The Medicalization of Desire

Men in the medical field couldn’t understand why their wives didn’t enjoy having sex with them, so instead of finding the clitoris, psychiatrists in the 1950s decided their wives must have a medical disorder. The Diagnostic and Statistical Manual of Mental Disorders has included a sexual disorder defined by a woman’s lack of sexual desire since the first edition. The name of this disorder has changed from frigidity to inhibited sexual desire to Hypoactive Sexual Desire Disorder to Female Sexual Interest/Arousal Disorder. While there are differences in the specific diagnostic criteria, all of the disorders apply to women who have low interest in sex. To be diagnosed with FSAD, a patient has to have at least three of six possible symptoms. Four of these symptoms involve lack of interest in sexual activity, cues or thoughts. The other two involve mental and physical reactions during sexual encounters. These symptoms must have lasted six months and have caused significant distress. Anyone who is experiencing significant distress should be able to get treatment for their distress, but the treatment has to understand the nature of that distress. The distress that patients with FSAD experience comes from flawed relationships and the pressure that tells young women what their relationship with sex should be. The sexual revolution had many benefits, but it didn’t achieve the sexual liberation that it claimed to be fighting for. Instead, the sexual revolution promoted the idea that women should be sexually active. The idea that a liberated woman is a sexually active woman justified FSAD while adding to social pressure on women.

There are many reasons why a woman could experience low sexual desire, and none of them are because there’s something wrong with her. A lot of women stop desiring sex because they have negative associations with past sexual encounters. This is common because the medical industry often equates sex and vaginal intercourse. A woman who experiences sex as just intercourse is unlikely to get significant pleasure from the experience, causing her to prepare less in the future and use less lube which can then cause pain. This pattern ends in a disinterest or outright dislike for sexual activity. Women may lack desire because their partners are bad at sex, not because they have a mental disorder. The DSM 5 tries to address partner responsibility by excluding cases where the woman has significant relationship distress, but that ignores the many men and women who are in healthy, kind relationships but have bad sex. An FSAD diagnosis puts the responsibility on the woman, because it tells her that the lack of desire is a mental problem without acknowledging the role her sexual partners may have played. This can result in more distress if she is unable to increase her desire. The only part of the FSAD diagnosis that should be treated is the distress about lack of sexual desire.

A lack of sexual desire isn’t bad or wrong. When people try to argue that sexual desire is good and necessary, they talk about the enjoyment that sex brings or the intimacy that sex adds to a relationship. Intimacy and enjoyment are not unique to sex. You can have fun with a partner without getting naked. Several of my friends think that video games are fun, but I have no desire to play video games, so I don’t miss the joy that they might bring to my life. I enjoy knitting, but know plenty of people who have no desire to knit. I would never criticize their lack of desire because I know that interest in different activities will naturally vary between people. There is no reason someone who doesn’t desire sex as much as others should be treated any differently. Sharing personal stories is very emotionally intimate and just cuddling can produce a similar intimacy to sex. People who desire sex might find the comparison ridiculous, but we need to check our assumptions about the importance of sex and what role it should play in relationships. Just because you want a lot of sex or enjoy frequent sex doesn’t mean that everyone does or should. The idea that frequent sex is an essential part of a healthy relationship is reinforced time and time again by pop culture and stories traded between friends, but there is nothing wrong with someone who wants less sex than their friends. If someone is distressed about their low desire, the only thing that should be treated is the distress, not the lack of desire.

When people defend FSAD’s inclusion in the DSM, they argue that the women who are diagnosed experience significant distress and deserve to be acknowledged and treated. This is true, but it ignores the significant differences between the way distress over low sexual desire and other types of distress are discussed. Firstly, there are many things that people are frequently distressed by that are not in the DSM 5. People are distressed by their outfits, their schoolwork and their finances. Despite the frequence of distress about each of these three things, there is no specific diagnosis for someone who is stressed about their schoolwork. Regardless of whether someone’s stress has a name or diagnosis, they deserve treatment and attention. 

The current diagnostic criteria of FSAD are not focused on distress, but emphasize the lack of desire which reinforces the idea that a lack of disorder is a clinical problem. Aside from the criteria that the patient must experience distress, the diagnostic criteria are not about the distress or how this distress impacts someone’s life. The diagnostic criteria focus far more on if and when a female experiences low sexual desire. If FSAD was about treating the distress caused by a perceived low level of desire, it wouldn’t matter how much a woman actually desired sex. It would only matter how much distress she experienced as a result of thinking she didn’t desire sex enough. This is fundamentally different from the FSAD diagnosis we have now. The current diagnosis relies on sexist ideas of female sexuality and reinforces negative stereotypes about sexuality. 

People sometimes argue that discussing FSAD is feminist. This was especially true in the campaign to gain FDA approval for Addyi, a drug that treated FSAD’s diagnostic ancestor. Treating sexual desire disorders acknowledges that women have sexual desire, and historically people have ignored female desire or emphasized the importance of virginity. This is different than never wanting women to express desire. Women were always supposed to have sexual desire when their partner wanted them to. After a woman was married, her sexual desire belonged to her husband and when it conflicted with his desires, it was wrong. FSAD continues this historical sexism far more than it confronts it. FSAD continues the traditional of telling women there is something wrong if they don’t want to have as much sex as their partner. Even if FSAD doesn’t directly say that low levels of sexual desire are unnatural, the emphasis the diagnostic criteria places on sexual desire will make women, or doctors, believe this. Due to the history of medicalization of women’s sexuality, FSAD reinforces sexist norms that hurt women.

This diagnostic criteria for FSAD are deeply flawed, to the point where the continued existence of the diagnosis cannot be justified. It is possible that with significant revision, designed to highlight the distress caused by the disorder, a similar diagnosis could still be relevant and useful. Almost everything about the disorder would have to be changed, from the name to the diagnostic criteria to justify its continued use in psychology. The continued use of FSAD as a diagnosis justifies the societal idea that if a woman isn’t enjoying sex, she has a mental disorder. Young women are more likely to feel like they are responsible for their lack of pleasure, instead of working with their partner. This has an especially devastating effect of young women who have naturally low levels of desire. In college, we are inundated with stories of dramatic hookups or messy relationships, so there’s pressure to have your own stories and live up to the ideal of the sexually liberated woman. Women deserve to have as much or as little sex as they want, without the medical community’s standards of normalcy.

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