What is this war on women you speak of, and why should I care?

02/16/2012 at 6:02 pm | Posted in Uncategorized | Leave a comment
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You may have noticed that there is a war on women being waged in the United States. It’s not a war (always) fought with weapons and explicit acts of violence (although violence against women is very much alive and well.) It’s not (always) a war confined to a physical area in space (although genuinely terroristic activities can target certain facilities used by women more than others.) It is very much a Cold War, one fought via politics and policies, threats and fears. And like all wars, this one has casualties – women, most obviously, though women are not the only ones to feel the shocks. You don’t have to be a lady to express femininity, and thus to be perceived as womanly – and therefore in need of “Correction.”

So what exactly is this war on women, and what does it mean?

The war on women is big enough so that you have to step far back to really take in its overwhelming scale. The war on women means that in the US, social services used by a whole lot of women are getting scaled and cut back. The war on women means that services related to sexual and reproductive rights in particular are the target of vitriol and budget cuts. Social services broadly include social safety net features like Title X and prenatal care, food assistance, and more.

The most talked about targets in the war on women’s sexual and reproductive healthcare (this week) are Planned Parenthood and contraception in general. When anti-abortion politicians infiltrate women’s health care organizations and then deliberately divert cancer screening funding away from other healthcare services – precisely because that targeted organization provides abortion among other thingsthat’s the war on women in action. When a bunch of old guys get together to whine to Congress about how much they hate contraception and don’t let the people who actually use contraception talk – that’s the war on women in action. When politicians create barriers to care – like when they design & then try to ram through “Personhood” laws and/or laws that require needless medical procedures or waiting periods to obtain legal medical servicesthat’s part of the war on women. It goes on.

Maybe you don’t want to call it the “War on women.” Maybe you are not a woman and so believe this does not apply to you – you’d be surprised. Sexologist Marty Klein and historian Dagmar Herzog address overlapping subjects when they talk about “America’s war on sex.” (In fact, Dr. Klein calls the PP/Komen debacle part of the war on sex here.) I am increasingly convinced that the “War on women” and the “war on sex” are two sides of the same coin. You can’t go after one without simultaneously demonizing the other, and I think resolution will require looking at both.

This war on women (or war on sex, if you prefer,) is basically one part of the exact thing feminist sexologist Dr. Leonore Tiefer is talking about in her work when she says we need to examine the social & cultural forces that negatively impact women’s sexuality and thus lead to sexual problems. There’s a lot more to the social construction model of women’s sexuality (you had to have been there,) but the war on women is part of it.

Remember: The social construction model of sex means that what we “Know” about sex isn’t set in stone – our understanding of sex & sexuality is shaped by our social contexts. Sex doesn’t have an inherent meaning so much as it has whatever meaning you, me, and our peers say it has. Get enough people saying the same thing about sex, women, whatever, and you get a big feedback loop that just feeds itself. By the way – there’s already a feedback loop.
I tend to criticize Dr. Tiefer’s work in particular since she’s recognized as a feminist leader in the social construction model of women’s sexuality and sexual dysfunction, yet her work still can’t be a panacea for all the sexual problems.

You don’t ingest the war on women – an idea, a description, a series of events – like a poison from a tangible cup. It’s a cumulative process, where the little things pile up and subtly alter your opinions & perceptions. In other words, you internalize the negative beliefs you’re constantly exposed to. So credit where credit is due – we’re seeing the social construction model of sex in motion before our very eyes. The war makes it harder to express & find what you want, to the point where if your desires don’t match up with what enough other people say is right, you can be subjected to violence (TRIGGER WARNING).

Social construction has limits and problems of its own. It cannot explain away and treat all the sexual problems. My vulvodynia & vaginismus didn’t spring up in response to any particular slight. Even if this war on women ended tomorrow, I’d still have physical problems lurking in my body. Medical science would still be confounded by my case. Kyriarchy would still be alive & well so we’d still be dealing with other kinds of prejudices & phobias. But it’s there.

I wish I could say that “No one wins when there’s a war against women going on,” but obviously someone’s coming out ahead or else this whole mess would never have happened. Someone out there – a few, elite powerful leaders maybe – must be gaining power and/or money off of it. There are a lot of casualties in this cold war; patriarchy hurts men, too. But from where I’m sitting, it looks like the deck is stacked against the ladies in particular.

I think the war on women goes something like this:

  • There’s cultural pressure for women to remain “Pure,” sexually,
  • So if you have sexual experience, if you have been raped, or are merely perceived as “Impure,” you have to take shit from surprisingly angry people about the fact that you may or may not have had sexual activity (Slut shaming.)
  • Simultaneously, there’s cultural pressure for men to have sex with women – the more, the better.
  • Yet paradoxically, this pressure to have sex with women exists even though there’s misogyny in the first place!

It gets worse: that’s not just pressure to perform sexually… Some folks think they are genuinely entitled to have sex with the very women they loathe so much. This is what social justice advocates are referring to when they use the term, “Rape culture.” Rape culture supports and even encourages ideas like: Violence and sex go together naturally. Women aren’t supposed to want sex and if a woman is raped, she must have done something to provoke it. Men can’t be raped and it’s funny when they are. I’m sorry to say, there are literally countless examples of Rape Culture. It is a culture in which rape is allowed to happen – in where it’s justified, or it must be made-up, or not that big of a deal, or what did you expect? Rape culture is the culture in which even I cannot distinguish between statements made by rapists and statements published in a lad magazine. I don’t know what the bigger backdrop is; the war on women, the war on sex, or rape culture, but they’re all going on at the same time in the same spaces, and I think it goes something like this:

  • Meanwhile, for the most part culture doesn’t know what to do with folks who don’t fit well in a gender binary – leading to unnecessary & malicious policing.
  • “Sex” means, “Penis-in-vagina,” = Intercourse.
  • “Penis-in-vagina” = 2 cisgender, heterosexual partners, so that pretty much wipes out queer relationships.
  • PIV intercourse has its own risks – notably, infections and potentially fatal diseases and pregnancy.
  • The responsibility for pregnancy prevention tends to fall on women in cis, het relationships – after all there are still only 2 kinds of birth control available to sexually active men (condoms & vasectomy.)

That’s about where the war on women steps in. Women are expected to be the ones to prevent pregnancy, and when women do have children, childrearing responsibilities still disproportionately fall on women. That makes it hard to bring up a baby and improve your career at the same time (and savings, and thus later on, your social security/retirement income.) The war makes it even harder to obtain contraception and family planning services.

I could just leave it at that, but this is a sexual dysfunction blog and there’s additional stuff that pertains to people with sexual dysfunctions.

  • Sex – that is, intercourse as defined above – isn’t so easy to pull off if you’ve got some form of sexual dysfunction.
  • If that’s the case, then you get to take on the additional pressure of not conforming to the problematic gender dynamics culture set up for you to adhere to in the first place!
  • You can’t perform your role as “Nature” (not necessarily) intended.
  • Not to mention the part where folks who aren’t het can also develop sexual dysfunctions.

This is the environment in which the medical model of sex thrives. Dr. Tiefer wrote extensively about this – how, in a setting where there’s so much sexual pressure and cultural rigidity around sex, marketers for drug companies can easily exploit people with sexual problems & insecurities. (I think the US’s lack of public healthcare contributes as well.) She’s explicitly anti-medical model though, whereas I recognize that some people still have a need for medical assistance even when there’s social forces whirling around. The marketing may make it look like medicine is easy to obtain, easy to use, and easy to get results – but in reality, it’s not so easy.

Anyway, the war on women sounds very limiting, right? But enough people just don’t see it that way, and are willing to serve as foot soldiers. There’s enough folks within the US who (Publicly) are so heavily invested in holding up this “One true way” of sexuality that they grew up with, so that it fucks up life for all the rest of us. So the war goes on:

  • We weren’t raised in a vacuum. You might have been able to buck some of the cultural pressure and expand your definition of sex as you grew up. But pretty much everyone has been stewing in it for a long time…
  • …Some people are just more heavily invested in upholding the dominant cultural sexual narratives than others.

So I’m seeing a lot of sexual double standards in place that make it a lot harder to enjoy sex and to, you know, live. For me, anyway; maybe you’re still totally cool… But the war on women creates a hostile environment in which to discuss and engage in sex. If I get hurt or in trouble, I may not be able to get help – something I’m sure some of you already experienced first-hand.

The almighty glass of wine

02/07/2012 at 12:28 am | Posted in Uncategorized | 9 Comments
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How many readers here have heard a variation of the following statements, with regards to their sex lives?

“Have a glass of wine and relax.”
“Sex life is lacking? May I suggest some red wine to go with dinner.”
“A pill for sexual dysfunction is dangerous and ineffective! After all, it’s not like a glass of wine.”

*Raises hand* Heard it? I’ll keep on hearing it till the day I die! There’s a reason I included the ol’ wine glass advice on our FSD Discussion Bingo card, version 1.0. I’ve heard it from doctors, I’ve read about it in advice columns, and I’ve heard it from my own family members.

Follow up question… …Does this advice ever work???

I’m so sick and tired of hearing this! And I know for certain that I’m not the only one frustrated with getting the same generic, useless advice. From a commenter on Jezebel:

I suffer, on and off, from severe pain during intercourse (diagnosed as Vulvodynia), and the worse part for me, is the lack of researched treatments and even the lack of knowledge among doctors about the condition (three doctors told me to “try to relax more” when I had sex. Another told me to “try drinking a glass of wine.”

Even feminist sexologist Dr. Leonore Tiefer, organizer of the New View Campaign, suggests alcohol can improve women’s sex lives:

“I mean there are a lot of inexpensive products like a glass of wine or a massage.” - June 11 2010, related to the Flibanserin controversy.

(After what I’ve been through, I figure if you actually have a sex problem troublesome enough to merit drug use then chances are you’ve already tried a lot of other, inexpensive solutions without satisfactory results.)

This isn’t the first time I’ve heard Dr. Tiefer mention alcohol in the context of sexual medicine; In 2004 when testifying to the FDA about the potential risks of a testosterone patch for women as a treatment for low libido, Dr. Leonore Tiefer stated:

Intrinsia is not a glass of Chardonnay, and yet we have already seen that it may well be promoted with a giggle and a wink as “the female Viagra.” Not so – this is a steroid hormone women must continuously take for weeks before getting an effect.

Dr. Tiefer is absolutely right that the Intrinsia patch requires continued use before seeing any effects, so you can’t just slap it on one night and expect to get horny. And it’s absolutely true that the FDA did not approve it for use in the USA due to concerns about health risks. But what I’m really interested in is Dr. Tiefer’s dropping wine in the context of women’s sexual health. What do you suppose she meant by that comparison, anyway?

Now you may be thinking, “K, the chardonnay was just an example. Dr. Tiefer could have used anything in her comparison of sexual medicine.” But wait — I keep finding examples of alcohol specifically in discussions of sexual health. That’s two comparisons of drugs for sexual dysfunction vs. booze by Dr. Tiefer. I’m noticing a pattern…

Between Dr. Tiefer’s comments and repeated comments about booze and sex found elsewhere -

There may be cheaper and faster ways to reduce inhibition—like a glass of wine and a more attentive partner.The Daily Beast

Agree with your partner that you will devote every Wednesday night or whenever to talking, sharing a glass of wine, a video, relaxing together… At least once a week try to think of some little extra to add a touch of glamour or luxury to your love life – a bottle of sparkling wine, a scented oil, a flower.Dear Deidre

Plan a date that you can both really enjoy, with a movie or dinner beforehand, or perhaps a walk or a glass of wine by candlelight. walk, have a glass of wine by candlelight, whatever the couple likes to do as a couple.Sex Therapy Online

- Why, it’s almost as if booze is being held out as a magical panacea to all sexual problems! Even if it’s not an appropriate course of action for everyone’s sex problems!

(Note also that much of this sex life advice is directed at couples – does wine still work on single people? I wonder what folks with religious restrictions or recovering alcoholics with sexual problems think of this advice. Is this advice regularly given to young folks with sexual problems but still below the drinking age?)

Yet somehow the wine recommendation is supposed to be more complicated and nuanced than considering medication to address some sexual problems. I don’t get it; the medical model simplifies women’s sexuality, but the social construction model recognizes the complexity. By the way, have you heard that wine is good for your sex life…?

It sounds like a large part of the push for alcohol instead of medication has something to do with the idea that drinking is cheaper than prescription medicine, but then I keep thinking of that old adage, “Life is too short to drink cheap wine.” I’d really have to run the numbers some time – if a decent bottle of wine costs $20+, maybe $40? split between 2 people and a one-time use of Viagra costs about $10 split between … 1 or more people… Or we have some top-shelf vodka at what, $35? $40? which will last for more than 1 evening vs. about a month’s worth of a prescription gel… But then wine aficionados will point to decent wine under $10 per bottle… or will Box Wine bought in bulk suffice?

Anyway, let me confirm your suspicions so far and this admission is probably going to make me very unpopular:

I hate booze.

I hate all booze everywhere.

I hate wine.
I hate beer.
I hate liquor.
I don’t even like Champagne.
I hate alcohol!

Hate all the booze!

[Description: Bug-eyed stick-figure type white lady in a pink dress. 1 arm raised triumphantly, the other arm holding a broom. Mouth wide open, big teeth. Caption: HATE ALL THE BOOZE! Original picture by Allie Brosh @ Hyperbole and a half.]

I’m one of those people who throws out good booze instead of drinking it, because I get tired of looking at the bottle take up space that could be used up by tasty snacks instead.

hate all the booze?

[Description: Bug-eyed stick-figure type white lady in a pink dress. Not quite so triumphant anymore. Mouth frowny face, tears in eyes. Caption: Hate all the booze? Original picture by Allie Brosh @ Hyperbole and a half.]

Now before we go any further, let me assure you: I don’t hate your booze. I have no interest in taking your booze away from you and I accept that drinking is a socially acceptable way of – being socially acceptable. If anything, I’m the weird one. Almost everyone drinks and does so responsibly. I just ask that you extend courtesy to me and please stop pressuring me to drink. No thanks, I’m fine; I’ll be your designated driver or whatever.

Now let me tell you why booze + I don’t get along:

It all tastes the same to me and the taste is Bad; I’m almost 30 and I’ve heard enough iterations of “You just haven’t found the one you like” to know that I’m never going to find the one I like.

If I drink enough to get tipsy or drunk, then I act out of character – I get giggly. This is not conductive to relaxation, as I must then consciously self-monitor myself to prevent saying something foolish. I can’t keep up with conversations or movies. I lose my wits. The room spins.

Alcohol can cause dehydration, which can then lead to feelings of vaginal dryness. The sugar content can tip some sensitive folks over into yeast infection territory, or at least make it harder to recover from yeast infections. Since my yeast infections last up to six months and tend to be complicated with simultaneous bacterial vaginosis, this is a concern that’s always on the back of my mind when I drink, even more then when I eat junk food.

I hate the smell. I associate booze-breath stench with alcoholic family members and the feelings of powerlessness I endured when I had to put up with them.

Alcohol makes my pelvis feel funny, like my vulva is swollen with blood, yet it decreases my feelings of physical sensitivity, making it harder to orgasm.

Annoyingly, there seems to be a direct correlation between amount I drink and my desire to go to sleep. Unfortunately I wake up multiple times per night on a good night, due to bladder problems. Having to get up & go pee makes it hard to fall asleep in the first place.

The absolute worst part is that alcohol tears the fuck out of my bladder and makes me piss approximately every 5 minutes – not conductive to a satisfying sexual encounter. This is the part I hate the most. Ohh, getting up to go pee every 5 minutes – that’s so sexy. Having to pause, stumble over to the bathroom and pee only to do it allover again a few minutes later. (This goes on for hours when I drink…) Hot.

So far alcohol & sex don’t combine well for my partner either. A single shot is enough to impair his ability to maintain an erection. He can still get one – but not for long. 2+ drinks and it’s just not happening – he’ll be too distracted & uncoordinated to give me the attention I need, and he becomes incapable of maintaining an erection & having an orgasm. Since we can’t enjoy each other sexually after drinking, I feel like if he drinks instead of fooling around with me, he chosen booze over me.
Worryingly, I think my boyfriend is more sensitive to alcohol than he acknowledges. Sometimes, booze will just knock him out even after 2 drinks. One time we split a small bottle of wine over steak and immediately afterward, he blacked out for awhile. He was conscious – or so it appeared – but he had no memory of playing a video game (and he accused me of taking his turn!)
That’s scary! I thought blackouts required more alcohol than that! So was he pulling my leg or is he really that sensitive…? I think we better not fool around after drinking. Nope, not gonna do it.

Yet I’m noticing a theme in the social construction arguments against sexual dysfunction: Women don’t need sexual medicine, because they already have booze. Wine can solve all your sexual problems. You’re just too uptight and need to loosen up, girl!

I don’t want to have to drink when I want to feel sexy. If I want to get drunk, then I’ll drink. If I want to have sex, then I’ll go work on that. The two things have, in my experience, combined very poorly.

So why sex therapists and sexologists suggest alcohol, which has known side effects on sexual health to patients with sex problems, I’ll never know. Perhaps the unofficial prescriptions had something to do with the common sense advice that red wine is good for you, except one reason why may need re-evaluation now, since a researcher’s data is in question. The effects of alcohol and sex are paradoxical: in some ways it might be good for you, but at the same time it can impair sexual health and enjoyment short term. This measurable negative effect has been researched mostly in alcoholics; yet almost half report positive effects.
However, in sexologists’ favor, there may be a link between drinking and higher levels of sexual satisfaction! So maybe there’s something to this advice after all in certain contexts – IF you live in Italy, where there are no doubt cultural differences to take into account, and IF you drink wine every day.

So when someone says about sexual medicine, “It’s not like a glass of wine,” I say…

Good!

I’m glad that sexual medicine isn’t like a glass of wine! Booze gives me more trouble than it’s worth. I say, “Not booze” is a benefit of our hypothetical sexual medication!

So please, reconsider that advice that I add a bottle of wine to my bedroom, and stop telling me it’s what I really need to solve all my sex problems.

The (slightly late) 2011 retrospective post

01/19/2012 at 9:22 pm | Posted in Uncategorized | Leave a comment
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2011 has come and finally gone, as have most of the retrospective posts around the rest of the blogosphere. As my time has been worn thin due to real life concerns, I’m only just now able to catch up to everyone else.

Slowpoke with top hat

[Image description: Slowpoke from the Pokemon franchise. Quadraped pink critter with its mouth open and big, dead eyes, and a blue top hat that says “HAPPY NEW YEAR!” Found via Know your meme.]

If I could give 2011 a theme as it relates to my personal life, the theme was Change, con’t. I made a big life-changing switch at the very end of 2010 and spent much of the rest of the year re-adjusting & getting back on my feet. Most of the changes involved in my personal life were positive, but there’s still one area that’s acutely lacking. I’m working on fixing the weakest link. Unfortunately for the blog, my attempts to further improve my personal situation continue to impede my ability to write on a regular basis. This trend will continue until such time as I get everything worked out to my satisfaction.

More broadly – politically and economically – 2011 was… more of the same shit from 2010… Pretty lousy. Unemployment in the US is still high, both the US and Europe had debt problems, the US continues to see record numbers of laws restricting reproductive rights, etc. Man-made and natural disasters did enough damage on their own and combined into some long-term destructive forces. But you already knew all that, and other bloggers have done a superior job delving into 2011′s news.

I didn’t see quite so much buzz re: sexual dysfunction in 2011 as I did in 2009 and 2010 though – probably because the flibanserin fiasco is done, with no change for ladies. You still don’t have an oral medication option to address a low sex drive. There are still activists who will do everything in their power to combat any such drug from entering the US market. I didn’t hear any news bits about vulvodynia or vaginismus coverage on the television or radio either, but if I missed something, let me know in comments.

One story I did miss re: vulvar pain is that, another study just confirmed what we here already knew: That vulvar pain is still ~uncommon, in the sense that less than a majority of vulva-possessing people experience it… but ~common enough so that you’d be surprised at just how many people do deal with it – up to 25% of women experience it at some point during their lives. Wow. Based on survey results, researches concluded that somewheres around 8% of women  (cis in this study, I presume?) have it now, and a lot of them aren’t able to get effective treatment. I wish I could say I’m surprised by the findings, but I’m not. Here’s an abstract to the official study.

My blogging schedule is reduced, but we’re still able to crank out some original content here. Let’s review some previous noteworthy content first.

The 2009 retrospective
The 2010 retrospective

Don’t miss the guest posts from 2011: 

Guest post – update from a guest poster – the return of Rhiannon, who provided readers with a follow up to her original 2009 guest post.
Guest post – the sexual subject – about pleasure and vaginismus, in a culture that works to impede women’s enjoyment of sex in the first place.
Guest post – on sexual pain, consent and treatment – an anonymous post from someone with PFD/vaginismus, addressing important topics. It’s still rare for me to see perspectives on these topics from someone whose sex life is made more complex due to sexual dysfunction(s.)

Top 10 don’t-miss posts I wrote in 2011: 

1. Feminists with FSD does Orgasm, Inc. – If you read just one 2011 post by me at Feminists with FSD, make it this one. This is the post that finally addresses the film that everyone’s talking about. You know – the sexual dysfunction documentary that didn’t talk about sexual pain, which Dr. Leonore Tiefer herself is surprisingly quick to pathologize as the One True sexual dysfunction. You know – the film that I’m not even sure if it took the perspective of women with sexual dysfunction, considering the one woman interviewed who talked about experiencing it, we’re supposed to question whether she really had it and even then at the end, she decided she was normal all along after all. Great for her, not so great for me, since I had another solid year of sexual dysfunction and stigma.
These cartoonish slaps the face somehow aren’t working to snap me out of it – they just annoy me.

2. Vulvar pain in women of color – This blog desperately needs perspectives of vular pain and other sexual dysfunctions from women of color. If you are a woman of color who would like to submit something, please leave a comment somewhere on this blog (this post is fine,) and I’ll get back to you with contact  details.

3. Conceptualizing the FSD hierarchy - So if dyspareunia is the one true sexual dysfunction, then what about every other kind of sexual problem? I cobble up graphics to show the relative importance placed upon a few different broad categories. I don’t like that there’s a hierarchy at all and I think it sucks.

A series of posts!:

4. Doctors debate dyspareunia (painful sex) – Starting off an in-depth look at the weird way painful sex is treated by sexual health professionals. It occupies a unique place in that it’s a hot potato no one knows wtf to do with.
5. Doctors debate dyspareunia part 2: is pain the only valid FSD?: Start of a 2-part series within a bigger series in which I take a more detailed look at that journal article/editorial/reply by Dr. Tiefer I’m always linking to.
6. Doctors debate dyspareunia part 3: Pain’s validity, con’t: We finish looking at Dr. Tiefer’s response in the debate about wtf to do with sexual pain.
7. Doctors debate dyspareunia part 4: The debate continues: My conclusion upon completion of our multi-part series is that, no one knows wtf to do with sexual pain; everybody has a different opinion and a basis for for their opinion and oh my god it’s a fucking mess out there. Ya’ll on ya’own. The fact that doctors are talking to each other without soliciting the feedback of patients contributes to the problem. Hey. Hey. We’re over here. *Waves arms* Hey. Can someone send up a flare signal over here or something?

8. For (belated) Lady Porn Day: What are the experts saying?: In which I feel like I’m in the middle of a tornado and the tornado is made up of different sex therapists’ opinions about pornography’s place in relationships and sexuality. Who do I believe and why should I trust you, but not this other person with likewise admirable credentials, who came to an opposite conclusion after years of practice?

9. Happy 3rd birthday, Feminists with FSD: I can’t believe I blogged that much… also, ponies.

10. Where are all the good advice columnists?: Yeah good luck finding one of those when it’s all just more of the same. Well, maybe not always – there’s a few good eggs out there I guess.

What’s next? We still have a lot of work left to do, if my previous retrospectives are any indication. There’s still a lot of topics we haven’t covered, and new areas to explore develop with every passing year. Those posts aren’t going to write themselves, people.

One painful topic I’m brainstorming on is sex or the lack thereof within marriages and unconsummated marriages. Why think about this now? Because I am so completely disgusted by some recent conversations about “Cutting off sex” – because there’s a very real possibility that that could be me everyone’s gossiping about someday and how could she do that to him etc marriage is a contract with certain expectations etc terms of the relationship etc disclosure etc no one is saying he’s entitled etc physical intimacy etc x number of weeks/months/years is far too long etc (why is marriage between asexual partners not coming to everyone else’s minds?) etc at least open the marriage up etc unreasonable demands etc…
Has everybody forgotten about the post, “Painful vagina? Your poor husband!” Cuz I didn’t.
So if’n anybody reading knows about sexless marriages/unconsummated marriages and divorce – comment and let’s see what you can give me to work with here. (Poking around on google, it looks like there’s no legal precedent for lack of sex to be a viable grounds for divorce in and of itself.) Yes I want to explore the very language used in these conversations, ie how exactly are we defining “Sexless,” “sex,” “unconsummated,” etc. I don’t mean to use these terms uncritically.

Alas, my time and energy levels are limited for the vague reasons outlined above – I only just now finished reading like 1 book for pleasure within the past year, so I couldn’t even crank out a book review.

But we’re still here… going at whatever pace I can manage. Stay tuned…

Feminists with FSD does Orgasm, Inc.

10/12/2011 at 10:51 pm | Posted in Uncategorized | 5 Comments
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It’s the post you’ve all been waiting for and the one I’ve procrastinated on for far too long.

Gather ’round readers and gender studies students (because I know that you’re going to watch this sooner or later for class,) and behold an opposing view of the sexual dysfunction documentary from someone who actually has female sexual dysfunction.

I’m not doing a chapter-by-chapter breakdown of what happens during the film; you can find that elsewhere. Today we’re going to look at problems and places for improvement in the film. Some problematic elements with the fim are intrinsic to the philosophy the director embraced, others are problems of omission: Viewpoints left out, intersectionality not explored, things that should be investigated further.

- Orgasm, Inc.’s alternate title could be,Sex is not a Natural Act, abridged version. If you’re short on time and want to learn about the feminist social construction perspective of sexual dysfunction, then the film will be a time-efficient crash course. To most uninitiated viewers, the film will entertain and present new information. I’ve already heard Orgasm, Inc’s. arguments regarding the history and validity of sexual dysfunction elsewhere, so I spent most of the 80-minute film bored to tears.

What’s the social construction perspective of sexual dysfunction? Basically, everyone’s sexuality is shaped by culture, and sexuality is varied with a wide range of normal. But the deck is stacked against the ladies, due to gender roles, restrictions on reproductive rights and misogyny. Under social construction, what might be called sexual dysfunctions are better identified as sexual problems – understandable, if annoying, responses to crappy circumstances. Most women’s sexual problems are social in origin, (stress) and can be addressed with broad changes – and some individual lifestyle changes. This is all well & good for most women.
Contrast this with the medical model of sex, which sees sexuality as a natural phenomenon, acted out in a fairly rigid series of steps (arousal, plateau, orgasm, resolution.) Problems expressing sex (performance) are viewed as dysfunctions from the norm, stemming from organic imbalances that can be addressed at the individual level – using medicine. But even under the medical model, most people are generally healthy and can perform sex.
No matter how you slice it, most women don’t have sexual dysfunction.

- Who is Orgasm, Inc. for? Who did Canner choose to interview? What audience did Canner have in mind? Whose care is prioritized?

Prominent interviewees include sex educators Kim Airs and Carol Queen, and neuroendocrinology professor Kim Wallen. Most of the interviewees included in the film represented members of the medical industry. On the flip side, Canner spoke with journalist Roy Moynihan and representatives of the New View Campaign, an activist organization which takes a social construction perspective of sexual dysfunction.

Orgasm, Inc. is for most women; the ones without sexual dysfunction. Liz Canner is deeply worried about the well-being of normal, healthy TAB women. Unfortunately the film left me feeling isolated, as one who actually does have and sought treatment for sexual dysfunction. Interviewee Moynihan states, “There’s a lot of money to be made telling healthy people they’re sick,” as recently recognized (if still contentious) diagnoses such as restless leg syndrome and social anxiety disorder scroll across the screen. The concern is that if Big Pharma can create the perception of a disease (that must be addressed,) and develop treatments, then there’s potentially billions of dollars worth of sales to be made. This quote prioritizes protecting the majority from Big Pharma, rather than prioritizing care for the largest minority, especially if we pause to recognize that many medicalized conditions are real – just invisible, and poorly understood.

# of interviews with someone who identifies as having female sexual dysfunction: Unknown. Liz Canner interviewed four non-professional women about their experiences with sexual problems. Of these, only one, Charletta, identified as having “A disease,” referring to FSD. Upon learning that most women require clitoral stimulation to reach orgasm during intercourse, she changed her mind and decided she was normal after all.
The film juxtaposes Charletta’s interviews with commentary about how most women reach orgasm, with the implication that Charletta never had FSD to begin with. Canner comments, “Charletta was enrolled in a study for women with FSD, despite the fact that she was healthy.” Yet clearly, Charletta identified as having FSD at one point and was upset about it – after all, no one wants to be considered diseased, right? Disease and mental illness and disability are bad things to have!
And then, she dropped it from her identity.
I won’t speculate as to her status. Rather, it is my firm belief that a valid alternative way to address the stigma & distress Charletta felt from identifying as having sexual dysfunction, is to recognize that it’s okay to have sexual dysfunction. Stigma need not be intrinsic to sexual dysfunction, it comes from outside sources. From where? Well, I’m not the only one who notices that there’s quite a lot of limp and small dick jokes in the media – a social force rather than medical.

It may be worth noting that during an interview with the founder of the pharmaceutical company Vivus, Virgil Place said he created the company after developing erectile dysfunction after undergoing a radical prostatectomy for cancer. This may be the only other person included in the film who openly identified as having sexual dysfunction – of the male variety.

So, why choose Charletta? Critically, she was one of 11 patients in a test of Dr. Stuart Meloy’s sensationally-(and un-originally)-named Orgasmatron. It’s surgically installed hardware that sends sends electricity through the body, with the goal of inducing orgasm. It reminds me of a TENS machine for pain management, though more invasive. This makes sense, because the device was originally designed for chronic pain patients and sexual stimulation was a side effect. Furthermore, the risks associated with surgical implantation of the Orgasmatron are derived from the Safety Information sheet about using Neurostimulation Systems for pain management. (The director makes no comment as to what decisions chronic pain patients should make when considering electronic stimulation for pain management.) Since installing the Orgasmatron involves surgery and potentially serious side effects, it’s an extreme measure. Nonetheless I can still see a potential application for some interested patients.

It took surgeons twice as long to install the Orgasmatron into Charletta’s spine as it did with other patients, and then it did not work as intended. She had to have it removed.

So what happened to the other 10 patients?
According to Dr. Meloy, the device stimulated 8 of 9 patients, or 10 of 11 patients (I don’t know why two figures are cited.) 6 of the women in the study kept the electrodes in. And “It worked” (Meaning it induced orgasm?) in 4 of those 6 patients.
So why don’t we get to hear the first-person accounts of these women? What’s going on with them? Unfortunately we’re not likely to find out any time soon, as I have yet to find Meloy’s peer-reviewed primary source journal study.

- # of times we learn about dyspareunia/sexual pain/chronic pelvic pain: 0.
Even though Dr. Leonore Tiefer has stated that dyspareunia is the only valid & important female sexual dysfunction, (a problematic statement with which I disagree,) Orgasm, Inc. doesn’t talk about it. How painful sex fits in with the critique of sexual dysfunction and pharmacological treatments (often off-label) broadly remains unknown. The film addresses pleasure, orgasm and arousal, but not pain, and certainly not other overlooked sexual problems. It’s another cop-out.

- Orgasm, Inc. criticizes the famous and questionable statistic that 43% of US (cis, I presume) women have some form of female sexual dysfunction. Even I agree that number is overestimated. But there was a subsequent 2009 study that included “Personal distress” as a criteria for sexual dysfunction, and using this modifier, the statistic revised downward, to some 12% of the US female population having a form of sexual dysfunction. And that’s only if we completely exclude dyspareunia from the definition of FSD! I still wonder whether the raw numbers really matter – if only 12% of the population experiences FSD, is that small enough to make it real?
In fairness, Canner did most of her filming prior to 2009. The new study came out too late for the filming, but could have been included with the DVD extras, which include documents through 2010.

The film’s coverage of genital surgeries is brief, but that 5-10 minutes encapsulates serious feminist critique. I never know how to address this topic, because I went through vulvovaginal surgery. And although I’m ambivalent about cosmetic surgeries, I hate the way almost all discussions about it go – including Orgasm Inc’s. 
The film makes no commentary on genital surgeries done for health reasons (cancer, vulvodynia, burns & injuries, etc.) or for bottom surgery for trans* people. Feminist discussions of genital surgeries usually exempt from critique genital surgery done for “Medical reasons,” whatever that means — medical needs are rarely defined. What scares me is there’s this binary, where surgery for medical reasons is “Okay,” and for asthetic reasons is “Not okay.” So what happens if someone undergoes genital surgery for reasons of both looks (or insecurity) and physical well-being – that person is likely to have to prove to an outsider’s satisfaction, that their procedure was in fact medically mandated. Canner focuses exclusively on non-medical surgeries, as a husky voice whispers, “Sex surgeries.”

“Sex surgeries,” eh? Maybe it’s not as medical and acceptable as I thought it was after all. This phrasing presents me with a unique problem, because the vulvar vestibulectomy allows me to have sex – theoretically, anyway; in practice, it’s a bit more complicated. Since I experienced pain, we can probably consider this a “Medical” surgery, but my life was never in any direct danger. VVS was not going to kill me, though it did depress me and send me into a dark place Idon’treallywanttotalkaboutrightnow. Theoretically, if I never attempted vaginal insertion of objects ever again until the day I die, then I might have been able to go my whole life with minimal discomfort. So since I could have made some lifestyle modifications instead, were my reasons for surgery still medical enough? Or is what I had just another sensational “Sex surgery,” yet another form of FGC?

Canner cites an editorial in the BMJ comparing cosmetic genital surgeries to female genital mutilation, and like many peer-reviewed articles & editorials, it generated critical responses. Responses brought up the difference between genital cutting forced upon young girls without their consent, whereas plastic surgeries are actively sought out by consenting clients. Other responses raised concerns that the comparison draws attention away from FGC globally.

That’s all I’ll say about the film’s coverage of genital surgeries for now. Although I’d like to talk more about surgery, I don’t even feel comfortable getting into my own experience on this blog.

- The critiques of sexual medicine apply to the medical industry broadly. Of course a movie about medicine and sexual dysfunction focused only on sexual medicine. However, most of the critiques about Big Pharma’s involvement in shaping medicine apply to the field broadly.
Canner et al address problems inherent in the growth of modern medicine, including a for-profit motivation, direct-to-consumer marketing, defining what it means to be sick and well, and financial conflicts of interest between doctors/researchers & pharmaceutical companies. I noticed that Vivus staff talked about the influence of stock market speculation as a driving force behind drug development, which in light of the current US recession & Occupy Wall Street protests and who is most likely to actually have stock in the first place, makes me go “Hmmm.” These are systemic problems, inherent in Big Medicine itself. As such, it’s going to take systemic changes to the healthcare industry in order to rein in corporate greed and improve patient health.
It becomes a delicate balancing act though, when we recognize that these systemic changes have to occur in such a way as to minimize harm to current and future patients who need and benefit from medical interventions. We can’t outright kill Big Pharma without there being casualties at the individual level. Canner’s DVD extras link to a few organizations that viewers can get involved with in order to critique Big Pharma, however, I myself am not comfortable with the tactics employed by one of the most vocal activist groups.

- Orgasm, Inc. does not address the stigmatization of sexual dysfunction, a stigmatization which regrettably the film contributes to.
I am constantly dismayed when I see arguments against the validity of sexual dysfunction broadly get used at the individual level to invalidate women’s experiences with sexual problems – to jeer, to crack jokes, to partner-blame. I fear that a woman who identifies as having sexual dysfunction won’t be able to talk about it, because someone more enlightened will refuse to believe her – and will instead ‘splain why she is so deluded and gullible and brainwashed. I have this fear, because that’s exactly how I feel when I try to talk about FSD on any blog other than my own. This already happens.

If you seek medical treatment for sexual or other health problems, then you are doing something bad and wrong. This is made abundantly clear with Orgasm, Inc’s. theme song lyrics, “Sex Pill! I need those poisons baby!” and when interviewee Kim Airs explicitly states, “The whole thing with taking drugs, for this or that, my belief is, living for [or 'we live in?' Didn't quite catch that - K] a drug-free America. I mean, don’t take drugs!”

Is this really the ideal America to strive for? The US war on illegal drugs reveals that enforcement disproportionately targets people of color. It also holds back potential treatments for some disabilities, leading a few states to legalize marjiuana. Patients with prescription drugs can get legally and medically busted, too. Legal use of prescription drugs for this (depression?) or for that (chronic pain?) is already sneered at by many (including some folks in my own family) with dangerous consequences to those who need the meds. (She didn’t say what this or that is.) So now we have people with chronic pain conditons who have to jump through hoops & present themselves “Correctly,” in order to not appear as a junkie. So some folks have to live in a drug-free America whether that’s what they need or not.

Some interesting areas for discussion were not explored; perhaps a budding documentarian is reading this and will run with it. The film does not talk about sexual dysfunction treatments + insurance. In the United States, there is an ongoing healthcare financial crisis. Millions of Americans – the figures range between 44 million to almost 60 million – are without health insurance, or spent at least part of the last year doing without. Recent news tells us that those who do have health insurance face increased out-of-pocket costs. Meanwhile, government safety nets for the poor are seeing their budgets cut. So there’s no word on folks who may consider themselves to have sexual dysfunction, but who cannot afford to seek treatment. This is something I’m facing right now, as I need to go get physical therapy again and can’t afford to pay for the deductible.

So if you can’t afford medical treatment, then that’s good, right? Now you must focus on non-medical interventions, which have fewer side effects. Hold that thought – remember that it is possible to seek non-medical intervention for sexual dysfunctions, such as talk therapy with a licensed sex therapist or psychologist, and to have such costs be partly covered by insurance. The blogger Minority Report has written about taking this route, and she’s done some math. Talk therapy can become pricey, and even sex therapists themselves express disappointment with the outcomes. I have no doubt that there’s a connection between deregulation and the privatization of healthcare (insurance,) but I do doubt that I can explain it here. (That hasn’t stopped me from trying, though.)

Orgasm, Inc. final thoughts:

- Do you still want me to do a play-by-play review?
- Do any regular readers here want to write a review as well? Maybe you saw it and just <3 it idk
- So basically, we have a movie here about FSD, with either minimal or zero representation of folks who actually have FSD (depending on how we look at Charletta.) We have an old guy with ED and one lady who decided she’s totally fine in the end.
- I’m hearing people talk for me, but not using an accurate reflection of my own voice.
- How much unchecked privilege do you have, that you can protest the very existence of a health problem, with no room for any exceptions, when there are people going, “Hey, I think something is going on over here I need medical help with”???
- I am still not convinced that FSD is an invention created by Big Pharma, nor that there is no place for pharmacological options for sexual problems.
- I am still wary of the social construction model of sexual problems.
- I am still wary, because it’s supposed to address weaknesses in the medical model, but it has its own fucked up weaknesses and all it does is fuck up in new ways. Like it tries to address blanket statements in the medical model, but then it just creates new blanket statements.
- I am certain that viewers will approach this blog to ‘splain to me how the film opened their eyes and how I still don’t know what I’m talking about, because I’m not looking at this ~objectively or something.

It wasn’t all bad. It’s definitely a movie. And I agree with some points in the film, and there’s parts that I appreciate Canner including, like the part where we hear an anonymous woman talk about negative side effects she experienced after her genital surgery. (What, am I supposed to say it’s totally risk-free and problems never happen and la-de-dah? If anything I know full well complicatons can result.) I know sex education matters, I know an equitable division of labor matters in couples (though where that leaves the single ladies who just miss masturbating remains unclear to me,) I know Big Pharma is motivated by profits. I know most women never have to deal with this shit, I know drugs cost money and have side effects, etc. etc. etc., Reganomics. I am fully aware of all this. But a lot of people love this film unconditionally – so why I am I still seeing some flaws. Was it overrated? Yes, at least I thought so. It still wasn’t enough to convince me to go over to the other side.

Doctors debate dyspareunia part 4: The debate continues

09/19/2011 at 10:51 pm | Posted in Uncategorized | 3 Comments
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“The sad truth is that at our current state of knowledge, sexual dysfunction is whatever sexologists or others say it is” – Yitzchak M. Binik, Ph.D.

The above quote comes from the person responsible for setting off the 2005 sexology debate about how doctors should address dyspareunia (painful sex,) and it succinctly reflects my own frustration with the field of sexology.

Recently, I have directed reader attention to a debate that took place amongst doctors and other professionals tasked with treating sexual pain problems. The debate started when Dr. Yitzchak M. Binik wrote in to the peer-reviewed journal of the International Academy of Sex Research, Archives of Sexual Behavior, on whether dyspareunia should be viewed primarily as a pain problem or as a sex problem. To catch up with this blog’s review of the debate, read part 1 here, part 2 there, and part 3 last.

Dr. Binik’s original article outlined his position that sexual pain is best classified as a pain condition under the DSM-IV-TR criteria. Currently it remains classified as a sexual dysfunction, though the soon-to-be-released DSM-V will likely change the name and the definition.

Dr. Binik’s publication in the Archives received 20 responses, expressing varying levels of support. I did not read all 20 of the responses he received. In parts 2 and 3 of this blog’s dyspareunia-as-pain series, I zeroed in on Dr. Leonore Tiefer’s fascinating and contradictory response, because I’m already familiar with the rest of her work with regards to sexual dysfunction.

Dr. Binik reviewed each response to his original article, and finally addressed them in a sequel, Dyspareunia Looks Sexy on First But How Much Pain Will It Take for It to Score? A Reply to My Critics Concerning the DSM Classification of Dyspareunia as a Sexual Dysfunction. Now this is another article behind an academic firewall, so most readers can’t see the full text. In the interests of spreading knowledge about sexual dysfunction, I can only provide an executive summary.

The first thing that jumps out at me in reading Dr. Binik’s final answer is that, this article is almost intolerable.
Basically, Dr. Binik says that he was late in getting back to everyone who replied to his original article because he was distracted by baseball season. I find it ironic that, in light of the continuing debate among sexologists about the appropriate use of the term “Sex addiction,” here Dr. Binik flippantly refers to his interest as “my baseball addiction” (63.) My amusement eventually gave way to groans of annoyance with all the sports metaphors and puns strung throughout the rest of the article. Clearly, Dr. Binik still had baseball on the brain when he penned this reply. That in no way diminishes the validity of his arguments; it just annoyed me on a personal level.
Remember, there is already a baseball metaphor used in casual conversations about sex – “Bases.” Each base represents an arbitrary milestone in heterosexual sex, where running through all 4 bases means you’ve progressed to hetero, PIV intercourse.
Fortunately, the article is short – about 4 pages, as opposed to the original 10+, so I didn’t have to put up with the sports jargon for long.

Dr. Binik acknowledges that his original article met with mixed reviews from his colleagues & peers. For the most part, Dr. Binik’s assertion that sexual pain should be reclassified as a DSM-approved pain condition did not go over well. Three respondents endorsed Dr. Binik’s original position that sexual dysfunction should be reclassified as a DSM-approved pain problem. Five vehemently opposed the change. Nine responses agreed with part of what Dr. Binik said, but not everything. And three didn’t really address the question at all (63). You can find publication details about the 20 responses here. PubMed does not provide full text or abstracts for any of them, but I have GOOD NEWS, everyone! Today I found a compilation of all of the responses to Binik’s article on Ohio State University’s website! If you’ve got hours of free time, you can read and analyze each individual response, spanning some 40 pages! Except for the response we’re looking at today.

Dr. Binik interprets the disagreements as stemming from four basic positions:

(1) I overgeneralized from one typ eof dyspareunia – vulvar vestibulitis syndrome (VVS); (2) my reclassification strategy for dyspareunia was of dubious clinical utility; (3) I did not recognize that dyspareunia really is a sexual dysfunction; and (4) I confused symptom and mechanism in my discussion of classification (63).

Dr. Binik did not deny focusing exclusively on VVS, even though it is not the only type of pain one can experience during sexual activity (63). It is, however, the best researched type of sexual pain, and the research on it provided the most support to Dr. Binik’s position (64). He talks about how post-menopausal dryness & vaginal atrophy may be another sexual pain – except for the part where, due to lack of systemic research on the topic, he isn’t convinced that these problems can account for dyspareunia (64).

To the criticisms that reclassification (moving dyspareunia from sexual dysfunction to pain condition,) wouldn’t solve any problems, Binik responds that the outcome results couldn’t possibly worse than they are now. Some critics pointed out that both the sexual dysfunction and pain condition categories in the DSM-IV-TR both have problematic elements (64). What those problematic elements are, is not discussed in this particular article; we need to examine the primary source responses in question for supporting details. Dr. Binik, however, contends (perhaps somewhat blithely,) that if professionals fix the problems inherent with the DSM pain classification, then sexual pain would fit in with that category (64). And with regards to concerns that pain clinics may not be prepared to handle sexual complaints, Dr. Binik says,

Several commentators (e.g., Carpenter and Anderson, Strassberg) implied that the sexual concerns of women with dyspareunia might get ignored if they go to pain clinics. I think they underestimate clinicians/researchers, such as Masheb and Richman, who work at such multidisciplinary clincs and are very sensitive to sexual issues. It is no more difficult for professionals at a pain clinic to learn about sex than for sexologists to learn about pain (65, emphasis mine.)

In that case, my fellow folks with sexual pain, we are fucked! And not in the good, clean fun way; I mean, I am so completely frustrated with how poorly some notable sexologists handle sexual pain! If I have to look to sexologists as an example of how professional disciplines handle overlapping issues, then I am hopeless that pain professionals could possibly do any better with sex! I have seen sexologists and popular sex bloggers online who write about dyspareunia, and the extent of their writing is, “Refer to your doctor.” That’s it; that’s the extent of their learning, to this day in 2011. Since there are still sexologists who can’t be bothered to learn about the intricacies of sexual pain, I remain unimpressed. So given sexology’s poor track record of handling dyspareunia, why should I believe a pain doctor could do any better at handling sexual problems?

Facepalm Carl Pictures, Images and Photos

[Description: Carl - a heavy, hairy white guy from Aqua Teen Hunger Force - looking exasperated and doing a Facepalm. Wearing a white tank top and tacky gold chain.]

Moving on, other commentators maintained that sexual pain is and should continue to be recognized as a sexual dysfunction. This was Dr. Tiefer’s surprising, contradictory argument. However, when Dr. Binik explicitly addressed Dr. Tiefer’s response directly, he clearly missed her point.
See, Dr. Tiefer’s whole schtick is that sexual dysfunction is an artificial construct designed to benefit the medical industry, Big Pharma in particular. The New View Campaign’s social construction perspective dictates that most sexual problems stem from social problems and can be addressed through broad, non-medical interventions. But Dr. Binik clearly is not familiar with The New View or with Dr. Tiefer’s work, because he said,

For example, Tiefer argued that “dyspareunia is the only true sexual dysfunction,” because “…sexual problems [are best defined] as discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience.” (p. XX). While I have some sympathy for this definition, it is too broad since everything that intereferes with sex (e.g., watching too many baseball games?) becomes a sexual dysfunction (65).

Wait, what the f—?! Gaaah!!! That’s not what she said! She never said that! That’s the opposite of what Dr. Tiefer’s been saying for ten years!!! I cannot believe — I can’t deal with this shit! The right hand doesn’t know what the left is doing!

[Description: Captain Jean Luc-Picard, a bald white guy from Star Trek, doing the Facepalm.jpg thing. From Know Your Meme.]

One area where Dr. Binik and Dr. Tiefer agree, is that the current classification of sexual dysfunction in the DSM-IV-TR is so problematic that it probably needs to be scrapped entirely and done over – and this is, apparently, one of the reasons why Dr. Binik wants dyspareunia moved out in the first place (65).

The last main argument against Dr. Binik’s reclassification scheme is the one I’m having the most difficulty understanding. Some commentators questioned whether Dr. Binik was endorsing a classification scheme based on symptoms or one based on mechanisms (the underlying causes of pain, like inflammation.) Dr. Binik clarifies that he doesn’t like symptom-based classification schemes, but we’re pretty much stuck with that until researchers figure out what the mechanisms behind sexual pain actually are (66).

Dr. Binik then responded briefly to a few additional criticisms of his original article, like the fact that he left vaginismus out of the discussion (an oversight he didn’t want to make but felt obligated to do since vaginismus is treated differently in the DSM for some reason) (66). Binik actually retracts one of his arguments in favor of moving dyspareunia over from sex to pain. Initially, Binik suggested research funding as one of the reasons he supported making the switch, thinking that pain research is easier to fund since it’s less controversial than sex research. He was called out for this claim by Black and Grazziotin (66).

In the end, Dr. Binik was not convinced by the respondents that sexual pain is best left as a sexual dysfunction. He is glad to have started the conversation though, and it’s possible that this discussion did play a role in the changes to dyspareunia as described by the DSM-V. Unfortunately, Dr. Binik uses a baseball metaphor with a double-entendre to conclude his article with an expression of gratitude with participants in the conversation,

“It is clear that my article did not hit a home run; however, dyspareunia is looking sexy enough to have finally gotten to first base. I think it will finally score in the major leagues” (66.)

He means his article wasn’t met with the adulation and acceptance he was expecting. This is an awkward way to put it though, considering that dyspareunia, in my experience, is the opposite of sexy and here again all I can think of is the sexual double entendre of baseball metaphors. Either I have a dirty mind or else Dr. Binik overlooked the phrase and how it might interfere with a serious discussion of sexual pain.

So what did we learn from this debate? Here’s what I learned:

If there’s only one lesson I want readers to take home, it is encapsulated in the opening quote to this post. Getting professionals involved in sexual research and medicine to agree on a definition of sexual dysfunction is like trying to herd cats. (Not to mention the fact that many professionals have neglected to involve their own patients’ feedback in the discussion – hint, hint!) We have an arbitrary definition spelled out by the well-known APA’s DSM, but in practice it’s more of a guideline than a hard set of rules, and there’s much it overlooks.

Different professionals may not agree with the DSM classification of sexual dysfunction for various reasons, and will come up with independent working definitions instead. These fractured definitons will reflect whatever agenda the professional(s) who developed it wish to spread and capitalize on. Different agendas may make some good points and thus be defensible, even when in direct conflict with one another.

I’ve seen examples of these contradictions illustrated before; One Ph.D. says porn addiction is a real thing that must be stopped, while another Ph.D. says there’s no such thing as sexual addiction, only sexual impulses. If both start sexual counseling clinics that reflect their views, then whose therapy the most appropriate? So in the end, sexual dysfunction remains a white-hot conflagration of controversy and disagreement – Looking at it pragmatically, to rephrase Dr. Binik, sexual dysfunction is whatever anyone wants it to be. You want it to be pain only? Boom, done. Wait, this other person wants sexual dysfunction to include lack of sexual arousal? Bam, here’s a phone number for a clinic you can call for that. Wait, this other person says all sexual dysfunction isn’t real at all? Boosh, here’s a whole lesson plan you can integrate into your gender studies program supporting that position. Even if some professionals manage to come to a stalemate and agree with each other on certain points, on others there will inevitably be disagreement.

I suppose this is the way science is supposed to work. Doctors and researchers are supposed to go back and forth at each other in order to find the correct answers to life’s big questions. It’s all part of the process.

But sometimes when I see these contradictory perspectives of sexual dysfunction, I get so frustrated! Then all I can do is think of the sexologists involved as chasing each other around, re-enacting the Yakety Sax scene from Benny Hill. Then I feel better:

(I couldn’t find the original Benny Hill chase scene in YouTube. Deal with it.)
[Description: Black-and-white chase scenes from Charlie Chaplin silent film, "The Tramp," set to the fast-paced & wacky music, "Yakety Sax." Charlie and co. generally cause mischief and misery to a team of cops trying to catch him and another character. Features running into some kind of fun-house boat with a hall of mirrors; Charlie and another character pretending to be animatronics in order to hide in plain sight from police, messing up a spinney Coney Island-era ride inside of a circus setting and general mayhem.] 

One interesting part of this debate is how it contrasts with the history of sexual dysfunction as presented by Dr. Tiefer in the chapter, “‘Female Sexual Dysfunction’: A New Disorder Invented for Women,” (quotations are hers not mine,) included in the anthology Sex is not a Natural Act. When she reported on sexual dysfunction conferences attended by medical professionals, she made it sound like a bunch of rich doctors all went in, bullshitted with each other, slept in the fanciest hotel suites, maybe bathed in goats milk and children’s tears, had a few drinks, and all agreed unanimously about a common definiton of FSD – a definition conveniently designed to line their own pockets. But instead, here, we’re seeing a much more lively & varied debate unfold.

Meanwhile, patients with sexual problems find varying levels of treatment and in some cases may be blocked from having sexual dysfunction treatments made available to them in the first place, whether that’s for safety reasons or purely political & idealogical ones. But its all in our best interests, right? …Right…?

On the other hand, I’m somewhat relieved that there isn’t a universal accord on sexual pain, precisely because that means there’s still a chance for patients to influence doctors along and get them to listen. But it’s a very slim chance – A notable omission in this debate is the involvement and perspective of patients. It’s possible that some participants in the debate themselves had experience with sexual pain, but judging from the credentials provided by the respondents, they were not answering as lay patients. These doctors talk to each other, but not to us; they talk about us, and that’s something disability advocates in particular have long recognized as a problem. Furthermore, the academic firewall helps reinforce doctors’ various levels of power over patients – I didn’t even know this debate happened until relatively recently. Then, I had difficulty researching it as someone no longer affiliated with an academic institution.

Other lessons include: Although sexual pain does not effect only women, it is still looked at as primarily a women’s issue. The most common reason I’ve seen cited for this is that sexual pain disproportionately impacts women. However, by focusing on women exclusively, professionals are probably hurting men and folks who do not fit onto a gender binary.

But as far as the original question goes: Should dyspareunia be classified as a pain or sex problem? Whether painful sex is best classified as a pain condition or as a sexual dysfunction, there is no final answer. Jury’s still out deliberating. Dr. Binik and commentators made good points defending their opinions, but no one budged from their original positions. There was no argument so logically perfect, it had the power to change minds.
Sorry gang, I don’t have an answer to this question.

Doctors debate dyspareunia part 3: Pain’s validity, con’t

08/24/2011 at 9:44 pm | Posted in Uncategorized | 2 Comments
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[We’re picking up this post directly where the last one left off, because it was getting too long. If you’re just joining us, we’re in the middle of a conversation about whether doctors think painful sex is best looked at as a pain problem or as a sex problem. Read part 1 here, and part 2 there. Stay tuned for the thrilling conclusion!]

In her response to Dr. Binik’s original article, Dr. Tiefer then goes on to acknowledge that dyspareunia is a surprisingly common experience. Dr. Tiefer says that sexual pain is deeply important to the feminist community: 

Beyond womens’ lack of sexual satisfaction or lack of orgasms, the common experience of pain during intercourse or vaginal penetration lies at the heart of the feminist critique of patriarchal sexual relations (e.g., Boston Women’s Health Collective, 1998, pp. 256-257) (51.)

*record scratch sound*

The heart of feminist critique of patriarchal sexual relations?

think in her citation, Dr. Tiefer is referring to an old version of Our Bodies, Ourselves. That’s The-capital-T Feminist Health Text Book put out every few years by the Boston Women’s Health Collective. It comes in different flavors, like one version for menopause and another for pregnancy, so I’m not certain which OBOS she’s referring to.

But…

Let me put it to you this way: I don’t know what’s on those two pages cited by Dr. Tiefer, because I no longer have a copy of OBOS. During my major life upheaval, I left it behind because it didn’t have anywhere near enough information on sexual pain. I remember about one page on vulvodynia, and there was a little bit about FSD in general - citing Dr. Tiefer’s work, in fact.
I was so disappointed at seeing little about sexual pain relative to chapters about pregnancy, sexuality, abortion, and other human rights issues, that I dumped OBOS. The Boston Women’s Health Collective let me down. I turned to other books, not specifically feminist ones, for more comprehensive information.

I don’t think there’s much support to the claim that vaginal or sexual pain lies at the heart of feminist critiques of patriarchal sex. Perhaps it’s just that feminist perspectives of patriarchial sex are a tiny niche, and so small that I miss them when scanning with my naked eye. After all, I often see feminist critiques of sex and sexuality generally, or I see critiques of patriarchal sex and rape culture that do not explicitly address the existence of unwanted physical pain.

But feminist perspectives on painful sex specifically are hard to find. I seek essays about vaginismus & vulvodynia in feminist-oriented traditional printed media on purpose. I have only just barely scratched the surface of a large feminist library, but it’s still pretty rare for me to find much about dyspareunia.
Online, I recall Twisty Faster’s post about vaginismus from a few years ago as a feminist perspective on patriarchial sex and a painful sexual problem – and even then, her post was more about treatment than about the experience of vaginismus itself. Every once in awhile I’ll find posts about sexual and genital pain on popular feminist sites, and I am eternally grateful when I receive guest posts that address the subject here. But big social justice & feminist sites have to keep up with all the other social-justice news too, and the pain posts get buried after awhile.

So to say that pain with sex or vaginal insertion lies at the heart of feminist critique of patriarchal sex is an exaggeration at best and bullshit at worst. It’s not there, not at the heart. It’s off to the side, maybe; on a good day you can see it poking out. Then it sees its shadow and bolts for another few months before making another appearance.

Anyway, back to the article. Dr. Tiefer then talks about how feminist sexologists have emphasized downplaying the centrality of penis-in-vagina intercourse as the end-all, beat-all form of sex – Dr. Marty Klein wrote an entire book about this, in fact. And then there’s a mention that sexual pain is implicitly (but for some reason not explicitly) covered by the World Association of Sexology’s Declaration of Sexual Rights (51.) For the record, I think the declaration document linked to in Dr. Tiefer’s original response has been updated since 2005. The URL changed to something else sometime in the last few years and the phrase “Sexual pain” does in fact appear in the body of the text (once.)

Towards the end of her response, Dr. Tiefer states that dyspareunia falls under the New View’s definition of a “Sexual problem,” whereas Dr. Binik’s view is that there is no special type of pain that applies only to sexual situations. (For example, in Dr. Binik’s view, vulvar vestibulitis is a primarily a pain problem rather than a sex problem, because you get the same pain during sex as you get during a routine gynecological exam.) According to Dr. Tiefer, even if sexual dysfunction as we know it were to be redefined or dropped from the DSM classification system altogether, pain during sex would still remain primarily a sexual problem that can be looked at from a social construction perspective -

We recommend that professional nomenclature dispense with the idea of norms and deviance… and move to a model wherein sexuality was viewed as a cultural construct and individuals could have various subjective or performance problems. Thus, sexual pain would be like swimming pain or swimming phobia, a problem that a person had with a desired behavior, not with some universal capacity (51, emphasis mine.)

Wait, what? “Swimming pain?” “Swimming phobia?”

Ironically I think comparing sexual pain to swimming pain strengthens Dr. Binik’s argument in favor of reclassifying dyspareunia as a pain condition – is there a special type of pain that kicks in only when swimming? Seriously, I’m asking because I’m not a doctor and I don’t know.

Swimming pain a vague term – are we referring to the pain of a muscle cramp, a broken limb, skin irritation from an over chlorinated pool, or swimmer’s ear? Plus, swimming doesn’t carry around the same gender, consent and relationship issues that sex does. (We could make an argument that swimming does carry performance issues, I suppose, especially when done professionally or in athletic competitions – but even then, I don’t think I’ve ever seen swimming activity stigmatized the same way I’ve seen sexual activity get turned into a problem in and of itself.)

I find the comparison of sexual pain to swimming phobia to be the more problematic half of Dr. Tiefer’s statement. I’ve come a long way from the time when I had a lot of fears and anxiety about sex. Somewhere along the line while puzzling sex out (and maybe while blogging about it,) some of the old fears started to slough & flake off. And at this point, It is no longer the act of sex that I fear. It’s the pain that I have come to expect if I try to engage in sex. So some folks who have experienced painful sex do have, or go on to develop, fear of sexual activity in and of itself. But now, years later, I’m still dealing with dyspareunia over here, not erotophobia or genophobia. I’m concerned that conflating sexual pain with sexual phobia will only complicate getting pain patients the comprehensive treatments they need the most.

Dr. Tiefer’s choice of words here was probably deliberate. This isn’t the first time she has compared avoiding sex and avoiding swimming:

Who’s to say, for example, that absence of interest in sex is abnormal according to the clinical definition? What sickness befalls the person who avoids sex? What disability? Clearly, such a person misses a life experience that some people value very highly and most value at least somewhat, but is avoiding sex “unhealthy” in the same way that avoiding protein is? Avoiding sex seems more akin to avoiding travel or avoiding swimming or avoiding invsetments in anything riskier than savings accounts – it’s not trendy, but it’s not sick, is it? (Sex is not a Natural Act, location 243).

Yet if a patient avoids sex due to dyspareunia, in that case it seems to be acceptable to view the avoidance as part of the sexual dysfunction that is painful sex. This is all very contradictory and confusing to me.

Dr. Tiefer ends her response to Dr. Binik by summarizing her position on the reclassification of dyspareunia: “As long as there are expert-based listings of sexual dysfunctions, we do women a disservice by failing to include pain as one of them,” but ideally she’d prefer to see classifications based on arbitrary norms dropped altogether (51.)

And that’s the way Dr. Tiefer’s response to Dr. Binik ends.

I find it disturbing that in spite of the New View’s probing explorations about how sexual dysfunction is arbitrarily defined in the DSM, in this response Dr. Tiefer felt it appropriate to make an artibrary decision about how to look at dyspareunia. Whereas in the past she has questioned whether or not disorders of desire and orgasm are truly a form of illness or disability, here, she made the unequivocal decision that sexual pain is in fact a sexual dysfunction.

I don’t know what to make of this contrast between Dr. Tiefer’s previous work and this article. Low sexual desire is not a disease… but feeling sexual pain is.
You are not sick if you can’t have an orgasm… but if your crotch hurts, then of course there’s something wrong with you. It’s normal and acceptable to go through periods of low sexual interest, especially if you’re tired… but if sex hurts, then that is not normal.

On the one hand, it makes some sense to me. Statistically, most people do not experience sexual pain – at least, not chronically, and not without some reason. In terms of raw numbers, it certainly is unusual to feel pain with most or every sexual encounter. And for me, personally, after careful consideration I view the pain I have as a sexual dysfunction.

But on the other hand, here I see a one-sided judgement about how normal my experience is, and by extension, how normal I may or may not be. If dyspareunia is recognized as a sexual dysfunction, then that’s an abnormality, isn’t it? So then, am I abnormal too? If so, what exactly am I supposed to do about it? Do I even have to do anything? What does it mean to have a feminist organization ask questions like, “Where are the women” in discussions of sexual dysfunction – and then have one leader of the organization declare what’s going on with women who have a certain type of sexual problem, without their feedback first? Where are the women, indeed – where are the women with sexual dysfunction when the doctors debate back and forth with each other?

When do the women with sexual dysfunction get a say? Dr. Tiefer does not speak for me; and I represent no one but myself.

By focusing on language, there are several dyspareunia issues Dr. Tiefer didn’t address. Practical questions like, if dyspareunia remains a sexual dysfunction, what treatments are appropriate to address it? Given the her criticism of the role of Big Pharma in marketing brand-name medications for other sexual problems, is it acceptable to offer oral pain medication as a treatment for this sexual problem? Or are pain medications and devices for sexual problems to be viewed as yet another tendril of dangerous, Big Bad Pharma? Is it appropriate to look at sexual pain as a relationship problem that exists only when trying to engage in partnered sexual activity, or is it a health problem in and of itself that exists independently of relationship status?

And it’s still not entirely clear to me which class of doctor Dr. Tiefer feels is best suited to handle complaints of sexual pain – If sexual pain is in the DSM, which various health professionals use, then does that make sexual pain a medical problem? Who should address it, medical doctors? Sexologists? Psychologists?

I don’t have the answers to these questions. I’m interested in the answers though, because in the end, I am someone directly effected by the decision makers. Ultimately it’s my health at stake in this debate. The decision of who is best equipped to address sexual pain will impact who I must seek out for assistance, what kind of help I can expect to receive, and how soon I can expect to see results, and how satisfactory results will be measured. It’s not an understatement to say that my future lies in their hands.

The debate about sexual pain didn’t end with Dr. Tiefer’s response, nor did it end with the other 20 or so articles generated by Dr. Binik’s 2005 discussion. Eventually Dr. Binik wrote up a conclusion in which he acknowledged & evaluated each reply. But an evaluation of his final answer on what to do about dyspareunia will have to wait until next time.

Doctors debate dyspareunia part 2: Is pain the only valid FSD?

08/17/2011 at 9:51 am | Posted in Uncategorized | 3 Comments
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Previously on Feminists with Female Sexual Dysfunction…

Many folks who experience sexual and/or genital pain share the experience of getting bounced around from doctor to doctor when seeking satisfactory resolution to their problems. In a recent post on this blog, I explored one of the many reasons the doctor shuffle occurs: there’s no definitive class of doctor designated to handle sexual & genital pain. And behind the scenes, doctors themselves are debating what medical specialty is best prepared to address this type of problem.

In 2005, a peer-reviewed journal published an article by Dr. Yitzchak M. Binik, Ph.D. His idea was to start a serious debate on how best to handle dyspareunia (painful sex.) Currently, under the DSM-IV, dyspareunia is classified as a sexual dysfunction. When the DSM-V revision comes out, it is likely to be kept there (though under a different name, genito-pelvic pain/penetration disorder.)

Dr. Binik made some compelling arguments in favor of of changing the classification of sexual and genital pain from a DSM-recognized sexual dysfunction to a pain disorder. But his position was controversial, and generated many professional responses against making the switch.

One such published response came from Dr. Leonore Tiefer, a feminist sexologist, author, college professor and organizer behind the New View Campaign, an organization opposed to the medicalization of sex, with a particular focus on the role of Big Pharma. I have read and reviewed some of Dr. Tiefer’s previous work on this blog, bringing to it my own unique perspective as someone who actually has FSD.

Unfortunately this time I won’t be able share the full ~2 page text of Dr. Tiefer’s response, Dyspareunia is the only valid sexual dysfunction and certainly the only important one, because it’s locked down behind an academic firewall. I think I can share a summary of what’s in it (with my own commentary,) but unless you’re enrolled at a school with journal access, you’ll have to take my word on good faith.

Dr. Tiefer’s disagreement with Binik’s reclassification argument focused exclusively on one argument: Nomenclature; the power of names. It’s a familiar theme in Tiefer’s earlier work – language is a powerful tool capable not only of reflecting reality, but of shaping it. And Dr. Tiefer has serious concerns about the language used to describe sexual problems in particular. In light of this, I was surprised to find that in her response to Dr. Binik’s article, Dr. Tiefer argued in favor of keeping dyspareunia classified as a sexual dysfunction instead of a treating it as a pain problem – At least, so long as such terminology is used by the American Psychiatric Association.

Dr. Tiefer starts her article by describing the origins and goals of the New View Campaign. One of Tiefer’s criticisms of female sexual dysfunction is that it’s based on the idea of deviations from a “Normal,” universal sexuality, but normal is arbitrarily defined and doesn’t account for all of the human population. In this case, the “Normal” sexual response cycle was defined by Masters & Johnsons’ work – the four-phase model that goes, excitement, arousal, orgasm and resolution. Sex doesn’t work that way for everyone, and so over the last few years – decades at this point – she has challenged the medicalization of sex, with a particular interest in libido and orgasm.

“My criticisms have, however, focused on the universalized notions of desire, arousal and orgasm in dysfunction nomenclature, and not on the inclusion of dyspareunia and sexual pain. Immersed in the feminist literature on women’s health, I was more than aware of the disgraceful history of neglect and mishandling of women’s complaints of pelvic pain and thus it seemed that dyspareunia was the only sexual dysfunction with validity in women’s lives (50, emphasis mine.)

(And that’s where the title of the article comes from. I don’t know whether Dr. Tiefer picked the name out herself, or if some editor arbitrarily decided it, but we have the same sentiment reflected in the body of the text.)

However, when criticizing female sexual dysfunction, Dr. Tiefer has in the past included pain. It’s true that she doesn’t talk about it much, relative to her body of work on orgasm and desire. But in the past she has let pain stay under the broad umbrella of the term, “Sexual dysfunction,” complete with scare quotes:

We believe that a fundamental barrier to understanding women’s sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association (APA) for its Diagnostic and Statistical Manual of Disorders (DSM) in 1980, and revised in 1987 and 1994. It divides (both men’s and) women’s sexual problems into four categories of sexual “dysfunction”: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. These “dysfunctions” are disturbances in an assumed universal physiological sexual response pattern (“normal function”) originally described by Masters and Johnson in the 1960s.

In the New View manifesto, Dr. Tiefer kept sexual pain disorders lumped with all the other dysfunctions that merit feminist skepticism and critique. Feminist critique, such as the perspective that DSM criteria for dysfunctions (including pain) are excessively genitally, and therefore reproductively, focused (Sex is not a Natural Act, location 737.) However in 2005 we see support for leaving dyspareunia behind, as the only valid sexual dysfunction.

Dr. Tiefer’s quote about the importance of dyspareunia as dysfunction is problematic for additional reasons: The implication here is that no other sexual dysfunctions recognized in the DSM have any merit as a health problem. That’s a key point of the New View Campaign: Desire, arousal, and orgasm problems may not be problems at all, and when they are, the problems can be addressed with lifestyle and social change instead of medicine. But here I interpret the idea that pain is a sexual dysfunction, and the only valid one, as maintaining a sexual dysfunction hierarchy. It elevates physical pain above all others. My problem matters; yours doesn’t. My physical pain is real, your emotional or psychological pain isn’t.

So what does this mean for folks who have one of the less-important, invalid dysfunctions? To whom can they turn when they have exhausted virtually all of the non-medical interventions for long-term sex problems?

Dr. Tiefer then briefly expands on some implications of Masters and Johnson’s work. In the next section of her response, she describes an alternate, benevolent way of looking at the inclusion of sexual dysfunction in the DSM: Recognizingsexual problems as health and medical problems legitimizes such problems in the public’s eye. Suddenly, sexual problems are no longer just about sex, which (according to vocal conservatives anyway) is dirty and wrong and immoral – sexual problems are now about the body and health, which is (relatively) socially and politically acceptable to talk about. “Looked at from this perspective, the inclusion of women’s problems with sexual pain in the sexual dysfunction classification system was a positive step” (50,) because then the ISSVD and NVA can harness that legitimacy for raising awareness and research funding.

It strikes me as odd that Dr. Tiefer mentions the NVA and ISSVD by name as working for the benefit of patients with pelvic pain problems. Not because I have any question that both organizations do good for the public, but because in Sex is not a Natural Act, Dr. Tiefer had this to say about patient advocacy organizations:

These advocates for medicalization include self-help group and newsletter promoters who have created a market by portraying themselves as something between consumers and professionals. The formation of Impotents Anonymous (IA), which is both a urologists’ advocacy group and a self-help group, was announced in the New York Times in an article including cost and availability information on penile implants. (Organization helps couples with impotence as problem 1984.) … The advocates for medicalization portray sexuality in a rational, technical, mechanical, cheerful way. Sexuality as an area for the imagination, for political struggle, or for the expression of diverse human motives or as a sensual, intimate, or spiritual rather than performative experience is absent (locations 2277-2282.)

Basically, according to Dr. Tiefer, patient advocacy groups – at least those for erectile dysfunction – existed partly in order to sell sexual health problems, to promote a select few doctors qualified to treat the problems, and then to sell medical treatments for big bucks. In these earlier statements, Dr. Tiefer made it sound like patient advocacy groups were just part of the packaging that came with so-called selling sexual dysfunction. In fact, the formation of patient advocacy groups is one piece of what motivated Dr. Tiefer to organize the New View Campaign in the first place:

This backlash dovetails with the analysis and critique of “medicalization” over the past several decades within sociology, the women’s health movement, the “anti-psychiatry” movement, and newly, from cultural historians examining the social construction of illness and disease. All these scholars argue that the medical model, with its hallmark elements of mind-body dualism, universalism, individualism, and biological reduction, is not well suited to many of the challenges of contemporary life and suffering.

Yet, at the same time, patient advocacy groups are clamoring for medical legitimacy, increased funding and research, and, above all, new drug treatments. And the drug industry continues to expand.

Allying with the backlash, I convened a “Campaign for a new view fo women’s sexual problems” in 2000 to provide a feminist anti-medicalization perspective in the debate about “female sexual dysfunction” (location 3550.)

Given these prior statements on patient advoacy groups, I’m surprised that Dr. Tiefer didn’t skewer genital & sexual pelvic pain advocacy groups in her 2005 response to Dr. Binik.

Furthermore, by classifying dyspareunia as a sexual dysfunction, isn’t dyspareunia and its treatment subject to the same criticisms that Dr. Tiefer has previously made about sexual dysfunction and Big Pharma broadly? I’ve seen the rhetoric used by the New View used (and unfortunately warped) in feminist arguments against sexual medicine. And let me show you, it can get real ugly real fast. Leaving sexual pain as a sexual dysfunction might lend medical and social legitimacy, but not when you do everything you can to undermine the legitimacy of sexual dysfunction broadly and stigmatize those who experience it.

This post is getting way too long, so we’re going to stop abruptly here and come back after you’ve had a few days to digest our story so far. To be continued…

Guest Post: On sexual pain, consent & treatment

08/09/2011 at 10:51 pm | Posted in Uncategorized | 10 Comments
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[Dear internet, we have a guest poster today! The following was written by someone who prefers to remain anonymous. A trigger warning applies, for questions of sexual consent and rape.]

I offered about two years ago to make a guest post on this blog, then tried to actually write it, and vanished into thin air because I was so uncomfortable with the issues it was dragging up. I was trying to write something hilarious, and political, and historically enlightened. But it turns out that the only important thing I need to share right now is what happened to me.

This is a post about feminism, sexual pain, and consent.

Here’s what’s wrong with me: I have a pelvic floor dysfunction. It’s originally a muscular problem: it means that somewhere along the line, I got the habit of carrying tension in my pelvic floor the way other people carry it in their shoulders. I get vaginal muscle spasms the way other people get neck cramps. They could get set off by any kind of anxiety, such as direct stimulation of an already-painful spasm, leading to a godawful feedback loop called “secondary vaginismus”—a conditioned psychological response of increased painful spasms, and aversion to sex, due to the association of vaginal penetration with intolerable pain. The happy ending is that my primary dysfunction was treated by physical therapy, which gave me strategies for combating the muscular issues; and the secondary aversion went away because the association was broken. The physical therapy process took about 3 months. I wasn’t able to find it for 9 years.

The horrible thing about getting to the correct therapy for vaginismus was that even reasonably well-educated doctors seem to routinely believe that the only way a woman gets a conditioned aversion to sex is rape, or a fundamentalist upbringing that teaches that sex is dirty. I have had fruitless arguments with puzzled GPs who, I believe, left the encounter convinced that I had somehow buried sexual abuse trauma somewhere in my brain—when in actuality, the genuine traumatic moments of my life had been occurring on their own gynecological exam tables. And all in the name of getting my poor, long-suffering boyfriend laid.

To say that this sort of thing breeds resentment is just a little bit of an understatement.

Here’s the thing of it. Since I had my first orgasm (clitoral, manual), I never really saw the big deal with getting my twat all stretched out into fighting shape. I liked sex, I was fully capable of climax, I could make my partner climax, and as the pain mounted, I was increasingly convinced that there was no logical need for vaginal intercourse specifically. The boyfriend didn’t share this analysis. At his urging, and my initial gameness to experiment, we tried, and failed, and tried, and failed.

Maybe it’s really bad for all girls, but they put up with it better than me. I’m a spoiled, privileged elite wimp. I need to grit and bear it before I can get the good stuff. “Our Bodies, Ourselves” taught me sex was supposed to be fun for me. Was that just rose-tinted glasses?

The more we tried, the less it worked, and the less I wanted to have sex at all. I went to the gynecologist. I grit my teeth around the speculum, was told I was “small” and needed to stretch, was handed a plastic dilator and sent home. I couldn’t look at it. I put it under the bed.

I am lazy. I am a coward. I am frigid. Did feminism make me frigid?

(Years later, on vaginismus support groups, I would encounter all these women who described their boyfriends as saints. Soooo patient, soooo understanding. Here’s the thing, ladies: he’s not the one suffering dysfunction and pain. That’s you. Him? He’s horny. It’s not a martyrdom. Last resort solution: he whacks off.)

I am denying sex to my boyfriend. Every day we are together is an archetypical punishment for him. If other people knew, they would think he was crazy to stay with me. I can’t tell anyone this is going on.

He stopped requesting that we try, but everything had already turned into guilt. Without really knowing why, I no longer wanted to have sex with him. He would ask, and because I felt like it was ungenerous not to, I would whack him off. I let him touch me only when I wanted it, because that’s what a good feminist does, and that was less and less often. I was frigid when he was home, and I masturbated when he went away. This went on gradually for about six years. It was some kind of screwed up, semi-coerced, semi-consentual sex; nobody made me do what I didn’t want to, but I didn’t want to. The logic goes something like this:

1) Who would ever date someone who can’t have intercourse? Such a person isn’t a functional woman. Such a person isn’t a whole woman at all.
2) Therefore, this is my only option for a life partner. I have to make it work.
3) He wants consentual sex with me. So we will have (unwanted) consentual sex.

(All the while I’m angry as hell, on some level, and undermining the situation like mad.) I sought treatment again, and was referred twice to a psychiatrist for vaginismus, which was described as a mental condition caused by the aforementioned rape or ignorance. I threw the pamphlet away in disgust. St. Boyfriend became depressed, I was pretty sick of it too, and he broke up with me. In the desperation of feeling like I was defective—which I felt very deeply and very abstractly and clinically—I finally went to a psychologist, who confirmed that the problem was physical and not psychological, and referred me to a specialist in pelvic pain, who referred me to a physical therapy specialist in pelvic floor dysfunction. Three months later I was having intercourse.

Here’s the kicker, though. I went through the therapy process because I felt defective without the capacity for PIV intercourse—even though I thought, all the while (and I still think) that this is a nauseatingly offensive and wrongheaded idea, and that all those quiet thoughts I had between the lines of what happened were horrible and wrong and poisonous, untrue things. And I got desperate enough to fight my fear and pride and begin the therapy process because I believed that no matter how poisonous I knew they were, precious few men would be enlightened enough to date someone incapable of intercourse. I might even be right about that. But I don’t think I’m ever going to be quite reconciled to the fact that even though a streak of self-destructive pride kept me from seeking treatment in time to quench the lust of my own St. Boyfriend, I did finally seek it for the sake of the hypothetical St. Boyfriend of my future—not for my own sexual needs. Now every time I give consent, no matter how willing, it’s always going to be tainted by that history. And that strikes me as very unfortunate.

Doctors debate dyspareunia (painful sex)

08/01/2011 at 1:26 pm | Posted in Uncategorized | 7 Comments
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No one knows what to do with sexual pain.

If you have experienced long term sexual and/or genital pain, you’ve probably seen multiple doctors about it. You may have started with a general practitioner, who referred you to a gynecologist or urologist, who referred you to a sex therapist, who referred you to a pain specialist. There may have even been a dermatologist or psychatrist in there somewhere. And you may have noticed that each of these professions have their own ideas (or lack thereof) about how to best handle the situation. When getting refered to yet another doctor, you’re getting clued into who your current caregiver thinks is likely to have the most knowledge about treatments. (Of course, this assumes you have the health insurance and cash to cover medical treatments.)

But having been through the doctor shuffle already, I have come to the conclusion that no one really knows what to do with sexual pain.

Part of the reason chronic pelvic pain patients get bounced around so much is that, behind the scenes, doctors themselves are still debating how best to handle sexual and genital pain. Are we dealing with a chronic pain syndrome akin to something like back or neck pain? Or are we dealing with something purely sexual? A gynecologist may feel inadequately prepared to deal with long-term genital pain that doesn’t resolve following standard operating procedures. But when the pain takes place mostly during, or most acutely, during sexual activity, a pain specialist may think the problem is purely sexual – and some pain specialists may feel uncomfortable addressing unwanted pain during sex. Sexual dysfunction as we in the US know it is a relatively new and highly controversial area of study. And it will take time for doctors, scientists and philosophers to sort out the defining characteristics and treatments of dysfunction – if indeed such standards can ever be decided. It is the nature of science and medicine to go through revisions and changes.

I just wish these doctors and professionals would make up their minds already about which one of them I’m supposed to go to for treatment.

One such behind-the-scenes debate about the appropriate way to address sexual pain took place in early 2005, when Dr. Yitzchak M. Binik, Ph.D. wrote in to the peer-reviewed journal, Archives of Sexual Behavior. You can view an abstract of Dr. Binik’s piece, Should dyspareunia be retained as a sexual dysfunction in DSM-V? A painful classification decision here. If you want to learn more, you can view the full text on Dr. Binik’s website. (I can’t determine if what we’re going to look at today is considered an editorial piece, a study or a research review.)

So who is this guy? Dr. Binik is the director of Sex & Couple Therapy Service up at McGill University Hospital in Canada. He was one of the contributors to the textbook, Female Sexual Pain Disorders, (wrote the foreword) and he has written many articles about dyspareunia. According to his website, he’s also been involved with research on painful sex – there are three grant-funded projects listed as of 2011. But wait, there’s more – his whole resume is up for perusal.

At the time of Dr. Binik’s submission to the Archives of Sexual Behavior, dyspareunia (painful sex – usually when professionals say it, they mean “Cis-heterosexual intercourse,”) was classified as one of the four female sexual dysfunctions then-recognized by the DSM-IV. (The DSM-IV is the Diagnostic and Statistical Manual of Mental Disorders – basically it establishes guidelines for recognizing and treating various mental illnesses and disabilities. Professionals that rely on the DSM include psychologists and medical doctors. As of today a fifth revision to the manual is pending.) The other three sexual dysfunctions recognized by the text are arousal, libido and orgasm problems. Until then, there was not much debate among professionals who deal with dyspareunia about how appropriate its classification as a sexual dysfunction is.

Dr. Binik set out to challenge the classification of dyspareunia, with the goal of shifting it out of the sexual dysfunctions and into the pain category of mental disorders in the DSM. Reclassification of dyspareunia as a pain disorder instead of a sexual dysfunction would not remove it from the DSM completely – it would just move the problem around and give it a different name, grouping dyspareunia with any other pain while recognizing non-sexual pain in the crotch – such as the pain of a gynecological exam or attempted tampon insertion.

In Binik’s discussion of the history behind the term, “Dyspareunia,” he makes it sound like sexual pain was pretty much just thrown in with the other dysfunctions for lack of any better ideas at the time. But painful sex presents some unique problems compared to the other three sexual dysfunctions – after all, sexual pain frequently bleeds out into non-sexual areas of life. He talks about the differences between pain during sex (an act) vs. arousal or desire dysfunctions (physiological reactions,) and how dyspareunia is a broad term – to Binik, its breadth is a weakness instead of a strength.

There are several sexual dysfunction issues that Binik didn’t explore, and these omissions mean something. He did not challenge or question the existence or appropriateness of the term “Dysfunction” for any other sexual problem. He excluded a discussion of vaginismus, though this may be because vaginismus isn’t technically a dyspaerunia issue in the current DSM for some reason. (I’m not yet 100% clear on what the reason is for vaginismus to sit on it’s own tier of dysfunction; I think the folks behind the DSM fixated on how it prevents vaginal insertion of objects as the main feature, instead of the pain associated with attempts at insertion. This distinction is likely to change with the DSM-V.)

As examples to bolster his reclassification argument, Binik focuses almost exclusively on vulvar vestibulitis (VVS) patients – so he’s talking about people like me. Binik did not talk about dyspaerunia and endometriosis, or dyspareunia and interstitial cystitis, or dyspareunia and cancer. For this discussion, dyspareunia and VVS are used almost interchangeably… even though VVS is not the only cause and kind of painful sex.

I summarize Binik’s main agruments to move dyspareunia out of the sexual dysfuctions and into pain as:
1. Dyspareunia is similar to any other pain in self reports.  Genital pain is similar to other pain conditions when visualized using brain scans (pages 14, 16.)
2. There’s more research on pain. “By contrast, there is a relatively large literature onhow pain is represented in the brain (Casey & Bushnell,2000; Talbot et al., 1991).” (page 16.) So there’s more material to work with.
3. Treatment plans for sexual dysfunction don’t usually include pain management. If professionals take a pain perspective of dyspareunia, it opens up more complementary treatment options. That means potentially better outcomes for patients (page 18.)
(Unfortunately, Dr. Binik doesn’t address this – it also means more anxiety about seeking treatment in the first place, since pain management can include oral medications – and certain feminist anti-FSD activists in particular and bootstrapists in general dedicate extensive resources to opposing medication for sexual and health problems. Just think of all those sensationalist news stories about celebrities becoming addicted to pain pills.)
4. Socially, pain is a more dignified, less controversial subject than sex – “Finally, as a seeker of research funding, I have noted that there have been several recent new governmental funding initiatives for pain related to dyspareunia (see National Institute of ChildHealth and Development, 2000). As far as I know, this is not being matched in the sexuality area where funding is constantly under attack” (page 19.) This is an unfortunate reflection of how sexual issues are downplayed and sneered at by the public. It’s just easier to get funding, research and respect if you’re exploring pain than it is if you’re exploring sex.

Judging from the passionate responses included with the same issue of Archives of Sexual Behavior, Binik’s article was quite controversial at the time. There were at least 21 responses, plus however many other e-mails and memos were written up and sent around but didn’t get published. Eventually Binik wrote a follow-up statement in response to professional criticism, which I’d like to look at with you later.

My biggest schtick with Binik’s article and the responses is: I honestly don’t get why this has to be an either/or question. 
I’m saying this as a patient: This isn’t a simple either-or issue. Dyspareunia isn’t something that fits neatly into a single box. Try to stick it in the sex box, and the pain stuff will still leak out into every day life. Try to place it exclusively in the pain box, and sexual problems will jump in. You can have pain AND another sexual dysfunction, like problems with arousal or orgasm.
If you ask me, pain in the genitals should be recognized as both a pain and sexual problem. For some patients, it may very well fit neatly into only one category. But whatever professional field is assigned as having the final say on the best way to treat dyspareunia – you need to be prepared to go outside of your own comfort zone, in order to bring me the comfort I need.

Unfortunately my perspective as a patient isn’t given much value. Just the location of publication presents a problem – the insular nature of being part of a peer-reviewed journal itself acts like a firewall to keep out non-professionals and non-academics. Which means ordinary folks probably don’t even get a chance to find out when debates like this happen, and we probably won’t be solicited for feedback. These debates excluded most women with FSD from participating.

It’s a bummer, too, since I got more to say about this article, which I’ll spell out here instead.

A major weakness of Binik’s argument and one that Binik had to address in a later, separate response, is that he did not really consider the sexual part of sexual pain.
Like it or not, pain in the genitals takes on a different meaning than pain in the arm or neck. And no it’s not fair, I think it sucks that it is socially unacceptable to say, “My vulva/penis/clitoris hurts today.” Not that its easy to talk about chronic pain to begin with though! Non-sexual, non-genital pain still gets heaps of stigma and able-bodied folks going, “Deal with it.” But right now, in the US at least, genitals are all tied up with issues of gender, identity and performance. So looking at dyspareunia exclusively as a pain problem won’t address the ways in which pain can impact sexuality. Even if the pain resolves satisfactorily, dyspareunia patients may still have to deal with long-term insecurity and body memories. If other dysfunctions like difficulty or loss of orgasm have gotten tied in with the pain, then those non-painful problems may not resolve at the same time as pain. To ignore the sexual component of genital pain, to the extent that it is present, is inadequate.

ON THE OTHER HAND, for some folks, skipping the sex part and addressing the pain is exactly what’s needed. This was actually more the case for me – what I needed the most when I went through the most intense period of genital pain and treatment wasn’t sex therapy or a better understanding of social construction. Gender roles and patriarchy, as much as they do hinder me in many other ways, did not reach inside of my body and cause my cells to rebel. What I needed most was something to address the physical pain and discomfort.
That urgent need is lessened now, but it’s not completely gone and it will probably never go away completely. So I remain open to medicine in my sex life now and in the future.

Now, of all the people who wrote in, who do you think would have been the most likely to agree that dyspareunia should not be classified as a sexual dysfunction? I’ll give you a hint: After all, sexual dysfunction is a controversial term – part of the resistance against it stems from concern that the medical industry will throw around the term to convince able-bodied women that they have physical problems, thus increasing sales of medications and devices to address it. Who’s to say whether a libido is low in the first place, and how exactly are we supposed to measure such a subjective experience?

So I was shocked, absolutely shocked, to see Dr. Leonore Tiefer, Ph.D., organizer behind The New View Campaign, sex therapist, educator, author and editor, write a negative response to Dr. Binik’s proposition. You may remember Dr. Tiefer from such posts as a 5-part series on Sex is not a Natural Act and A Review of A New View of Women’s Sexuality. You may also recognize her name from prolific writing on feminism, social construction and female sexual dysfunction. Dr. Tiefer is a critic of female sexual dysfunction, particularly the way it is handled by organizers of the DSM and its end-users (the end users being doctors and other professionals.)

So if, in other cases, Dr. Tiefer supports the view that female sexual dysfunction is a myth manufactured by medicine (even if she herself is careful to avoid using that exact phrasing,) then what’s she doing getting involved with the reality of dyspareunia?

To be continued…

How I spent my unplanned hiatus

06/29/2011 at 10:20 pm | Posted in Uncategorized | Leave a comment
Tags: , , , , , , , ,

It has been far too long since the last post here.

So it seems that the blog took a bit of an unexpected hiatus. Being a feminist/social justice type of blog, I chalk it up to the inevitable, and figure it was bound to happen eventually. Lots of feminist blogs go on breaks for awhile, or disappear entirely, for various reasons. Only a fortunate few can afford to write full time, and even those who can must still attend to the non-financial matters.

I finally got a little burned out, frustrated with speaking out but seemingly never being listened to. In looking over materials for a few recent conferences on sexual dysfunction, and noting who was selected to speak about what topics, I cannot help but feel a bit hopeless.

Yet another variation on a theme, yet another news article with a title like, “Is female sexual dysfunction real? You vote and decide!” “Is sexual dysfunction a made up hoax? News at 11.”

Why is my life up for debate?

More then that though, as I’ve been saying for awhile now, a lot of shit went down in my offline life within the last six months or so. Lots of changes, and the last two or three months were particularly intense, requiring more energy than I originally anticipated. There isn’t always much left of me by the end of a work day.

But some of what I’ve been up to has been worthwhile. Here’s some of the more interesting and relevant activities I’ve been up to while hiding from the internets:

- Got a new computer to work on. There was an adjustment period with the new system.

- Went to a sex education workshop.
- Participated in one of the US Slutwalks.

I’d love to talk about what I saw at both events and my opinions on the execution, however I fear that doing so will give enough details away to narrow down my geographic location(s). Suffice it to say that with Slutwalk in particular, there was some good stuff and some areas that sorely needed improvement; nonetheless I am glad to have participated in such a Walk – if only for the social aspects of it, because I need to get out more.

- I have attempted multiple times to have PIV intercourse with my partner…
…However, in spite of this hands-on experience with sexuality and attending a workshop, and in spite of exposure to sexually educational materials, I still somehow have sexual dysfunction. The additional education did not cure me. I still haven’t been able to have pain-free intercourse in about two and a half years.
Yeah it’s still not happening, the vaginismus is acting up. At least, I *think* it’s mostly vaginismus right now. I’ve been learning how to enjoy digital insertion of small-to-medium objects & fingers into my vagina, but I’m struggling again with anything I consider “Large” – it gets stuck and can feel painful. I can’t quite tell if the pain is muscular or if it’s closer to the surface.

- I am still having bladder problems to the point where I’m starting to worry about repercussions at work. One of my co-workers already asked me, when I got up to use the restroom for the nth time, “Are you okay?” Frankly the answer is “No, not exactly; it’s a long story.” Sooner or later someone is going to pin me down about my bathroom habits and it’s going to be really awkward.

So since I’ve been out of commission for awhile, I missed a lot of stuff in the news and blogosphere, and I cannot hope to ever catch up. We missed out on our chance to make timely commentary on stuff including but not limited to:

Blogging against disablism day!
All of Masturbation month! (May)
Juneteenth!
Most of Pride month! (June)
Gay marriage in New York state!
US and global politics and media scandals, including but not limited to Anthony Weiner’s weiner! (For better or worse, there’ll be no shortage of political news all the way through 2012.)
On a more serious note, multiple attacks on reproductive rights in the US!
Hearings in California over whether or not pornographic film actors & actresses should have to use barrier protection!
Multiple well-covered internet security breaches!
A slime The DSM-V’s revision draws near!
The Orgasm, Inc. DVD should be available on Netflix now!

And more!

But before we get into any of that, my intention remains to write one or two sex product reviews first before getting into much detail with politics & sexual dysfunction related news – if only because after such a long break, I need to flex my writing muscles. And I should try to get a review of Orgasm, Inc. up before September, because you know that it’s going to become a staple of all sexuality and gender study courses.

Unfortunately I need to stretch and flex my writing muscles, because clearly there is still a need for a hands-on perspective of sexual dysfunction.
That there is still a need for such self-advocacy is a disappointment to me.

For you see, there are still some credible professionals, academics and feminist advocates who do not themselves have sexual dysfunction, yet who continue to participate in programs which declare that female sexual dysfunction is an utter fabrication and any efforts to legitimize it as a diagnosis meriting medical intervention (and social acceptance) must be stopped at all costs. Which I interpret as a direct threat, because if sexual dysfunction does not exist, then people with sexual dysfunction – female sexual dysfunction in particular – must not exist.

I am a woman with sexual dysfunction.

The goal is usually something along the lines of stopping the long arm of Big Pharma from tapping into people’s sexual insecurity in order to capitalize on sexual insecurity. Sexual insecurity being a pretty common thing that a lot of people have, short of dysfunction.

The unfortunate consequence, deliberate or not, is that to hear for the millionth time that sexual dysfunction is not real is the millionth erasure of my existence and the validity of my experiences. And I know I’m not the only one who feels this way.

When I read such impassioned speeches rallying against recognition of sexual dysfunction as a health problem, a disorder, a label, it’s like hearing, “Everything you went through and continue to go through is invalid. She doesn’t really have sexual dysfunction, because sexual dysfunction isn’t real. What an utterly useless description for an experience.” Hence me writing a snarky April Fool’s Day post about mythical Unicorns – because apparently I am a mythical beast as well. I don’t exist, and as such clearly I can not speak for myself, because there is no one to speak for.

Do I really have to sit back quietly and let people talk “For” me, even when what they say causes me to feel endless anguish? Do I really have to sit back and not say something back?

So some things changed in the last few months, but others remain the same. The feminist perspective that female sexual dysfunction isn’t a valid thing continues to frustrate me. Remember, my problem is that I have dyspareunia, which has been described by Dr. Tiefer as “The only valid sexual dysfunction and certainly the only important one.” That article continues to disturb me because it throws my friends with non-painful sexual problems under the bus – what they have isn’t valid and therefore it certainly isn’t important. And the contradiction that sexual dysfunction simultaneously does not exist and yet selectively does exist, confounds me to no end.

Thus motivating me to write again.

Now how fast I’ll be able to crank out posts with actual content and not just this fluffy stuff remains to be seen. There’s enough distractions around me so that I’m often doing stuff offline and nowhere near a keyboard. Once again I would like to put out a reminder that I am open to Guest Posts. Check out some of these previous guest posts for examples. (You need to leave a comment with a valid e-mail address to contact me about guest posting, or with any other questions.)

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