Interest, Arousal, and Shifting Diagnoses of Female Sexual Dysfunction, or: How Women Learn About Desire

Abstract

The newly released Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) brings together “interest” and “arousal” and removes “desire” from the language of the most commonly diagnosed female sexual dysfunction. I examine the shift from Hypoactive Sexual Desire Disorder in Women (HSDD) to the new diagnosis, Female Sexual Interest/Arousal Disorder (SI/AD). Whereas “complex,” “flexible,” “responsive,” and “receptive” have long been popularly associated with femininity, these descriptors are now framed as essential features of female sexuality via neuroscientific and photoplethysmographic research and as in need of training. Lack of responsiveness to a partner's advances is included as a criterion for diagnosis of sexual dysfunction in women, and thus the move from HSDD to SI/AD evidences the eradication of desire as a constitutive component of female sexuality. These diagnostic and therapeutic shifts influence how women relate to their sexual bodies and those of their partners and have biopolitical, experiential, and psychorelational consequences.

In crafting the new Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of Female Sexual Interest/Arousal Disorder (SI/AD), responsiveness has been brought forward as a metric for healthy sexuality in women. Claims regarding feminine receptivity are based primarily on quantitative data from survey research with women and on experimental research in which subjective accounts of sexual arousal are compared with purportedly objective measurements of genital response to sexual stimuli. Laboratory investigations consistently report that both healthy and dysfunctional women experience a disconnect between their subjective and objective sexual states, unlike healthy men, who experience more concordance. I argue that heteronormative prescriptions for “healthy” sex and sexuality guide research paradigms, diagnostic schemas, and treatment protocols for desire management and training regimens and that these are primarily directed toward women, who are understood to have less desire (in terms of frequency, intensity, and spontaneity) than men. With regard to sexual pathology, whereas men are perceived as disproportionately likely to suffer from physical ailments such as erectile disorder, women are considered more likely to suffer from psychological blocks to sexual enjoyment. These perceived differences in sexuality result in drastically different framing and treatment of sexual dysfunction for men and women with gendered consequences for sexual health, attitudes, and relationships.

“DIAGNOSABLY LOW” FEMALE DESIRE: A BRIEF CLINICAL HISTORY

Although many sexual disorders are accounted for in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision [DSM-IV-TR]; American Psychiatric Association, 2000), the only sexual disorder with the language of desire is Hypoactive Sexual Desire Disorder (HSDD). ¹ Both men and women can be diagnosed with HSDD, although women are diagnosed much more frequently than are men (West et al., 2008). In the DSM-IV-TR, HSDD is defined as “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.” ² According to the 1999 National Health and Social Life Survey, between 27% and 32% of women between the ages of 18 and 59 are afflicted with low desire. A nationally representative study conducted in 2008 (n = 2,207) suggested that 26.7% of premenopausal women and 52.4% of naturally menopausal women fit the criteria for diagnosis with HSDD (West et al., 2008). Estimates of the number of women afflicted have remained fairly stable over the last decade (Basson et al., 2001). Although recent estimates do not indicate an increase in the actual number of women with HSDD, widespread attention to women's desire problems in clinical literature, a proliferation of recent reports in the popular media (for examples, see Bergner, 2009a, b, 2013; Elton, 2010; Schreiber, 2012), and an increasing number of women reporting a lack of interest in sex in both clinical settings and on national surveys gives the impression that female HSDD is on the rise, at least in the Global North.

By now, it is widely accepted that women are more likely to have problems with low desire than are men (Leiblum and Rosen, 1988; Basson et al., 2001; Basson et al., 2005; Brotto, 2010). Women's most common sexual problem (low desire) is also understood as qualitatively different from that of men (erectile disorder): in almost all of the clinical literature regarding female sexual dysfunction, women's desire is consistently characterized as more passive, receptive, responsive, and complex, whereas men's desire is characterized as more spontaneous, driven, initiating, and constant. These gendered characterizations of sexual concerns are supported by and support broader Western cultural narratives about heteronormative sexuality, as they are disseminated via myriad outlets from television shows to public school sex education programs (Fine, 1988; Tolman, 1994; Irvine, 2005).

Reviewing the diagnostic trajectory of sexual problems in contemporary Western medicine reveals the fraught history in which desire patterns have consistently been gendered—albeit in different terms per scientific paradigm. Up until the publication of the DSM-III (American Psychiatric Association, 1980), there was only one diagnosis for sexual dysfunction. As Leiblum and Rosen (1988) elucidate, this catch-all category—“psychophysiologic genito-urinary disorder”—was applied to both men and women but was generally called impotence when it was diagnosed in men and dyspareunia when it was diagnosed in women. Dyspareunia (technically defined as painful or difficult sexual intercourse) was also used as an alias for “frigidity” in women—a much more amorphous category. Despite its ambiguous and overdetermined nature, frigidity was diagnosed regularly by clinicians and scientific researchers through the middle of the 20th century and was understood to be the feminine correlate of impotence in the male—but with a uniquely psychological etiology (Bergler, 1947; Lazarus, 1963). According to Lazarus (1963), “Frigid women may be placed on a continuum from those who basically enjoy coitus but fail to reach orgasm, to those for whom all sexual activities are anathema” (p. 272). Many early- and mid-20th-century clinicians believed that the root of the physical pain for frigid women was either some type of early trauma or that it was a physical manifestation of a psychological resistance to (penetrative) sex (with men): “Frigidity may generally be regarded as a learned pattern of behavior, although some females are probably genetically unequipped to respond erotically” (Lazarus, 1963, p. 272). The diagnosis of frigidity has been subject to rigorous feminist critique (for an example, see Boyle, 1993) and has been posited as a medicalized metaphor for feminine sexual indifference or rejection of sexual norms (i.e., the refusal of intromission) under the guise of medical beneficence.

Since its publication in 1966, Masters and Johnson's Human Sexual Response has set the tone for Western medical debates about sexuality. These clinicians argued that male and female sexual responses are largely similar, both falling along a four-phase “human sexual response cycle” (HSRC) that begins with excitement, progresses to plateau, moves along to orgasm, and ends in resolution. Although Masters and Johnson were proponents of a single model of sexual response applied to both men and women, they did much to propagate the notion that men's and women's sexual problems were very different—with men more commonly suffering from physical problems related to impotence and women more commonly afflicted with fear of (or indifference to) penetrative sex. They also perpetuated the heteronormative notion that the most natural and healthy way to have sex is via penile-vaginal intercourse, and thus the “completion of the sexual act” (i.e., male ejaculation through intercourse) was the goal of their therapy with heterosexual couples.

In 1977, two sex therapists, Helen Kaplan and Harold Lief, began to identify low sex drive in their patients, publish reports on the phenomenon, and implement new models of sex therapy in their own practices in order to alleviate what they referred to as “inhibited sexual desire” ³ (Kaplan, 1977; Lief, 1977). Both researchers reported that most of the individuals afflicted with the disorder were women, but as sex therapists, they were interested in thinking beyond individuals to treating couples with complaints. Thus, with the introduction of Inhibited Sexual Desire (ISD) into the DSM-III in 1980, there was more of an emphasis on desire disorders as dyadic, as afflicting the (implicitly heterosexual) couple rather than the female partner specifically—at least in the context of sex therapy treatment (Leiblum and Rosen, 1988). ⁴ In the DSM-III-R (American Psychiatric Association, 1987), ISD was divided into two categories: Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder, and when the DSM-IV (American Psychiatric Association, 1994) was introduced, these diagnoses remained the same. At this point, the disorders could still technically be diagnosed in both men and women, but since the initial inclusion of ISD in the DSM, clinicians and researchers have typically reported that low desire disproportionately affects women. As low desire diagnoses in the DSM and associated treatment protocols have shifted, there has consistently been critical response; for the last several decades, feminist critics and antimedicalization activists have argued that low-desire disorders are diagnosed in women who don't conform to heterosexist norms such as the ability to orgasm from penile-vaginal intercourse and thus are based on masculinist models of sexuality.

Since the late 1970s, a variety of changes have occurred in the realms of research and treatment of desire disorders, particularly as they pertain to women, who make up the majority of current diagnosees. After a consensus conference was convened to analyze female sexual dysfunction in 1998, a group of conference participants called for more attention to women's sexual issues by clinicians and researchers, particularly in light of the recent glut of attention given to male sexual problems such as erectile disorder (ED). ⁵ The specialists who were involved in the consensus conference—many of whom went on to form the International Society for the Study of Women's Sexual Health and some of whom served on the DSM-5 sexual and gender identity disorders work group—set forth new criteria for discerning and treating women's sexual disorders that they hoped would be taken up on a widespread clinical basis (Basson et al., 2001). One of the most notable suggestions for a change in protocol concerned the diagnosis of HSDD. The consensus committee called for the introduction of the criterion of “receptivity” or “responsive desire” for women. This new criterion indicated the group's belief that a woman shouldn't be diagnosed with HSDD just because she doesn't desire or initiate sex spontaneously but only if she is also unreceptive to her partner's advances.

This proposed change was a response to criticisms that the HSRC is based on a specifically masculine version of sexuality and desire. Since this time, diverse figures—from antimedicalization activists to experimental psychology researchers—have argued that women experience sex differently from men (Basson, 2000; Basson, 2001; Tiefer, 2001; Heiman, 2002; Brotto, 2010), although they posit different explanations for this fact. ⁶ Many psychologists have argued that this discrepancy is at least in part due to biological differences between men and women and that the lack of attention to this disparity represents, at best, a serious lacuna in medical practice and research and at worst, willful ignorance by doctors and researchers. Rosemary Basson, in particular, has been a proponent of an alternative model of sexual response for women on the basis of four claims: (a) women are not biologically driven to release sexual tension in the same way men are because they do not have as much testosterone as men; (b) women experience different motivations to engage in sex than men, including incentives and rewards that are not strictly sexual in nature and that might be much more important to their willingness to engage in sex than any biological urges to do so (i.e., promoting intimacy, pleasing a partner, preventing relational discord); (c) women experience subjective mental arousal that may or may not be accompanied by genital arousal (or they may be unaware of their own genital arousal); and (d) women do not always experience orgasms during sex; even if they are orgasmic they are not always driven to reach orgasm; and when orgasmic release does occur for women, it may take a variety of forms that deviate from the traditional sexual release model. In the seminal article in which Basson (2000) initially introduced this alternative model, she stated, “Sensing an opportunity to be sexual, the partner's neediness, or an awareness of one or more potential benefits or rewards that are very important to them (but not necessarily sexual), women move from a sexual neutrality to seeking stimuli necessary to ignite sexual desire …” (p. 53; italics added).

I recognize the importance of representing and attending to diverse models of sexuality that provide alternatives to the four-staged HSRC model of human sexual response, but here, I want to analyze and interrogate the cultural obsession with women's sexuality as a deviation from this linear model. I also want to consider the potential consequences of marking this kind of deviation as uniquely feminine. Advocates of an alternative model for feminine sexual response argue that women's general state of sexual neutrality, their need to be sexually triggered due to their natural receptivity or responsiveness, and the importance of nonsexual incentives regarding their participation in sex must be taken into account when assessing feminine desire. Explicit is the notion that women do not experience sexual fantasies, particularly visual fantasies, to the same extent or in the same way that men do. Another crucial aspect of this model is the notion that for women, physical arousal is often antecedent to a conscious interest in sex.

The newest incarnation of low feminine desire is Female Sexual Interest/Arousal Disorder (SI/AD), which took the place of HSDD in women and also incorporated the DSM-IV diagnosis of Female Sexual Arousal Disorder in the DSM-5. According to the DSM-5 website, ⁷ the revision subsumes the following criteria:

Lack of sexual interest/arousal for a minimum duration of approximately 6 months as manifested by at least three of the following indicators: 1. absent/reduced frequency or intensity of interest in sexual activity, 2. absent/reduced frequency or intensity of sexual/erotic thoughts or fantasies, 3. absent/reduced frequency of initiation of sexual activity and is typically unreceptive to a partner's attempts to initiate, 4. absent/reduced frequency or intensity of sexual excitement/pleasure during sexual activity on all or almost all sexual encounters, 5. absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues, and 6. absent/reduced frequency or intensity of genital and/or nongenital sensations during sexual activity on all or almost all sexual encounters [http://www.dsm5.org; italics added].

It is crucial to note that SI/AD is a female-specific diagnosis; low-desiring men will still be diagnosed with HSDD. Brotto (2010), a member of the DSM-5's work group on sexual and gender identity disorders, argues that “interest” is a better descriptor than “desire” for women because it “emphasizes a broader construct than the more biological ‘drive’ connotations of sexual desire and it [a diagnosis of low sexual interest] reflects the lack of motivation” (p. 234).

I want to draw attention to certain assumptions about female sexuality and how they are promulgated through uninterrogated research premises that support the new SI/AD diagnosis. Interest (a stand-in for “desire” but with connotations that imply cognitive, incentive-based, and reward-seeking behavior) and arousal (physiological changes in genital response, including vasocongestion and lubrication) are understood as often out of sync for women yet are simultaneously merged in this diagnosis. This seems like a paradox at first, but when pushed to its logical conclusion, this move indicates more than a simple proclamation of asynchrony and concomitant diagnostic “lumping”; it rests on and perpetuates the assumption that, for women, arousal often precedes or even governs sexual willingness or interest—or at least that it does in sexually functional women. At the same time, it implies that willingness and interest are often nonsexual experiences for women, and if they do precede arousal, are almost entirely cognitive in nature, divorced from the sexual body with its “lubrication-swelling response” (and also divorced from any kind of agentic want or need for sex outside of a woman's partner's wants and needs). In addition to interest and arousal, another term that is often used in this research is “subjective arousal”—the perception or recognition of one's own “objective” genital arousal. According to Brotto (2010) and Graham (2010), many women express difficulties distinguishing something like an internal sexual propensity from this subjective arousal—meaning that if a woman does not rationally and deliberately invoke a cognitive interest in sex, then noticing that her body is exhibiting physical changes in response to a stimulus may be her only or primary cue to begin to engage in a sexual act. Amidst these tortuous narratives of feminine interest, physiological arousal, and subjective arousal, desire is increasingly left out of the discussion completely.

All of these presumptions resonate with current experimental psychological and neuroscientific research that purports to show that many women have a hard time recognizing when they are physically aroused or that there is often a disconnect between their objective/genital/physical response and their subjective/psychological arousal (Chivers, Seto, and Blanchard, 2007; Chivers, 2010; Chivers et al., 2010). Although the contemporary notion of biological, testosterone-driven sexual desire or “sexual urge” (Brotto, 2010, p. 227) is arguably hegemonic and masculinist, a replacement of this with incentive-based feminine sexual interest and responsive arousal may be equally problematic. For one thing, it implies that the woman who suffers from SI/AD (or at least a diagnosee who fits criteria #1 and #3) is pathologically uninterested in creating intimacy through sex with her partner. For another, it suggests that she has an abnormal lack of concern with the rewards she would otherwise receive by placating her partner and/or by laboring sexually to create a conciliatory environment in the relationship. ⁸

These narratives about sexual rewards and benefits may be harmful to women, a point that Meagan Tyler (2009) has elucidated at length. Regarding the formulation of feminine receptivity as a “willingness to proceed [with sexual activity] despite absence of sexual desire at that instant” (as cited in Basson, 2002), Tyler (2009) makes the case that “using receptivity as a benchmark for women's sexual desire may actually reinforce male sexual demands, and promote coercive sex in heterosexual relationships” (p. 41). It is worth noting that a uniquely feminine, incentive-based sexuality sounds remarkably similar to the service-oriented feminine sexuality espoused in evolutionary psychology narratives about sexual relations—for instance, Donald Symons (1979) states that among all known societies, copulation is often essentially “a service or favor that women render to men” (p. 28). Positing women as the “receptive” sex in biological terms might not only reinforce male sexual demands, it may also force women into a cost-benefit analysis regarding their own sexual behavior, it could potentially foster traumatic sexual experiences, and it will further devalue the murky notion of consent. But, beyond Tyler's practical and clinical critiques of responsive desire as they pertain to heterosexual relationships, I am concerned with the overarching tales that this logic promotes and deploys regarding femininity, female sexuality, and heteronormative gender relations more broadly—including how these might affect women of diverse gender presentations, sexualities, and lifestyles.

In light of these arguments, an emphasis on feminine responsiveness, receptivity, flexibility, and complexity does not sound so liberating for women. This is particularly so when feminine complexity and flexibility are juxtaposed against masculine desire's stability, constancy, activity, and (dependable) spontaneity. Many of those who have argued most vehemently for a different model of feminine sexual response have done so in order to challenge the rigidity and normativity of current conceptions of desire: something it has been argued time and again that women simply do not have in the same way that men do. SI/AD reinforces this notion of feminine lack. In the new SI/AD diagnosis, we see the formulation that for women, sexual interest is often difficult to line up with arousal; desire is no longer even part of the equation; and, for more than a quarter of the premenopausal female population in the United States (Laumann, Paik, and Rosen, 1999; West et al., 2008), getting the psyche in line with the body during any given sexual experience requires quite a bit of coaxing. Thus, although a critique of the traditional HSRC may be worthwhile, it is important to consider the retrograde and gendered implications of this diagnostic shift—particularly in light of the rising prevalence of the diagnosis and the deluge of public attention that low feminine desire has received recently. This shift is especially problematic for reasons that relate to its gender specificity or to the fact that only women will be diagnosed with SI/AD, including (a) the responsiveness criterion is thus feminized, (b) desire is removed from the diagnosis language altogether in favor of the term interest—but only for women, and (c) interest and arousal are brought together diagnostically but for female patients only.

As a result of our highly medicalized, pop science-infused cultural milieu, these research and treatment protocols affect nonpatient women as well as those who present for treatment. Given the far reach of these narratives, I want to consider the broader cultural, clinical, and experimental context these discourses are situated within, examine the empirical research used to instantiate changing psychiatric diagnoses, and evaluate the treatment protocols for dealing with female patients who present with desire troubles.

BRINGING BODIES AND MINDS INTO LINE: PLETHYSMOGRAPHY, PHARMACEUTICALS, NEUROIMAGING, AND COGNITIVE BEHAVIORAL THERAPY

Much contemporary research within the realms of experimental psychology and neuroscience supports the same models of sexually dimorphic gendered behavior, response, and sexuality that are called forth by those who design DSM diagnoses (Karama et al., 2002; Chivers et al., 2007; Maravilla and Yang, 2008; Chivers, 2010; Chivers et al., 2010). One of the most prolific researchers in the field of experimental psychology, Meredith Chivers, recently conducted a broad meta-analysis along with four colleagues (Chivers et al., 2010) to assess differences in male and female sexual response. This meta-analysis asserted a statistically significant gender difference in sexual response with men showing more subjective-genital concordance (agreement between self-report of subjective arousal and “objective” measurement of genital arousal) than women and also greater category specificity with regard to the correlation between their stated sexual orientation and measured physiological response (they were objectively aroused more by erotic videos featuring their “preferred gender” or gender arrangement than by films featuring their “nonpreferred gender” or gendered sexual scenario).

It is unclear how most of this research could possibly assess anything approximating the intense, powerful, sometimes fragile, and very personal experience of desire, as these studies utilize poorly operationalized variables to quantify this phenomenon and are performed in manufactured experimental settings. Measurements of physiological sexual response are assessed with a vaginal photoplethysmographic or phallometric device attached to participants’ genitalia (for women, this is a tampon-shaped device inserted into the vagina; for men, it is a device that contracts around the penis). Assessments of concordance and category specificity are based on comparing a participant's stated sexual orientation and subjective sexual arousal (in some cases this is a measure of how turned on a participant states she is by audiovisual stimuli; in some cases it is a measure of her “awareness” of her own genital changes) with “objective” measurements from the photoplethysmographic or phallometric device.

Sweeping generalizations about male and female sexuality are made based on this research, and there appears to be very little public critique of this work on even a simple methodological basis. The sample sizes in these studies are often very small and homogenous (an example is a study by Chivers and Bailey [2005] in which fewer than 20 heterosexual men and 20 heterosexual women, all of whom were financially compensated and most of whom were in their mid/late 20s, were compared), which makes any statistical findings unreliable at best. Vaginometric and phallometric measurements are assessed in a lab while participants are exposed to a variety of different types of pornography, neutral stimuli, and sometimes “nonsexual stimuli with positive or negative valences” (Suschinsky, Lalumière, and Chivers, 2009). Participants in one such study were asked “to respond to the films as naturally as possible, and to avoid contracting their muscles, manipulating their responses, touching their genitals, moving, or talking during the films” (Suschinsky et al., 2009, p. 563). The pornography in any given study might include male-female, male-male, and female-female sexual encounters; women and men exercising in the nude; sexual coercion and rape scenes; and sometimes even nonhuman animals such as bonobos having sex (Chivers and Bailey, 2005).

My primary concern in this essay is to expose the ways that male and female sexualities are produced as inherently dimorphic via this research, and thus I will not extensively attend to the obvious critiques of the research methods being discussed here. But beyond the issues with inadequate sample size; homogeneity; and potential problems with reliability, validity, and conceptualization of assessment measures, there are myriad irresolvable issues regarding the generalizability of the experiment, including the fabricated and isolated nature of the experimental setting and the fact that it is divorced from any environment in which sexual activities would actually take place; that the audiovisual stimulus is predetermined by the research team rather than chosen by participants themselves (who may or may not even enjoy pornography); that a device is attached to the genitals throughout the experiment, which may produce enjoyment or displeasure outside of the audiovisual stimulus and is thus a potential intervening variable; that the audiovisual stimulus—combined with the situation in which it is being viewed—may have unintended effects on the participants; the artificial variables by which sexuality—an inherently dynamic and interpersonal phenomenon—is being measured; and the fact that a complicated phenomenon such as sexuality is being measured and quantified at all. There are other extra experimental dynamic and contextual issues such as individual life history, cultural background, sexual history including possible trauma or abuse, relationship status and quality, and other interpersonal issues that are not taken into account in this research either and that invariably affect the outcomes of these studies. This research leaves objective and subjective arousal as proxies for desire, the vicissitudes of which clearly cannot be captured in an experiment.

Studies featuring plethysmography span decades (Geer, Morokoff, and Greenwood, 1974; Hoon, Wincze, and Hoon, 1976, are two of the earliest) and are widely cited in literature from pop science to evolutionary psychology to the DSM. This research is used to support the notion that women's sexuality is less “directed” or “target specific” than men's—that women don't have a clear, defined, goal-driven sexual orientation in the same way that men do; that they are often physically aroused by sexual acts and individuals that do not fit with their self-described identities; and that women are thus more flexible, malleable, and complex in their desire. ⁹ Although the etiology of subjective-genital feminine discordance has been speculated upon, and not all researchers agree that it can be attributed to a clear difference between male and female sexual response patterns, the potential conclusion that it is due to a biologically rooted feminine disconnect between physical and psychological arousal is regularly put forward to reaffirm narratives of sexual difference.

Assumptions about healthy women's sexual flexibility and receptivity beg the following questions: What is the line between flexible and confused? What is the truth of a woman's desire? Should a woman trust her “psychological” state or her “physical” state (as if these states are separate for anyone …)? Should she trust her partner to let her know when she should be sexual? ¹⁰ The logic that popular evolutionary psychologists employ around adaptive or evolved sexual difference is a far cry from what those who crafted SI/AD surely had in mind when they incorporated (lack of) responsiveness as a criterion for diagnosis, but as DSM work group members and evolutionary psychologists utilize the same experimental research and come to similar conclusions (not to mention that experimental psychology researchers like Chivers and some neuroscientists regularly explain their findings via the theoretical tropes of evolutionary psychology), I argue that they are all implicated in the retrograde movement of sexual and gender relations. It is important to note that all of these scientific tendencies exist within the same contemporary psychomedical lexicon, in the same biomedical moment, and they all have broad import. These discourses are interpreted by many in the general public as evidence of the “complementarity” of male and female desire—and complementarity here reads as masculine = initiating and feminine = reactive. Narratives such as these are frequently cited in widely read science and psychology literature in the popular sphere as well. ¹¹

Chivers et al. (2010) also purport that there is a correlation between female discordance and sexual dysfunction: “The potential for concordance to vary with sexual functioning has been demonstrated in studies of sexually dysfunctional women; women with sexual arousal problems report lower subjective sexual arousal to sexual stimuli in the laboratory, but do not show significantly lower genital responses when compared to women without sexual arousal problems” (p. 12). Here, these researchers are suggesting that the diagnosis of sexual dysfunction in women is tied to their lack of awareness regarding their physical state but claim that even sexually healthy women experience a disconnect between their psychology and physiology; for these researchers, the difference is that a healthy woman can recognize her (aroused) physical state and be psychologically receptive to it, whereas that task is more difficult for a sexually dysfunctional woman.

Although he approaches the theme of feminine malleability from a different angle than it appears in alternative models of women's sexual response, prominent evolutionary psychologist David Buss (1994) similarly describes women's desire as “complex” and “enigmatic” (p. 19). Buss implies that women's sexuality is almost entirely driven by the procreative incentive to bear children fathered by high-quality mates ¹² and that much of their sexual behavior is manipulation or subterfuge; because women don't have a clear sexual orientation, they largely engage in sexual acts to get what they want from men (i.e., men who have strong, direct, biological sex drives and who can protect women and their children from danger and provide resources).

Recent developments in this investigation include the intensification of neuroscientific sex difference research using brain-imaging technologies and the proliferation of a multitude of techniques utilized to treat sexual dysfunctions. In particular, neuroscientific imaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) are used more and more frequently to explore sex differences in desire and have affirmed the same conclusions regarding female sexuality as have other types of experimental psychological research (Karama et al., 2002; Maravilla and Yang, 2008). Although using fMRI to this end is still in its nascent stages, it is clear that this is the direction in which desire research is heading. Researchers have argued for a number of sex differences in arousal-related brain activity. For example, recent studies purport that during processing of sexual stimuli, brain areas associated with emotional inhibition in the anterior cingulate cortex are activated among women, whereas men have greater control over their genital response as demonstrated by activity in the prefrontal cortex (Laan, Scholte, and van Stegeren, 2006; Laan, 2007, as cited in Chivers et al., 2010); level of perceived sexual arousal is significantly higher in male than in female participants as indicated by hypothalamic activity when viewing visual erotic stimuli in a lab setting (Karama et al., 2002); and differences can be observed among men and women and between healthy women and those with sexual interest/arousal disorders based on “overall brain activation” as determined by fMRI (Maravilla and Yang, 2008). In addition to experiments that directly compare men's and women's neural sexual processing, other studies examine sex differences by analyzing neural correlates of parental and romantic love (Bartels and Zeki, 2000, 2004) and conclude that women and men also differ in these realms. What can be gleaned from these studies is questionable at best, as many unstated narratives about sex differences in cognition, sexuality, and desire abound and inform hypotheses and experimental design—before the research has even begun.

Although interrogating these new realms of research that delve deep into our brains is an important task, it may be just as important to consider the techniques currently being used to treat women with desire troubles. One hotly contested realm is the pharmaceutical treatment of low female desire. In 2010, the drug Flibanserin went through FDA trials but was ultimately not approved (Wilson, 2010), in part due to protest by a critical outpouring of members of Tiefer's New View Campaign among other antimedicalization activists (http://www.newviewcampaign.org/flibanserin.asp). Flibanserin is a neurotransmitter drug that works on the central nervous system, specifically on serotonin receptors, purportedly enhancing libido in women (Stahl, Sommer, and Allers, 2011). The newest addition to the neuropharmaceutical lineup is Lybrido, which was undergoing field tests at the time of this writing (Bergner, 2013). Pharmaceutical treatments for desire problems such as Flibanserin and Lybrido have been referred to as “pink Viagras,” but to analogize these treatments with Viagra is baseless for a number of reasons. Conceptually comparing the ways these drugs work illustrates the differences.

In their critique of the cultural and medical fixation on Viagra in the early 2000s, Mamo and Fishman (2001) elucidate the compulsory heterosexuality prescribed by pharmaceutical technologizing of the male erection. They claim that by focusing all attention on the mechanical workings of the penis—or lack of this “functionality,” in the case of erectile disorder—Viagra and the culture surrounding it perpetuate the idea that male desire is unproblematic and available in a never-ending supply. Thus, Viagra posits male sexual problems as generally physical rather psychological and concomitantly legitimates heteronormative penile-vaginal intercourse as the proper, healthy, and ideal way to have sex.

In light of the regulation of men's sexuality via the attention to impotence or erectile disorder within what has been called a “Viagra culture,” it is particularly important to draw attention to the framing of feminine sexual disorders at the current juncture. Popular medical discourses concretize the notions that Viagra brings the (disordered) body into line with the (intact, normal, and sexually healthy/functioning) mind for men, whereas neurotransmitter drugs like Flibanserin and Lybrido bring the (disordered) mind into line with the (intact, normal, and sexually healthy/functioning) body for women. ¹³ In men, the problem is framed as hydraulic, mechanical, and easy to fix, whereas in women the problem is in the organization or design of the system itself: there is a “computational” error. Thus, that drugs like Flibanserin (a drug that had previously been used as an antidepressant) and Lybrido are sometimes referred to as “pink” or “female” Viagras is actually very misleading, as the mechanism of action is entirely different.

Although pharmaceutical and hormonal management of female sexual dysfunction is a terrain not yet fully carved out, other therapeutic treatments are becoming more and more popular. As psychoanalytic and psychodynamic explanations and treatments for sexual problems have fallen out of vogue in the past decades—and in many cases are actively renounced as flawed, retrograde, or “too psychological” or “too theoretical” in their orientation—Cognitive Behavioral Therapy (CBT) techniques have taken their place. One of the most popular types right now—and increasingly so in the realm of sexual dysfunction—is “Mindfulness-based Cognitive Behavioral Therapy” (MCBT).

CBT is a psychotherapeutic theory and practice in which goal-oriented, explicit, and systematic procedures are utilized to change one's thinking or relationship to thinking so that behavioral changes may follow. It can be conceived as a method of self-directed behavioral training in order to enhance the quality of one's life. MCBT incorporates the notion of “being in the present” with this model and is rooted in the concept of “mindfulness” as it appears in Buddhist spiritual practices. Many of the same practitioners who were involved in designing SI/AD and/or who are proponents of an alternative feminine sexual response cycle have supported the use of MCBT as a therapeutic tool to improve the low-desiring woman's sexual response. Brotto (2011) states,

Because mindfulness exerts its effects by deliberately bringing one's full awareness to the here and now, otherwise intrusive and distracting thoughts are left to the periphery of one's awareness … the sensation of pain [here, she is talking about a female patient with dyspareunia] may be experienced as a purely physical sensation, without the multitude of layers of affective and cognitive suffering [p. 216; italics added].

MCBT is often used in a therapeutic setting involving multiple women who experience low desire or other sexual dysfunctions in the context of psychoeducational interventions that may integrate elements of education, cognitive and behavioral therapy, and mindfulness (Brotto, Basson, and Luria, 2008). Patients engage in “self observation” and “touch” exercises as homework assignments that challenge them to imagine themselves as “competent, sexual, feminine, and sensual” (Brotto, Krychman, and Jacobson, 2008, p. 2743). They also engage in group activities, some of which involve concentrating on the sensual qualities of an object, such as a penny or raisin, over a period of several minutes in order to train themselves to remain focused on one thing, in the present. ¹⁴

It is only in a context in which men and women are posited as inherently different kinds of sexual beings (i.e., women are not understood as directly sexual at all, whereas men are seen as the guiding sexual force) that CBT and MCBT techniques become worrisome. In assessing these technologies and their use in the current moment, we must responsibly inquire: What are the goals of these training techniques? What is the underlying theoretical orientation regarding male versus female sexuality that is espoused within this framework? What forms of desire are encouraged, and which escape, or which are produced but go unaccounted for or are neglected in these interventions? MCBT is increasingly used in therapeutic settings in which women learn to maintain awareness of the thoughts that might prevent them from harnessing their responsive desire or from taking advantage of an opportunity to be sexual in their everyday lives (e.g., when stimulated by an initiating partner who wants to engage in penile-vaginal intercourse). The technique is used as a way for women to become attuned to their physical arousal so that they may experience more concordance between their subjective and objective sexual states. Although the benefits of being “in the present,” mindful, and attuned to one's body and experiences are undeniably beneficial to women (and men) broadly, I am concerned about the pairing of a technique such as this with discourses of feminine receptivity—receptivity of the psyche to the body and receptivity of a woman to her initiating partner. How is this technique evidence of a type of training of desire, and what are women being trained (and training themselves) to experience or to engage in? To enjoy? To ignore? And to what end? Within a framework in which feminine desire is discursively absent and in which “interest” is framed as cognitive and “arousal” is understood as physiological—mindfulness appears to be more about bringing the “frigid” mind into line with the “lustful” body than with simply bringing the two into harmony. This arrangement lends itself too easily to a potential service requirement of the feminine to their tacitly masculine partners and betrays the assumption that, within these discourses, the truth of desire lies in the aroused body—or possibly outside of it, in the (male) partner and/or in heteropatriarchal culture.

IMPLICATIONS OF SHIFTING DIAGNOSES: SEXUAL (SELF-)CONTROL AND THE HUSBANDRY OF FEMININE DESIRE

In a milieu in which neoliberalism, (self-)medicalization, and biopolitical regulation thoroughly influence our everyday lives, any changes to a major psychiatric interventionary tool such as the DSM must be taken seriously. The discourse exemplified and disseminated by the DSM influences how we understand our embodied and gendered identities, how we define our sexualities and our relationships to others, and which medical procedures and treatments are culturally acceptable (and if we live in the United States, which of these our insurance plans will pay for). When femininity is produced as elusive, mysterious, and in need of direction, and sex and sexuality are constantly interrogated and used as metrics of pathology/normalcy, the current sex-dimorphic incarnations of sexual disorders in the DSM become particularly troubling and worthy of examination.

The ways in which bodies, lives, and relationships are modulated and made productive through the biopolitical discourses of public health, epidemiology, medicine, and technoscience is of key concern. For Foucault (1978), the most important site of modulation through these discourses is unequivocally human sexuality. We can understand sex as the nexus between the public and private, the population and the individual, the species body and the body-as-machine. In his discussion of the deployment of sexuality, Foucault elucidated a shift from the disciplinary or “deductive” (1978, p. 136) power of the sovereign to the “regulatory control” (p. 139) of a cluster of powerful relations that took the form of an apparatus of governmentality or what Deleuze (1992) later called a “control society” (p. 4). One of the most important characteristics of this shift is that regulation is no longer focused on the domination over the individual transgressor for the sake of punishing him or her but is rather framed as a means of protecting the larger populace from “biological dangers” (Foucault, 1978, p. 138) that, if not preemptively guarded against, could potentially destroy the human race or species body. Foucault (2000) and followers of his later work (Rose, 2001; Frank and Jones, 2003) have emphasized that within this shift to governmentality, prescriptions for how individuals can and should regulate their own behavior are brought to the fore and that these prescriptions for leading a healthy and productive lifestyle are always asymptotic (they are impossible to reach, and thus we are always striving to be better citizens within a framework of constantly shifting prescriptions). The flip side of sex-as-biological-danger is the framing of sex as a space of optimization, useful for securitizing populations and for generating subjects who will live productive lives. Our contemporary cultural formulations of these mechanisms of (self-)control and (self-)optimization are evidenced by a proliferation of media accounts that espouse a keen interest in healthy sex as a mode of producing healthy citizens. And we see these accounts particularly in female-targeted magazines such as Cosmopolitan and on self-help websites that many women frequent (for examples, see Jones, 2012; http://www.ivillage.com/secret-health-benefits-sex/4-a-283856#axzz2BrV38kbe).

In our current biopolitical context, experimental psychology research on sexual difference; therapeutic techniques for regulating one's own behavior; and new modes of measuring, imaging, and diagnosing desire come together in a unified framework with dire consequences for the governance of sexual life. This network abides in our fantasies and sexual practices, and thus I am concerned with the implications of this powerful conglomeration, particularly in light of “postfeminist” arguments celebrating the purported alleviation of gender disparities in most domains of life in the contemporary Global North. Not every woman goes to a clinic because she has concerns about her low desire, and many people do not come into direct contact with diagnostic literature or scientific research that supports neurobiological explanations for behavioral sex differences. However, the popularization of self-help psychology; the introduction of findings from experimental research into colloquial discourse; and the pervasive integration of evolutionary psychology, neuroscience, and clinical and experimental psychiatry demonstrate the far reach these discourses have.

The release of the newest version of the DSM is notable in light of our cultural reliance on this “psychiatric bible” and because how we define pathology has implications for how we understand what is normal (Foucault, 1973). The diagnosis of SI/AD in women is worthy of investigation because gender and sexuality are part of what is prescribed by the DSM, and these have particular import in a world in which sexual regulation is an exemplary tool of governance. The notion of feminine receptivity is pervasive in the DSM and in pop psychology discourses, and the notion that women are only disordered if they don't respond appropriately to their sexual partners’ advances informs how we understand “healthy” femininity. Brotto and others who have paved the way for the inclusion of responsiveness as a criterion for Female Sexual Interest/Arousal Disorder have argued that all sexuality (men's and women's) incorporates this notion of receptivity, triggering, or “incentive-motivation” (Brotto, 2010, p. 225), but the female specificity of the SI/AD diagnosis suggests otherwise, discursively and via the sex-specific medical research, practices, and treatments it is based on and supports (i.e., to date, MCBT is used only with low-desiring women, and it is primarily women who are chosen to participate in studies of desire). Narratives about women's naturally fraught and murky mind/body relations, and their inherent proclivity to respond or receive, also lend themselves easily to corollary narratives about women's need for sexual guidance—or their essential desire to submit.

Although psychoanalytic explanations of “feminine masochism” may be out of trend, the notion of feminine submission is now naturalized and promoted through popular neurobiology and evolutionary psychology. Although stories about the innateness of receptivity and submissiveness for women are perpetuated and also explicitly theorized through the notion of ancestral genetic survival as espoused within evolutionary psychology, they are also perpetuated through the language of the SI/AD diagnosis and its associated practices but not theorized at all (as the DSM explicitly strives to be an “atheoretical” document). This lack of theorization is actually quite pernicious—we are left with notions of feminine receptivity and submissiveness tacitly supported but have no explanation for why this might be the case or how this situation has come to be, ¹⁵ as psychoanalytic explanations are actively disregarded. Thus, we are left to assume that those who are responsible for the responsiveness criterion and female specificity of SI/AD believe that these feminine tendencies are innate, also, or at least that these individuals are not concerned with the etiology of differences in male and female sexuality (including the social and psychological influences on those differences). Analyses of power, and an analysis of historically oppressive relations between men and women and the devaluing of femininity, are entirely unexamined. Questions regarding why women would need to find reasons to be interested in (heterosexual) sex or responsive to their (male) partners outside of their own desire are not engaged with, let alone answered. Questions concerning the inequities and systems of internalized domination that might produce this unequal sexual situation between men and women are similarly ignored.

In this context, an “alternative sexual response cycle” for women based on the female specificity of sexual receptivity actually re-essentializes human desire, producing it once again as sexually disparate, and, as it is situated on the same stage as evolutionary psychology in our current context, as neurobiological and teleological in its gender essentiality. Proponents of an alternative sexual response cycle for women and a corollary SI/AD diagnosis jettison psychoanalysis on the grounds that the Freudian version of desire is about “innate spontaneity” or “drive”; this notion is critiqued by some of these proponents on the basis of its male-oriented and male-serving history and because it is said to pathologize women's natural responsiveness. Not only is this framing of desire not in accordance with the totality of Freudian conceptions of desire (i.e., Freud saw sexuality as an anaclitic outlet for internalized aggression, among other things) but it also ignores all of the psychoanalytic theorizing since Freud, from the sexual fantasmatization of Jean Laplanche (1976) to Jessica Benjamin's accounts of desire as bound up with heteronormative gender relations and domination (1988). Relational psychoanalytic accounts of intersubjectivity and mutual recognition (Benjamin, 1988) are especially useful in thinking about sexuality from a clinical perspective, but proponents of SI/AD do not embrace these concepts and instead choose to (re-)emphasize sexual complementarity, which in their framing may be paradoxically violent, or at the very least, conceived of as provocation/reaction, and normatively on masculine terms (i.e., male as provoker, female as responder).

The dismissal of psychoanalytic accounts of desire by those who have paved the way to SI/AD is not only a rejection of psychodynamic accounts of one-on-one sexual interactions but it is also a denial of the broader theorizations about gender and domination that contemporary psychoanalytic and psychodynamic practices have proved so useful at accounting for. I want to argue that CBT (even MCBT, strangely enough, as it is intended to be about openness and living in the present) and neurobiological explanations for behavior are more rationalistic and masculinist in their very form than are many psychoanalytic or psychodynamic explanations. The version of CBT expounded in the research I cited earlier suggests the utility and propriety of an internalized master-slave dialectic and ultimately involves denying or ignoring cultural, social, psychodynamic, experiential, and phenomenological explanations, proclaiming instead the importance of “taking control” of one's own behavior as a means to an end (and the end in this narrative, it is important to note, is a normative heterosexual relationship in which “successful” [that which keeps the penis erect and induces male orgasm] intercourse is privileged). Radical, feminist, relational, and object relational psychoanalytic accounts have instead emphasized the body, mutuality, and how the social and dyadic context of sexuality inform sexual experience and thus should inform treatment (the concept of “treatment” itself is also broadened in this field: it is not just about instituting a regimen of penile-vaginal intercourse but about making sex better by taking into consideration social, cultural, and broadly political explanations for low desire). Although the treatment protocols for SI/AD allow for some of this psychosocial/dynamic evaluation (i.e., in some current psychoeducation manuals there may be a discussion of relationship satisfaction and partner's level of desire), the language and practical utilization of the DSM discursively produce a significantly less dynamic system of analysis and a restrictive narrative around sex. The use of (M)CBT as a training of desire paradoxically indicates an internalized dominating and objectifying orientation toward one's own sexuality. The disorder language and SI/AD's treatment via CBT-style interventions leave the patient's individual history (except as it specifically concerns the immediate reasons she doesn't want to have sex with her husband and how she can overcome this problem)—and the social context in which men and women end up with such disparate patterns of desire—largely unaccounted for.

Analyzing all of these factors together is imperative because people live out these themes in and through their sexual practices (and also in their everyday intimate relationships, including in nonsexual moments). There are bio-/anatomopolitical consequences to the popularization of these notions of sexual dimorphism and sex-specific disorder diagnoses and treatments. If receptivity; responsiveness; reactivity; lack of spontaneous interest; and in some accounts, even submissiveness, are assigned to women as neurobiologically essential feminine sexual traits, and this assignment goes untheorized and unaddressed, then the modulation of feminine desire within the quotidian field of sexuality (particularly among women with male partners) might easily turn into a form of husbandry. Women who are produced as specific kinds of sexual beings live these identities out with their partners (and their partners experience them as such). Labels and experiences interact, in a never-ending feedback loop, and this process cannot be described simply in terms of “social construction.” It is about the living of embodied hierarchies, sexual categories, and ways of being in the world, which take shape within fields of power. We modulate our sexualities through drugs, behavioral training, and other therapeutic interventions, in accordance with optimization, securitization, conceptions of the health and wellness of the population, and narratives of “happiness”—all of which come to us in the form of medical and scientific expertise. But we rarely think through the patriarchal, biocapitalist terrain in which these modulations are practiced; the consequences they may have for people's relationships, behaviors, bodies, and orientations toward themselves and their partners; or the systems of oppression and domination under the guise of “evolved” “complementarity” (which here may be abusive) that all of this reinscribes.

In this milieu, it is easy to see how desire—the most subjective, elusive aspect of sexuality—may now be the most worthy of investment, as improper or unproductive desire might be conceived of as dangerous, or, at the very least, unhealthy and bad for society as a whole. According to the omnipresent discourses of evolutionary psychology, behavioral biology, and clinical experimental psychology as they are taken up by the authors of the new DSM, feminine desire is uniquely enigmatic and mysterious or in need of direction. Current psychomedical discourse reinforces the purported naturalness of sexual difference, linking it to neurobiology and cognitive neuroscience through the concepts of innate “hardwiring,” evolution, and adaptation, while simultaneously prescribing and deploying proper gender relations and forms of social reproduction. Thus, it is imperative that we consider the stakes of this broad framing of desire and its “peculiar” feminine incarnation as potentially useless and unproductive—or possibly even biologically dangerous—if not managed correctly.

Most women will never be diagnosed with SI/AD, and many will never hear of the disorder. Diagnosis will be reserved for the few women who seek treatment for low desire. But we can be certain that the further medicalization and diagnosing of feminine receptivity will continue to have intractable consequences for human relationships—sexual and otherwise. Husbandry is on the horizon.

Notes

¹This was the case up until the publication of the DSM-5 (American Psychiatric Association, 2013) in May 2013, which was released after this essay was written.

²Throughout this essay, I use the term desire the way it is used in this definition of HSDD, in the colloquial sense of the term. The Oxford Dictionary (http://oxforddictionaries.com/us/definition/american_english/desire?q=desire) defines desire in its verb form as “to strongly wish for or want (something)” or “to want (someone) sexually” and in its noun form as “a strong feeling of wanting to have something or wishing for something to happen” or “a strong sexual feeling or appetite.” My argument in this essay is instantiated through both conceptual and linguistic analyses; as feminine desire is eradicated from our psychomedical lexicon, interest (a term rooted in cognitive-rational conceptions of behavior) and arousal (a purportedly empirical and biological descriptor) are taking its place.

³It is important to note that Kaplan is also credited with adding “desire” to Masters and Johnson's HSRC, as she argued that it must motivate successful completion of the rest of the cycle for both men and women.

⁴It should be noted that even therapists during this time generally attributed the inhibited desire to the female partner initially, and thus it was her aversion to sex that was likely to bring a couple in for treatment.

⁵ED is generally not categorized as a desire disorder. It is instead considered a physical sexual dysfunction; although in some cases ED is attributed to psychological difficulties, its desire-related manifestation is only a specific clinical subtype of the broader disorder.

⁶Tiefer represents an outlier in this list—through her antimedicalization activism she has consistently argued that women experience sex differently from men because of sociopolitical reasons over biological ones (for more information, see http://www.newviewcampaign.org/).

⁷Although this website is still accessible, since the publication of the printed DSM-5 in May 2013, a listing of the criteria for SI/AD and all other new diagnoses is no longer available for free online.

⁸According to the new DSM, women will only be diagnosed with SI/AD if their low desire causes them “clinically significant distress or impairment.” This is arguably an improvement over the old criteria of “interpersonal difficulty,” but I suggest that “significant [personal] distress” in many cases may be caused by “interpersonal difficulty” (i.e., a male's frustrations over his female partner's lack of desire).

⁹The theoretical conclusions of this research are often based on early evolutionary psychology literature (e.g., Symons, 1979), and more contemporary popular evolutionary psychologists have also taken up the notion that a purportedly “noncategorical” feminine sexual orientation (or nonorientation) is an evolved protective mechanism that has developed to defend women against vaginal tearing, infection, or other physical harms that ancestral women might have experienced in the case of rape (Chivers and her team repeatedly cite this argument, as do Ogas and Gaddam, 2011, among others).

¹⁰Although Chivers has stated that “a woman's genital responding might reveal little about her sexual interests” (Chivers et al., 2010, p. 48)—suggesting that arousal does not imply consent—the discourses around “healthy receptivity” and a “natural feminine disconnect [between objective and subjective arousal]” are arguably problematic, especially when placed within a larger cultural conversation about the female body's proper response to “legitimate” rape and amid other questions that have recently been invoked about consent in the public sphere (e.g., in 2012, Todd Akin, Republican candidate for U.S. Senate, publicly stated that “it [legitimate rape] can shut that whole thing [pregnancy] down,” raising questions around the relationship among biology, legitimacy, coercion, and feminine truth-telling).

¹¹For example, when popular bloggers such as Leon Seltzer (2012), who writes for Psychology Today, make statements about women being “at war with themselves sexually,” it is precisely this same research that they invoke (http://www.psychologytoday.com/blog/evolution-the-self/201205/paradox-and-pragmatism-in-women-s-sexual-desire).

¹²Many evolutionary psychologists have described the feminine subjective/objective arousal disconnect as an adaptive response that actually serves women's long-term reproductive interests—according to this logic, it is better for women not to be psychologically attuned to their physical arousal so they can be more discerning or “judicious” when choosing a father for their children (Symons, 1979).

¹³Flibanserin still undergoes clinical trials and was revived for FDA approval by Sprout pharmaceuticals in July 2012 (http://www.fiercebiotech.com/story/upstart-sprout-scores-20m-round-revive-fallen-female-libido-drug/2012-07-13); Lybrido is undergoing trials currently (Bergner, 2013).

¹⁴The paradoxical queerness of a group of women being “in the present” together and sensually focusing on the contours of a piece of metal or fruit in order to train themselves to be more sexually receptive to their [tacitly male] partners is beyond the scope of this article but will be addressed in my own future work. I am particularly interested in the queer eroticism ironically produced in a therapeutic space designed to treat low or absent heterosexual desire.

¹⁵One major exception to this lack of theorization is the work of John Bancroft, who, in his discussion of the “dual control model” of sexual inhibition/excitation, suggests that it is logical and a learned response for women to be sexually uninterested if they know that the sex they are avoiding would not be pleasurable for them (Bancroft, 2002; Bancroft, Loftus, and Long, 2003).