Feminists with Female Sexual Dysfunction

Conceptualizing the FSD hierarchy

A couple of times on this blog, I and guest posters have briefly mentioned something called the female sexual dysfunction hierarchy. This is an idea that formed in my mind while reading various interpretations of  female sexual dysfunction – I noticed that not all forms of FSD were handled equally in terms of social (and professional) acceptance and priority for treatments. But what is the FSD hierarchy, exactly? What do we mean when we talk about it? Let’s think about it and see what we can come up with.

To me, the FSD hierarchy means that certain types of sexual problems are more readily recognized as sexual dysfunctions than others, and are given a higher priority for treatment by doctors and therapists. It means that if you have some sexual dysfunctions that are not recognized as serious and real you’re more likely to have to present some reason, a justification, for the dysfunction to exist in the first place and you may face barriers to satisfactory resolution. Conversely, the FSD hierarchy means that other types of sexual dysfunctions are more readily recognized as valid health problems for which medical treatment (and insurance reimbursement) is more likely to be available and socially acceptable.
It’s not that all forms of FSD can or should be treated with a single magic bullet. Different types of FSD need different treatment options, including the option to not treat at all. A woman with low libido may not require a pain management program and a woman dealing with orgasm difficulties may already have an otherwise high sex drive. However, what the hierarchy does is prioritize some women’s personal experiences and feelings with regard to sexual dysfunction, but it dismisses others.
Basically you get shit about having certain types of FSD but not others. The hierarchy does not necessarily mean that women with any form of FSD will be treated the way as they should be – that is, with respect and dignity.

Ultimately, I think it means that some sexual dysfunctions are “Okay” to have and treat, while others are not okay to have or to view as dysfunctions, regardless of how much a sexual problem is interfering with your life. I believe that a hierarchy of FSD is something that both medicine and social construction contribute to.

And I don’t like it. No sir, I don’t like it.

I hate the hierarchy of sexual dysfunction. It isn’t fair. It’s artificial and hegemonic; it compartmentalizes different types of sexual dysfunction, so you lose a chance explore overlap. Coupled with the stigma of having FSD in the first place, keeps women with sexual problems broadly from sharing experiences with one another. Unfortunately the hierarchy of FSD in and of itself adds to the stigma – since some kinds of FSD aren’t valid in the first place, it’s hip to make fun of anyone who thinks they have sex problems.

Medicine is rigid in defining what is recognized as FSD. Generally, under the medical model of FSD, (hotly contested and informed by the DSM) there are four broad categories of sexual dysfunction – pain, lack of arousal, lack of orgasm/pleasure, and/or a low or absent libido (sexual desire.) To this day, as evidenced by the JAMA study citing a 43% prevalence rate of FSD in the US, a sexual problem may be considered to cross the threshold into “Dysfunction” regardless of the feedback of the individual. To ignore a patient’s personal feelings is a problem in and of itself, for it’s fairly common to experience snafu sexually from time to time. And even if you do experience what might be considered a “Problem,” if you are comfortable with that, then it’s less of a problem in the first place.

The social construction model, particularly the New View model of women’s sexuality, is looser in recognizing sexual problems and their causes, but stricter in defining limits for the term dysfunction.  Stricter limits on the use of the term sexual dysfunction are called for because of a long history of abuse at the hands of those who had the authority to dispense with such terminology in the past. Additionally, sexual dysfunction is stigmatized and so a diagnosis of FSD can in and of itself create anxiety – you lose your status as a “Normal” person, sexually. (If you ask me, it makes more sense to take out the sting of sexual dysfunction in the first place rather than to elevate TAB status to its position of privilege. There’s nothing wrong with having a sexual problem, so, what’s wrong with having sexual dysfunction?)

Here’s a picture of what I think the FSD hierarchy looks like. I whipped this up in Excel so the graphic is Butt-Ugly. My hierarchy is based on the four broad medical categories of FSD, because that’s how I most often  see sexual dysfunction talked about. That medical model of sexual dysfunction certainly does have a long reach. What does the FSD hierarchy mean to you, and how would you describe it?

[Description: The sexual dysfunction hierarchy pyramid, version 1.0. A 4-tier pyramid sitting on top of a brown rectangle. Each tier in the pyramid is a different color and labeled, in descending order, "Pain," "lack of arousal," "lack of pleasure/orgasm," and "low/absent libido." Caption next to the pain tier says, "Pain is generally recognized as valid. May be considered a pain condition, disability and/or sexual dysfunction (depending on the individual with pain and who you ask about it)." Caption next to the lack of arousal tier says, "can sometimes be a problem may be addressed with lubricants or medications ED in cis men usually recognized more readily". Caption next to the lack of pleasure/orgasm tier says, "Starting to get controversial as sexual dysfunctions now since these problems may be social, physiological or both". Caption next to the low/absent sexual desire tier says, "The illegitimate child of FSD Desire, libido, HSDD - all highly contested Is it a dysfunction or just part of your personality?". The rectangle under the pyramid is supposed to represent underground and it's labeled "PGAD, Endometriosis, Overlap and Intersectonality, Stuff I forgot about, Interstitial Cystitis and Stuff I hadn't thought of."] Caption next to the rectangle says, “Stuff underneath the pyramid Doesn’t get talked about much”.

Under both the medical and social construction models of sexual dysfunction, pain is generally recognized as valid problem that cannot always be explained away. It is the sexual problem for which medical intervention is the most acceptable, relatively speaking. Even Dr. Leonore Tiefer, proponent of the social construction model of sexuality, who organized the New View Campaign, has stated that sexual pain is the one and only valid and important sexual dysfunction – at least so long as we continue to use that terminology. Pain might be due to a vulvar pain condition like vulvodynia or vaginismus, or it might be part & parcel of another chronic health condition. It may be exclusively limited to sexual situations.
I’ve noticed that since pain is more readily recognized as a medical problem and a sexual dysfunction, it’s treated funny in discussions of FSD. Even though pain falls under the broad umbrella term of FSD, it’s frequently ignored or gets at best one-line mention in an article. So there’s a poor exploration of overlap between pain + other sexual problems. And as someone with sexual pain problems, I can’t ignore the way that other non-painful forms of FSD are discussed; the way sexual medicine is stigmatized – that’s a lot of stigma to get over, when you need to reach out to a medical professional for help. The take-away message stuck in my mind is, “Of course HER distress is palpable and important – she’s in physical pain! HER sexual problem is okay to treat with a pill or whatever, but YOURS isn’t. Why are you so worried about anything other than pain, anyway?” It is as though the distress I feel from experiencing pain with sex is more legitimate than the distress that another woman feels from lack of orgasm, or whatever else.
Even though sexual pain may be treated with relative respect in discussions of sexual dysfunction, the reality remains that it’s still viewed as a joke. Write frankly about dyspareunia and you may find trolls come out of their dark hiding places. In real life sexual pain gets no special treatment.
(For the record, I know that I talk about sexual pain with more detail than I do other types of sexual dysfunction on this blog. This is not because I think other forms of sexual dysfunction are unimportant – it’s because I have the most experience with sexual pain.)

I placed arousal problems on the second tier. This can be a problem because a lack of arousal in and of itself can contribute to physical discomfort with vaginal insertions of objects say, if you are not  producing sufficient lubrication. I’ve found that a little lubrication can also make vulvar stimulation more comfortable with a partner. I also placed this one second on the hiearachy chart because there are sex toys and some medical tools (I’m thinking of vacuum pumps and lubricants) available for women with arousal difficulties. (There’s also that Zestra thing that’s been going around stirring up double-standards in advertisements controversy too but I don’t know how effective it really is.) This is also where erectile dysfunction would go, as the presence of an erection is not necessarily the same as the presence of sexual desire (a distinction which in and of itself can be difficult to come to terms with.)

I placed lack of orgasm and/or sexual pleasure on the third tier, in orange. Things are really starting to get messy & controversial now. There’s sort of a medical treatment available for this (the Orgasmatron spinal cord stimulator) but it’s heavily sensationalized and it may not even work well.
And orgasm itself can be controversial – How much should an expert and an individual emphasize the importance of orgasm? Does emphasis on sexual pleasure create pressure to have an orgasm? What if you’ve tried everything and it’s just not happening? What if the reason you cannot orgasm is because of poor sex education; because no one ever showed you or your partner how? What about if you were previously orgasmic and subsequently developed difficulties orgasming – say, from an injury, antidepressant use, or something else? If you are having difficulty with orgasm because of a medical problem then should that be recognized as a sexual dysfunction in and of itself or as a symptom of something else?

The fourth tier is the one that sets off alarm bells most frequently. When the media covers sexual dysfunction, this is usually what journalists are talking about and what sexologists respond to – low or absent sexual desire. It’s very controversial as far as sexual dysfunction goes – How are we defining low sexual desire, what is the measuring stick? Could a low or absent sexual desire be part of your personality or sexual orientation (asexuality) and, if so, how do we make that distinction? What terminology should we use; should we call it a sexual dysfunction or a sexual problem? Does it have a cause and if so, what is that cause; are you stressed out or have you started on a new medication? If not, then have you stopped to consider social construction arguments to explain a drop in libido? Could low libido ever be more than one of the above or possibly all of the above?
In terms of the FSD hierarchy, this is the dysfunction that is most socially unacceptable to have (or at least to publicly disclose) and certainly the least acceptable one to seek medical treatment for. The New View Campaign’s activism during buildup to the flibanserin hearings explicitly stated, “Low sexual desire is not a disease.” This is a theme repeated throughout Sex is Not a Natural Act and A New View of Women’s Sexual Problems.
However, somewhat paradoxically, it may be acceptable to have low or absent sexual desire – so long as we don’t call it a dysfunction and so long as we avoid medical options to address it.

And then there’s the fifth tier, which isn’t even part of the pyramid. I put it underneath the pyramid, underground – because it contains stuff related to sexual dysfunction that rarely gets discussed. This is where stuff that gets swept under the rug goes. It’s where alternative views of sexual problems and dysfunctions are – brigid wrote about this in her guest post, On the FSD hierarchy and why it hurts all of us – here, she discussed endometriosis and the lack of discussion about how it impacts sexual functioning, and she said, “By silencing other women who suffer from FSD just because it doesn’t fall under one individual’s narrow view of what fsd is and how it works, we are hurting every woman who needs help.” Another example would be an alternative interpretation of sexual pain proposed by a co-author of Secret Suffering – that sexual pain can also mean pain in the sex organs.
This is where interstitial cystitis wound up when MTV ran the True Life episode, I Can’t Have Sex. One of the participants of the program, Tali, has IC and IC activisim is an important part of her life. So one of the criticisms with the True Life episode (and this is in no way Tali’s fault,) is that it did not even mention the words, “Interstitial cystitis;” instead the episode focused exclusively on sexual pain. It’s related, but not a purely sexual topic.
And underground, off the pyramid, is where overlapping issues go – for example, to have both sexual pain and a low libido. These two topics may very well be related – it’s possible to experience a drop in sexual interest due to sexual pain; I’ve also seen it suggested that women who have sex with a low libido may experience sexual pain. But what happens when one problem or another resolve? What happens when you find a way to address sexual pain but your libido does not rebound?
And underground is where intersectional issues go – to have a sexual dysfunction and be any sexual orientation other than straight; to be a woman of color with sexual dysfunction; to be a trans person with sexual dysfunction; to have a disability + a sexual dysfunction (which in and of itself may be another disability;) to be kinky yet sexually dysfunctional. (All topics which I’d like to see covered on this blog in 2011 – hint, hint.) Part of the reason I started this blog is because I felt like there weren’t a lot of good resources available specifically for folks with sexual dysfunction. Why would there be such resources, after all, if sexual dysfunction isn’t a real thing: If it isn’t real, then there’s no need for such resources and support – just use whatever anyone else is using. That ought to be good enough, right?

But then I was thinking to myself, this is the way that I’ve seen discussions of sexual dysfunction go in online interactions… but what drives these discussions in the first place? Usually, it’s media coverage. And the media prioritizes coverage of sexual dysfunctions differently than what’s shown here.

So here’s a different model of the way sexual dysfunction discussions might be pictured, as driven by the media:

[Description: another multi-colored 4-tier pyramid graphic, this one inverted so the narrowest point is at the bottom. Labeled The Media and sexual dysfunction pyramid V. 1.0. Representing how the media covers sexual dysfunctions and problems. On the top is "BONERS," second tier is "Libido," third tier is "Orgasm" and the bottom tier is "Pain."]

And here’s an explanation of this pyramid:

1. BONERS – (inspired by Sady Doyle of Tiger Beatdown.) It’s okay to show commercials for erectile dysfunction but not a commercial for Zestra, which supposedly acts on sexual arousal in women. BONERS may or may not be equivalent to libido and orgasm.
2. Libido – after getting past all the commercials and in-print advertisements for Cialis and Viagra you might find yourself reading an article about some other such medication that’s supposed to increase libido or about relationship tweaks you can supposedly make to get more satisfaction.
3. Orgasm – then you may see some advice columns talking about figuring out ways to have an orgasm.
4. Then sometimes sporadically there’ll be an article somewhere about sexual pain.

Not pictured: My total lack of effort in making this graphic and my own amusement in using the word “BONERS” in a graphic on an otherwise serious feminist blog.

As with thinking about sexual dysfunction in terms of disability, this is something that’s very new even to me, and something I’d appreciate feedback on.