Difference or dysfunction?: Deconstructing desire in the DSM-5 diagnosis of Female Sexual Interest/Arousal Disorder

Definitional dilemmas and (missing) discourses of desire

There is considerable ambiguity and variability in how sexual desire is defined and assessed (Basson, 2002; Fahs & McClelland, 2016; Graham et al., 2017; Kaschak & Tiefer, 2002; Meana, 2010). This lack of definitional clarity is not unique to desire and has been highlighted as a significant issue in sexuality research more generally (Fahs & McClelland, 2016; McClelland, 2010, 2011). Sexual desire is one of many terms that is taken for granted; most definitions have not been derived from exploring what the concept actually means to individuals and how their idiosyncratic experiences are influenced by broader social pressures and/or possibilities (Fahs & McClelland, 2016; Meana, 2010; Thomas, 2017).

How desire and, relatedly, “dysfunctional desire” are defined has implications for who is diagnosed (potentially leading to inflated prevalence rates of desire disorders) and for individuals’ beliefs about their own sexual functioning. Research shows that women who perceive higher prevalence rates of sexual dysfunction in the general population of women are more likely to monitor themselves for signs of sexual difficulties, which may be detrimental to sexual functioning (Chang et al., 2013). Definitions of desire also have implications for how so-called low desire is conceptualized by professionals and what treatments are offered.

Most models of desire are based on physiological conceptualizations of men’s sexual responses and are dissonant with women’s own accounts of sexual desire and, similarly, with what women report causes distress during sex (Bancroft et al., 2003; Laan & Both, 2008; Wood et al., 2006). Qualitative research shows that women describe desire in myriad ways, referencing cognitive, psychological, emotional, and interpersonal aspects of desire (Fahs et al., 2020; Goldhammer & McCabe, 2011). Further, desire for sex is not always the primary motive for engaging in sex; women describe a range of personal (e.g. increasing self-esteem) and interpersonal (e.g. increasing connection with partner; feeling obligated) reasons for engaging in partnered sex.

It is important that researchers attend to women’s manifold descriptions of desire; at the same time, addressing definitional issues does not guarantee a nuanced understanding of the complex decision-making processes that determine whether or not to engage in undesired sex. Entitlement to wanting sex is highly gendered and tethered to cultural expectations that men initiate sex and women respond affirmatively, leading to a multifaceted set of sexual mandates that complicate sexual refusals (Cense et al., 2018; McClelland, 2010). Understanding relational aspects of desire and the entanglement of dominant heteronormative sex scripts is key to understanding reasons for low desire; for example, lack of desire may be judged relative to how much a partner desires sex, rather than being an indicator of individual pathology.

To address the idea that women’s sexual responses are not always linear (i.e. desire preceding physiological arousal), Rosemary Basson (2000, 2002) developed an “alternative” model of female sexual response. This model is cyclical and based on assertions that women prioritize intimacy over physical pleasure and that women’s motivations to engage in sex differ from those of men, emphasizing perceived incentives (e.g. pleasing a partner and maintaining a relationship). Female receptivity or “responsive desire” is central and framed in terms of a woman’s “willingness and ability to find and respond to sexual stimuli” (Basson, 2002, p. 293). Here, female desire is understood as a desire to respond to a partner’s advances (i.e. willingness, which is more in line with definitions of consent than desire), rather than subjective, embodied desire. It appears that Basson’s (2000) intention was to normalize the finding that desire generally decreases over the course of a long-term relationship, arguing that while men more often “experience their desire as independent of context” (p. 52), women experience desire after they have chosen to have sex based on “needs other than desire” (p. 53). Indeed, women report myriad reasons for engaging in sex; desire can be experienced outside of sexual activity, and even within sexual activity, desire can target relationship satisfaction or emotional closeness, for example, rather than desire for sexual pleasure (Brown-Bowers et al., 2015; Thomas et al., 2017). Importantly, men describe similar reasons for having sex (e.g. Ford, 2018), although this has not often been studied since the male sex drive discourse (Hollway, 1989) underpins most mainstream sexuality scholarship. ³ It is also worth briefly differentiating desire from consent; these concepts are often conflated in the literature and in popular media. Sexual consent, another taken-for-granted concept, is most often defined as willingness to engage in sex, whereas desire represents wanting to engage in sex (Peterson & Muehlenhard, 2007). Having undesired sex is a common experience for women, and even when individuals want to engage in sex, sexual desire is multidimensional and does not always equal desire for sex. Basson’s (2000) model does little to unpack factors that influence women’s experience of desire as responsive rather than what Basson terms “spontaneous”, and ultimately it supports male-centered models of sexuality.

In summary, it is important to consider how sex and desire are being defined when assessing sexual satisfaction and (lack of) desire in psychological research (Fahs & McClelland, 2016). Definitions matter; they can either illuminate or obscure material conditions that shape people’s sexual lives. Without clear definitions, it is difficult to interpret participants’ responses (i.e. responses are contingent upon how questions are asked). For example, participants may draw distinctions between mental/emotional desire and physical desire, which may not be captured when simply asked about “sexual desire.” Further, how “low” desire is defined has implications for who is referred to treatment and what is being targeted in treatment. When limited, generalized definitions dominate mainstream media, individuals are not exposed to other means of enjoying sexual pleasure (Frith, 2015) and lack of desire for (a particular penetrative version of) sex becomes conceptualized as a medical problem requiring intervention.

Diagnosing (low) desire in the DSM-5

The gendered nature of FSIAD has sparked much debate, including arguments that this is the only disorder in the DSM with differential diagnostic criteria for the same construct based on gender, and that deleting desire from the diagnostic nomenclature altogether is indicative of the eradication of desire as an essential part of female sexuality (Spurgas, 2016). Removing “desire” from the FSIAD nomenclature was intended to highlight women’s sexual responses as heterogeneous and different from men’s, and to move away from biological connotations associated with the term desire (Brotto, 2010; Graham, 2016). We argue both that the deletion of desire in FSIAD (and retention of desire in the parallel category of Male Hypoactive Sexual Desire Disorder [MHSDD]; APA, 2013) reifies naturalized gendered constructions of sex and, moreover, that the entire enterprise of treating low desire as a disorder is flawed, for any gender. While people may experience distress related to low desire, labelling that distress as “dysfunction” does not address the imbricated intrapsychic, interpersonal, and sociopolitical forces that might lead to it.

The fifth edition of the DSM provided significant changes to the classification of female sexual disorders (APA, 2013; Graham, 2016; Sungur & Gündüz, 2014). The working group of experts tasked with revising the section on sexual dysfunctions documented three main goals in revising DSM nomenclature: (1) to emphasize “subjective and relational aspects of women’s sexual experience” (Graham, 2016, p. 38); (2) to avoid pathologizing normal variations in sexual functioning; and (3) to specify duration and severity of symptoms required to meet a diagnostic threshold (Graham, 2016). The working group highlighted several rudimentary challenges in addressing these goals, specifically pertaining to definitional issues. As explored in the previous section, despite a growing body of literature, little was known about the subjective experiences of sexual desire, and therefore distinguishing between “normal” and “dysfunctional” desire presented significant challenges to revising diagnostic criteria (Graham, 2016). The group also identified a dearth of research on women’s sexual problems in non-Western contexts, noting the limited ability to incorporate sociocultural factors (Graham, 2016) that are central to women’s experiences of desire (Tolman & Diamond, 2001).

For women, FSAD and HSDD (DSM-IV-TR; APA, 2000) were deleted and consolidated into a new diagnosis of FSIAD (DSM-5; APA, 2013), based on an assumption that women’s sexual desire is more responsive (i.e. arising in response to sexual cues) than men’s (Brotto, 2010) and on research suggesting high concordance between desire and arousal in women (Sungur & Gündüz, 2014). At the same time, research showed that many women experience physiological arousal without subjective desire (e.g. physiological studies of genital arousal showed that women exhibit signs of genital arousal both in response to stimuli they rate as arousing and stimuli that are not sexually appealing; Chivers & Bailey, 2005), which complicates this amalgamation (Sarin et al., 2016; Spurgas, 2016). Replacing “desire” with “interest” in the diagnostic nomenclature was described as a way to circumvent definitional desire issues highlighted above, and working group member Lori Brotto argued that the term interest goes beyond biological connotations associated with the term desire to reflect lack of motivation to engage in sex (Brotto, 2010). We argue, instead, that deletion of desire and installation of interest in the DSM-5 further perpetuates dichotomized views of sex based on gender, in which women are positioned as responsive to advances for sex as opposed to experiencing corporeal or psychological desire.

Female Sexual Interest/Arousal Disorder: Displacing desire

The FSIAD diagnostic criteria adopt a polythetic approach in an attempt to recognize that women’s sexual responses and descriptions of desire are heterogeneous (Graham, 2016). That is, endorsement of any of the following three criteria, along with clinically significant distress and a symptom duration of 6 months or more, meet the diagnostic threshold for FSIAD:

Lack of, or significantly reduced, sexual interest/arousal as manifested by at least three of the following indicators: 1. Absent/reduced interest in sexual activity, 2. Absent/reduced sexual/erotic thoughts or fantasies, 3. No/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate, 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts), 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (i.e. written, verbal, visual), and 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situation contexts or, if generalized, in all contexts. (APA, 2013, p. 433)

Notably, the separate diagnostic categories pertaining to arousal and desire in men (MHSDD and erectile dysfunction) were retained during revisions from the DSM-IV-TR to the DSM-5. In the section on MHSDD, the DSM-5 states the reason that desire and arousal disorders were retained as two separate disorders is that “men do report a significantly higher intensity and frequency of desire compared with women” (APA, 2013, p. 443), with no critical attention to social expectations and differential performance pressures that may influence differences in reporting. Further, “[unresponsiveness] to a partner’s attempts to initiate” (APA, 2013, p. 433) is not part of the criteria for the corresponding male diagnosis of MHSDD. The terms “interest” and “responsiveness” are entirely absent from diagnostic criteria for MHSDD, categorized solely by “persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity,” in addition to duration and clinically significant distress (APA, 2013, p. 440). Responsiveness and interest are not discussed until the “Associated Features Supporting Diagnosis” section, where it is specified that the male partner typically initiates sex and lack of responsiveness is only a problem if it is the man’s preference for his partner to initiate (see also Spurgas, 2016). This is another instance of how the unexamined male sex drive discourse (Hollway, 1989), rooted in biological essentialism, dominates the diagnostic arena, ignoring the sociopolitical scaffolding that underpins the installation and ossification of such sexual scripts. This also runs counter to scholarship that finds that many men experience an obligation to be primary sexual initiators as undue pressure and prefer to share the “labour” of sexual initiation (e.g. Dworkin & O’Sullivan, 2005). Men and women in relationships are also equally likely to favorably respond to sexual initiation by their partner (e.g. O’Sullivan & Byers, 1992; Vannier & O’Sullivan, 2011).

Lack of sexual thoughts and fantasies, often understood as an indication of sexual desire, is another FSIAD criterion. Brotto (2010) suggests that fantasies may be more relevant to men’s desire than women’s, as research has found that men are more likely to report fantasy independent of sexual experiences with a partner, whereas women cite fantasizing about their own experiences as a way to facilitate arousal. Therefore lack of sexual fantasy may not be a good indicator of (absent) female desire. It is important to consider that this gendered difference may be due to women underreporting certain types of fantasies. The nascent but growing inquiry into women’s active use of pornography (Ashton et al., 2018) as negotiated practice, with specific erotic, ethical, sociopolitical, and geopolitical contours (e.g. Chowkhani, 2016; Marques, 2018), suggests that fantasy is a key aspect of sexuality for many women. Likewise, the largest study of porn use to date (international sample of 5490 people; Smith et al., 2015) found that women aged 18–25 regularly consume more porn than do men, and for those under 18 and between 26 and 35 years of age, porn frequency use is the same for men and women. While people cite a variety of reasons for using porn (e.g. intensifying sexual pleasure; expanding sexual expression; consolidating sexual identity), young men and women, in particular, are equally likely to emphasize fantasy as central to satisfying sex (Smith et al., 2015). While some of this may be indicative of demographic shifts, with younger people being more able and willing to express and experience diverse desires, this large international sample also contains a high proportion of older adults. In highlighting these findings, we are not suggesting that the absence of fantasy should be retained as a diagnostic criterion, but rather that it is important to consider that women may be less likely to report (at least some types of) sexual fantasies as a reflection of what women feel comfortable (and not ashamed) to explore and disclose.

With regard to absent physical sensations during sex (“absent/reduced genital or nongenital sensations during sexual activity”), research comparing women diagnosed with DSM-IV-TR disorders of arousal (FSAD) and desire (HSDD) to a control group with no sexual difficulties found no significant differences in reports of genital arousal; rather, reports of subjective arousal and desire differed (Sarin et al., 2016). Therefore, genital arousal alone may be a poor predictor of subjective desire. Further, a recent study found several hormonal markers of HPA axis dysregulation—e.g. lower morning cortisol, dehydroepiandrosterone (DHEA) and cortisol awakening response (CAR)—in women diagnosed with HSDD (as compared to women without this diagnosis; Basson et al., 2019). These markers are associated with early experiences of adversity (e.g. sexual assault histories), which can impact adult sexual functioning. For example, increasing DHEA levels can lead to increased genital sensations. Thus, even if there are underlying physiological differences in women diagnosed with low desire, these differences may originate from stressful circumstances, and, therefore, we question whether including problems with arousal and desire in the DSM (as opposed to recommending therapy to resolve difficult childhood and relational experiences) is helpful and whether it unnecessarily locates the impact of external events within the individual.

It is interesting that the above criterion (6) related to absent physical sensation and the criterion related to absent sexual excitement/pleasure (4) can apply to both “situational” contexts and “all” contexts. Similarly, in making a diagnosis, the clinician is instructed to specify whether the symptoms leading to a diagnosis are generalized or situational (“only occurs with certain types of stimulation, situations, or partners”; APA, 2013, p. 433). The two criteria that are most related to pleasure and bodily feelings are the only two symptoms that do not have to be present all the time (indicating that individuals may experience pleasure and (non)genital sensations in some situations). If feelings arising within the body are absent only in certain situations or only with certain people, does this represent a dysfunction or, more likely, does it represent normal fluctuation in desire across people, places, and contexts? If contextual variations in desire were not pathologized, would there be a problem that requires treatment?

The requirement that women report distress to meet the diagnostic threshold was another significant addition to FSIAD. Brotto (2010) suggested that adding distress as a criterion for FSIAD is important to allow us to distinguish between people who identify as asexual and only feel distress “in reaction to sociocultural pressures to be sexual” (Brotto, 2010, p. 230) and people who experience distress due to diminished desire. We argue that similar sociocultural pressures apply to women (and men) who do not have the prescribed amount of desire and that this may account for distress, as opposed to distress based solely on “symptoms.” For example, older women report higher rates of low desire whereas younger women are more often distressed by their low desire (Laumann et al., 1999; Stephenson & Meston, 2012). What is being diagnosed here is not necessarily absent desire, but rather non-conformity to a particular set of expectations about female sexuality and desire. The “Associated Features Supporting Diagnosis” section states that “unrealistic expectations and norms regarding the ‘appropriate’ level of sexual interest or arousal” as well as “poor sexual techniques and lack of information about sexuality” (APA, 2013, p. 434) may be observed in women who are diagnosed with FSIAD. This acknowledgment, however, does not preclude a woman from receiving a diagnosis. The only identified “functional consequence” (p. 436) is decreased relationship satisfaction (with no indication of the direction of this association). It is important to consider whether low interest and arousal cause decreased satisfaction or whether less satisfying relationships lead to decreased interest and arousal. Notably, there are no listed functional consequences of MHSDD, and this is the only disorder in the section on sexual dysfunctions (and perhaps even in the entire manual) that does not list any functional consequences. If there are no functional consequences, then why are differences in desire diagnosed?

Severe relationship distress is also listed as a diagnostic exclusion (i.e. a context in which low desire would not be diagnosed), yet it is unclear how severity is measured. Is it only extreme cases of relational violence that are considered to be a legitimate reason for a woman not to desire sex? How is this determination made? A study exploring how women with sexual problems (low desire and vulvar pain during intercourse) negotiate sexual activity in the context of heterosexual relationships found that women reported either avoiding intimate situations or engaging in intercourse even when it was painful or undesired, and mentally preparing themselves for sex (Hinchliff et al., 2012). These findings highlight that lack of desire can be problematic even in the absence of “severe” relationship distress. Further, although “severe relationship distress” and “significant stressors” are assessed when diagnosing FSIAD, trauma history is not explicitly a part of the recommended assessment (Spurgas, 2016). As Spurgas (2016) argues, it is critical to assess sexual violence histories, as women who report low desire also often have experienced sexual violence.

To summarize, while some diagnostic changes reflect research findings from mainstream sexology, critical interrogation is lacking about why experiencing distress about so-called low levels of desire is pathologized in the first place. The DSM-5 collapses heterogeneously derived and experienced distress about sex into a homogeneous diagnostic category. How can we diagnose so-called low/absent desire when we have a limited understanding of what embodied desire actually feels like for women, and the conditions for its (im)possibility? And how do we disentangle women’s distress about desire from political and interpersonal pressures to project and enact a socially desirable sexual self? Our analysis of FSIAD demonstrates that a diagnosis devoid of consideration of the structural conditions for enabling and entitlement to embodied desire is a vacuous epistemic placeholder for producing theoretically or clinically useful knowledge about experiences of sexual distress.

We have highlighted examples of the ways in which the DSM nomenclature continues to reflect gendered (and medicalized) descriptions of desire. While shifting criteria, such as adoption of a polythetic approach and a duration requirement, reflect attempts to acknowledge that women’s desire is diverse, undulating, and influenced by contextual factors, diagnosing “low” desire as a mental disorder is antithetical to this effort and runs counter to the DSM-5’s definition of a mental disorder (“clinically significant disturbance in an individual’s cognition, emotion regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental function”; APA, 2013, p. 20). The manual clearly states that “conflicts that are primarily between the individual and society are not [indicative of] mental disorders unless the deviance or conflict results from a dysfunction in the individual.” By diagnosing desire differences as dysfunction, variations in desire (influenced by a complex array of social and interpersonal experiences and expectations) are mislabeled as problems of individual functioning. This framing fails to acknowledge unequal gendered power relations supported by social structures that remain largely unaltered (Gill, 2008, 2009).

Conclusion

In heeding Fahs and McClelland’s (2016) “invitation to trace how concepts travel,” acknowledging that they are always “sites of debate” (p. 393), we have attended to a conceptual analysis of the term desire, with a particular focus on diminished or absent desire as a reflection of the medicalization of female desire more generally and as an instantiation of pathology within the DSM-5. Notably, the removal of the term “desire” and its replacement by the term “interest” (often in response to partner initiation) in the category of FSIAD signals a retreat into the missing discourse of desire for women (Fine, 1988; Fine & McClelland, 2006). When the language of desire is displaced by the language of interest (particularly when framed as receptivity), the capacity to theorize wanting as entitlement to available discourses and material resources is undermined. Fine and McClelland’s (2006) concept of “thick desire” locates desire beyond individual bodies and minds; it frames desire as a product of intimate and social arrangements and resources. A theory of wanting promotes questions (along with activism and treatment) about the sociopolitical and interpersonal conditions needed for wanting to be knowable—that is, palpable, pleasurable, and possible.

Embodiment considerations are necessary, if not fully sufficient, conditions for understanding why some women find sexual satisfaction elusive or a burdensome aspiration. Feminist theorizing of embodiment has been influential in establishing that the body is where social and political relations converge, while it is also the site of contestatory possibilities (e.g. Bordo, 1993; Grosz, 1994). The colonization of subjectivity takes root through disciplinary forces exerted on the body (Foucault, 1977). While the body’s materiality is undeniable, it is not a pre-discursive clean slate upon which cultural meanings are imposed, but is always already a discursive accomplishment masquerading as grounding, often used to make essentialized claims about sexual difference (Butler, 1993). We have argued that the FSIAD diagnostic category, while attempting to attend more carefully to the specificity of women’s sexuality, reiterates a long history of capitalizing on the materiality of the body to position gender differences as natural and biologically based. Consigning (distressed) female sexual subjects to a diagnostic category that serves to evacuate women’s variegated embodied experiences of desire recapitulates an essentialist conception of gendered sexual subjectivity. In our analysis of the FSIAD diagnosis, we have attended to the ways in which women’s embodied sexual subjectivities—as a form of sociality, ineluctably interpersonally and socio-politically inflected—are sidelined in favor of individualized, atomized classifications and explanations.

We have also briefly addressed the clinical implications of definitional discrepancies, when desire or non-desire are defined by professionals who do not inquire about women’s contextual and structural experiences of sex and relationships. This highlights the power dimensions of knowledge production and dissemination (Foucault, 1972) and the ways in which scientific sexuality discourses, specifically, serve both productive and policing functions (Foucault, 1978). Conceptual analysis is essential in sexuality scholarship and clinical practice in order to critically evaluate how de-contextualized diagnostic labels come to describe and pathologize structurally and relationally embedded experiences, with gender as a key marker of status and power.

In summary, we add our voices to those of other critical sexuality scholars and clinicians who encourage the consideration of relational and contextual factors as core to approaching women’s desire dilemmas in order to re-situate concerns about sexual functioning in the inter/personal (as ineluctably political), rather than medical, realm. This requires continued interrogation of concepts and specific meanings for women, and being mindful of definitional challenges when constructing questionnaires, interview guides, or speaking with therapy clients. A framework that considers the impact of relational conflict, barriers to talking about sex, guilt and shame about sex, past trauma, and gendered societal expectations—as just some parts of a complex web that cannot be disentangled—promotes broader conceptualizations that may more accurately reflect women’s lived experiences and allow for diversification of desires.