Low desire, trauma and femininity in the DSM-5: a case for sequelae

Abstract

The recently released DSM-5 (2013) includes a new sexual dysfunction: female sexual interest/arousal disorder (FSIAD). For the first time, the low sexual desire disorders are split along gender lines, and lack of sexual ‘receptivity’ is offered as a criterion for diagnosis in women only. Although ‘severe relationship distress’ or other ‘significant stressors’ are to be considered during evaluation for FSIAD, the patient’s trauma history is not evaluated as part of the protocol. The presence of violence or distress can potentially elicit a differential diagnosis, but what constitutes ‘severity’ is not articulated either, except to designate ‘partner violence’ as the primary example. Thus, past relational violence, sexual abuse and trauma are not explicitly considered – nor is the vast spectrum of gendered violations that many women describe experiencing on a regular basis. I examine potential problems with separating the trauma diagnoses (i.e., post-traumatic stress disorder, depersonalisation/derealisation disorder, and other trauma- and stressor-related or dissociative disorders) from FSIAD in the DSM-5. Drawing on interviews with low-desiring women who describe being violated, I elaborate how this diagnostic separation may be re-traumatising for women who have experienced such violence and have low sexual desire as a result. I also question the utility of framing psychological disorders and symptoms as co-morbid (i.e., concomitant but unrelated), and argue instead for more thorough aetiological or sequelic investigations of low desire.

Keywords:

• female sexual interest/arousal disorder (FSIAD)
• post-traumatic stress disorder (PTSD)
• trauma
• violence
• desire
• gender

Notes

1. Brotto (2010) sometimes refers to the ‘alternative sexual response cycle’ in non-gendered terms in her article, and engages with critiques of a linear model of desire on the basis that ‘the Masters and Johnson model purports that women (and men) first experience sexual desire before experiencing sexual arousal [which she argues, along with Basson, is untrue]’ (p. 226, italics added). Although she includes the parenthetical caveat that men, as well as women, may experience ‘responsive desire,’ her model of sexual responsiveness in this article is based on Basson’s (2000, 2001) model of responsiveness, which Basson defines as applying specifically to women. In addition, up until the last few years, research on sexual responsiveness was uniquely conducted on women. Thus, there is a problematic slippage between: (i) an empirical lack of evidence to support responsiveness in men, and (ii) a theoretical instantiation of uniquely female responsive desire. As I will argue, the existence of two separate low desire diagnoses in the DSM-5, one for men and one for women, with correspondingly gendered language in each (e.g., an emphasis on receptivity and responsiveness in FSIAD), discursively and diagnostically produces masculine and feminine desire, and male and female sexuality, as very different.

2. According to Chivers et al. (2010), female discordance may be the result of an evolutionary adaptation designed to help women make more evolutionarily sound choices regarding whom they mate with: ‘Unlike men … concordance is not necessary for women to engage in sexual intercourse. In fact, the more conservative sexual strategy (in terms of greater choosiness regarding sexual partners, having fewer sexual partners and longer term relationships) adopted by many women might be compromised by high concordance (see Symons, 1979). From this perspective, partial independence of psychological and genital processes may aid female sexual decision-making by reducing arousal-dependent appraisal of suitable mates…’ (p. 50). Graham (2010), the other primary author of the FSIAD diagnosis, cites this research, and Brotto (2010) herself cites other research by Chivers and her colleagues (e.g., Chivers et al., 2007). This incorporation demonstrates how the evolutionary psychology perspective (e.g., Symons, 1979, cited in the excerpt above) on sexual difference in regard to concordance is also fundamentally intertwined with the FSIAD diagnosis.

3. That this violence must characterise the current relationship is tacit in the diagnosis, which I elaborate below.

4. It is important to note that all of the participants in my study were cisgendered women (they identify as women and had been assigned a female sex designation at birth), and the men they described having sex with were cisgendered men – although many currently identify as queer, and many are no longer in heterosexual relationships. Previous or current sexual relations with cisgendered men was an important variable, as this study examines the role of heteronormativity and patriarchal violence in low-desiring women’s experiences of their own femininity, and as it paid particular attention to experiences in early and present-day sexual, romantic, emotional and familial relationships with men. This research thus contributes to the burgeoning field of critical heterosexuality studies (Fischer, 2013).

5. Although I did not ask my participants whether or not they had ever been diagnosed with any trauma- or stressor-related or dissociative disorder, many described experiencing the types of gendered and sexual violence and abuse which, in many cases, do result in trauma (Herman, 1992), and some mentioned PTSD or described symptoms consistent with a diagnosis (it was unclear whether or not these individuals had received a clinical diagnosis from a practitioner). Many participants used terms such as ‘traumatic,’ ‘violent,’ ‘violating,’ ‘coercive’ and ‘abusive’ to describe previous sexual experiences, and did not clearly distinguish among these terms. They also used this language to describe the development of their own sexualities, femininities and experiences of ‘living as women in the world.’ Thus, in keeping with the colloquial and loose way these terms were used by my participants at the expense of precise medical or legal terminology, I focus on the pervasive experience of gendered violence and sexual transgressions while acknowledging that these result in clinical trauma for some, but not all, women. I do not suggest that every participant in my study fits the criteria for diagnosis with PTSD or any other trauma- or stressor-related or dissociative disorder.

6. I acknowledge that my incorporation of a feminist psychoanalytic framework cannot be fully divorced from a medical framework. A feminist psychoanalytic therapeutic encounter between a clinician and patient, in accordance with the way I discuss that encounter, would involve a more thorough accounting of history, power, interpersonal relationships and the sociopolitical context in which diagnoses are made, though, and would thus eschew some of the most glaring problems with ‘medicalisation’ that I cite here (this is in line with the type of ‘feminist therapy theory’ espoused by Brown, 1991, among others).

7. This lack of clarity around ‘severity’ begs the questions: Is clear-cut physical violence or brutality at the hands of a present partner the only legitimate form of ‘severe relationship distress’ that might factor into a reconsideration of the diagnosis? Are other kinds of distress legitimate? Just how distressing must these factors be to sensibly or legitimately affect a woman’s responsive desire? What if the violence is distressing to her, but not to her initiating partner? And: who will be making the call?

8. I do not suggest that the HSRC, as articulated by Masters and Johnson (1966), is more appropriate for women (or men) than the alternative female sexual response model, only that the alternative female sexual response model does not offer a true or viable alternative to the HSRC and thus does not account for the diversity of human desire, which, in many cases, is not sexually dimorphic (as either essentialist model purports). Masters’ and Johnson’s HSRC has been critiqued at length elsewhere (for examples, see Tiefer, 1995, 1996, 2001), and both Angel (2013) and I (Spurgas, 2013a, 2013b) have elucidated how some of these feminist critiques and the alternative female sexual response model itself unfortunately reinscribe binary, gendered and rigid frameworks for sexual desire.

9. Feminist scholars, including popular writer Rebecca Solnit (2014), have made similar points about economies of violence within heteropatriarchal societies.

10. ‘Somatisation,’ or the conversion of anxiety or trauma into physical symptoms, does not fit with definitional criteria for somatic symptom and related disorders as they appear in the DSM-5. Psychologists, psychiatrists and psychoanalysts have long been interested in the physical manifestation of repressed desires and traumatic experiences, as earlier explorations of hysteria clearly demonstrate (Breuer & Freud, 1955/1893–1895; Freud, 1963). But, although Molly’s description here may have been in line with somatoform disorders as they appeared in earlier versions of the DSM, including in the DSM-IV, the DSM-5 in general marks a shift away from psychosomatic explanations of trauma and psychic life, and a concomitant move towards cognitive–behavioural explanations (these shifts apply to somatic symptom and related disorders as well as to FSIAD). I would like to thank an anonymous reviewer of an earlier version of this essay for pointing this out.

11. An important exception to this lack of theorisation is Chivers and Bailey (2005) and Chivers et al. (2010), who suggest that female mind–body discordance and the ease with which women are posited to become objectively sexually stimulated could potentially be the result of evolutionary adaptations in ancestral females that have evolved to protect the vagina from tearing during rape, in line with the tenets of evolutionary psychology (e.g., as it is epitomised by Symons, 1979).

Additional information

Notes on contributors

Alyson K. Spurgas

Alyson K. Spurgas is Assistant Professor of Sociology & Women’s Studies at Southern Illinois University Edwardsville.