and says, well, I don’t see any other mental disorders that might be causing this. I don’t see any evidence that you’re experiencing partner violence. I don’t see that there are any substances or medications that could be attributing to this.

Courtney: So with this framework, instead of saying, “Maybe this is just how you are, and maybe this is a natural variation of humanity and that is okay, and how do we get you to a place where you can feel confident in this?” The answer is, “Must be a sexual mental disorder.”

Courtney: What people, what systems, what frameworks stand to benefit from that being the default. As we will go uh further down that rabbit hole in a future episode, a lot of it is pharmaceuticals. Viagra was an enormous hit for pharmaceutical companies, made all kinds of money. With the success of Viagra, there was an immediate response of how can we sell something similar to women? And much like uh HSDD got sort of separated out in the ICD, it does prompt the one diagnosing female sexual interest slash arousal disorder to specify whether it is lifelong or acquired, generalized or situational. And when they specify lifelong or acquired, they call it the “disturbance.” “The disturbance has been present since the individual became sexually active.” Or acquired.

Courtney: “The disturbance began after a period of relatively normal sexual function.” So to me, even if we were looking at the full DSM right now with one little line that doesn’t do enough to say some people are asexual and that’s fine, if someone’s asexual, don’t diagnose them with this. They’re literally calling- their worldview, their framework here is absence or reduced interest in sexual activity is a disturbance. Not only if it just, you know, poof, happens one day and completely changes your entire world, it’s still called a “disturbance” if this has been lifelong. That in and of itself, we need to push back on. Because it’s not a situation of everyone needs to have enough sex and the right kind of sex and sex with the right people to live a good, happy, healthy life, asterisk, unless you’re asexual.

Courtney: That in and of itself is a harmful worldview that is perpetuated by diagnoses like this. Specify whether it’s generalized, not limited to certain types of stimulation, situations, or partners. Or situational, only occurs with certain types of stimulation, situations, or partners. Again, who is the judge of, “Oh, you don’t have arousal or interest in this particular type of stimulation?

Courtney: Maybe you should.” Maybe you should. Oddball behavior.

Courtney: But then we add, specify the severity. Mild, moderate, or severe. Mild is evidence of mild distress over the symptoms, evidence of moderate distress over the symptoms, or evidence of severe or extreme distress over the symptoms. Even though I personally have no distress, uh my lack of sexual interest and attraction is quite severe. It’s it is strong within me.

Courtney: Honestly, at this point, someone ought to just give me a Shirt that says “severe frigidity.” So let’s move along now to male hypoactive sexual desire disorder.

Courtney: All of the specifications remain the same. So lifelong, acquired, generalized, situational, mild to severe. That language all stays verbatim.

Courtney: So what are the signs? A, persistently or recurrently deficient or absent sexual slash erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual’s life. I ask you, if they specify for male hypoactive sexual desire disorder that it is the judgment of the clinician as to whether or not they have enough erotic thoughts or sexual fantasies or enough sexual activity, and they don’t say it’s at the judgment of the clinician for uh the female-

Royce: Medical science is like, okay, we understand men, but we have no idea what’s going on over here with these women.

Courtney: It’s also- it’s so weird. It’s so weird because these two branched off from the same general HSDD diagnosis.

Courtney: But because of the state of women’s health and the overt sexism in medical care, I know damn well in other areas of medicine there are women who have not been able to make their own medical choices because, well, their husband needs to sign off on it. Or if they are young and don’t have a husband yet, what if your future husband wants kids? Like, I I know instances of this where women literally have not had their autonomy respected in medical settings because of either a man or a theoretical man. So it seems downright dangerous to me that they’re like, well, for men, the clinician’s going to judge this. Because I just don’t trust that for lack of that line for female sexual interest arousal disorder, that they’re like, we’re just going to trust the woman on this one. Because medical science doesn’t tend to just trust the woman on this one.

Courtney: Is this a situation where in a, you know, hetero-presenting type relationship, the man is like, “We’re just not having enough sex. She doesn’t wanna have sex with me. She doesn’t, you know, respond when I initiate. She never initiates.”

Courtney: Eh, I I don’t like it. I don’t like it.

Courtney: It’s odd enough that you already split it into male and female, but to add that extra content on male alone is, it’s it’s suspicious. We should look at targeted, you know, heavy quotes again, “sex-based” changes and differences with an abundance of skepticism.

Courtney: And just like in the previous diagnosis, we do have “persists for a minimum duration of six months.” We have “causes clinically significant distress.” And also verbatim, we have “not better explained by a non-sexual mental disorder or substances or severe relationship.” So another very suspicious difference here is that for the female version of this disorder, they have six criterion and say you need to meet at least three. For the male version of this disorder, it’s just one. It is just persistently or recurrently deficient or absent.

Courtney: Sexual slash erotic thoughts or fantasies and desire for sexual activity. That’s weird. That’s suspicious. So here is the last little nugget that I’m gonna leave you off with today before we dive further down this path next week.

Courtney: When we pop over to the full text in the DSM-five, under female sexual interest slash arousal disorder, there is one line amidst all the paragraphs defining diagnostic features that says, “If a lifelong lack of sexual desire is better explained by one’s self-identification as ‘asexual,’ then a diagnosis of female sexual interest slash arousal disorder would not be made.” Male hypoactive sexual desire disorder has no such caveat.

Courtney: Please join us next week for what I believe will be the last chapter of this little series, where we’re gonna dive further into the full text of the DSM-five. Under each of these respective disorders, as they define them, there are several paragraphs defining diagnostic features, Associated features, supporting diagnosis, prevalence, development and course, risk and prognosis factors. It’s it’s it’s just goofy to me to even have the word prognosis anywhere near a lack of sexual desire. I guess I do have a doctor friend that every now and then if I see a like, “You’re at an increased risk of death if you don’t have sex at least two times a week,” those kind of statistics. It is fun to screenshot those and say like, “Give it to me straight, doc. How much time do I have?”

Courtney: But that is all in jest within our own community. There are, you know, extrapolations on culture-related diagnostic issues, gender-related diagnostic issues, functional consequences of the disorder, differential diagnosis, and comorbidity. So we’re going to dive deep into the text of all of those subsections for female sexual interest slash arousal disorder and male hypoactive sexual desire disorder. But first, I am going to leave you off today, as always, with our fabulous featured marketplace vendor, Bwilet Comics, where you can find games and comics featuring queer characters and queer stories by a disabled ace. creator. And oh my goodness, are there some fun stories here, such as the Sorcerer’s Apprentice, Midnight Menagerie, The Final Boss’s Son loves the protagonist, and our current favorite, Kaiju Crush.

Courtney: As I said, some of these are comics, some of these are games. Kaiju Crush, for example, is a visual novel. That you can download on itch.io or Steam. Links to find Will it Comics, as always, are going to be in the show notes on our website as well as the description box if you happen to be listening on YouTube.

Courtney: As always, thank you all so much for being here, and we will see you all next week for even more DSM-nonsense. Goodbye!