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.

Where are all the good advice columnists?

12/16/2011 at 11:31 am | Posted in Uncategorized | 7 Comments
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I can’t find an advice columnist I like.

I’ve been searching for the right agony aunt for years. It shouldn’t be too hard, since advice columnists are a staple feature of most major news outlets and magazines. Even smaller media outlets and blogs recruit advice columnists to generate new content.
Besides, sooner or later, just about everyone goes through a period where they believe they are equipped to start giving advice, so some folks take the “Dear so-and-so,” mantle upon themselves, without solicitation.

Perhaps I should put an ad in the paper – “Single (not really) white female seeks competent sex, relationship and general life advice columnist. Must maintain a predictable schedule, be open minded, patient yet firm, and be knowledgable on every topic addressed… Must never screw up.”

Part of my problem is timing and schedules. I liked the Feministing.com column, Ask Professor Foxy when it was still active, but the eponymous Prof. Foxy hasn’t written a new Q&A column for the site in about a year. Good Vibrations Magazine occasionally answers reader submitted questions in the feature, GV Housecalls, but this feature is irregular. There can be weeks or months between new columns.

I believe that folks gravitate towards the advice they want to hear. So how open-minded your agony aunt is, is likely a function of how open-minded the advice seeker is. In other words, if you value spiritual guidance, you probably wouldn’t reach out to a secular agony aunt for relationship advice. You’d probably look for an advice columnist with a spiritual bent instead. “Dr.” Laura Schlessinger is one such spiritual agony aunt, but for multiple reasons her programs, which include racist rants, repulse me.
With regard to advice columnists in general though, that desire for certain types of advice means different agony aunts will attract certain types of audiences. I’m sure that agony aunts figure out their target demographics. Advice columnists then hone their responses to better meet their readers’ expectations.

Advice columnists specialize in certain areas too. Although one agony aunt responded to every submitted query, I think this is an absolutely terrible idea. The sheer amount of research required to give yourself a crash course before answering curveball questions would draw time away from more relevant queries. I wouldn’t ask a self-described expert on cooking about when it’s appropriate to move out-of-state. (I might ask a financial advice columnist though.)

And so much advice-giving is really permission granting. I notice that the way questions are written offer clues as to what the the submitter already perceives to be true – submitters want confirmation from someone perceived as an authority figure. I remember reading an article about the real Erin Brockovich a number of years ago, in which she described talking to herself when facing dilemmas. (An Amazon review of her book provides backup that Brockovich does indeed describe talking to herself.) I think a lot of advice seekers could similarly find the answer they seek by looking within and confronting themselves.

Frankly I’m not even fond of the direct question-and-answer format of advice columns. With Q&A columns, there’s no way to get all the relevant information required to make an informed decision on behalf of the submitter. Printed letters have to be edited for space, too, which can be even more confusing for readers.
An example of a format I especially want to avoid though, can be found in Wayne & Tamara’s column. The authors usually respond to questions with unrelated stories, with the advice buried in parables. I love it and I hate it all at the same time – the responses can be so cryptic it’s funny.
I prefer blogs, since bloggers frequently follow the “Show, don’t tell” principle – though there’s still some telling involved with blogging. Even then, personal stories & experience work well as examples to illustrate a larger point – the personal is political, after all.
But not all bloggers are agony aunts.

So there’s still plenty of popular advice columnists left to consider, right? Maybe not. My last criteria may be unfair, since everybody makes mistakes sooner or later. And what I view as an error, someone else may perceive as a positive feature. (The social justice blogosphere frequently critiques examples of ignorant “Advice.” Feminist & social justice readers probably recognize the problems in this recent gaffe, but if you’ve been swimming in privilege, you may be all like “I don’t get it.”) But when an advice columnist is recommended and has a strong reputation, I expect more. I’ve been disappointed and disgusted by popular columnists, and once I’m disappointed enough I just stop reading. From that point on I’ll be more reluctant to trust the agony aunt and whatever advice zie have to offer. Sometimes advice-givers apologize after getting called out for obvious screwups, but it may be too little, too late… Doubling down on privilege doesn’t help either. For example:

I stopped reading Dear Abby on June 27, 2007 when I saw this Q&A posted. In her response to a 33-year old virgin woman with anxiety over the prospect of her first gynecological exam, Abby wrote in part:

DEAR SCARED: A woman should be seen by a gynecologist if she is sexually active, or if she has reached the age of 18. She should DEFINITELY see one if her regular doctor tells her to — so please start acting like the 33-year-old adult you are and stop listening to “horror stories” from friends. Pap smears are not painful, and women do not normally bleed after having one.

Sounds spot-on, right? Wrong. Pap smears can be painful for some women – Abby’s response makes it sound like anyone who says otherwise must be a drama queen or a liar – instead of someone who may have a treatable medical problem that any competent gyno could make accommodations for.

Abby doubles down and adds insult to injury with the snide implication that “Scared” is acting like an immature child, just like a childish woman who can’t suck it up and deal with it at the gyno’s.

I never got into Dan Savage’s advice series because by the time I found out about him, it was because his reputation had been recently marred – and not for the first time. I know he’s done good things for the gay & lesbian community in particular, notably the “It gets better” project and comically redefining “Santorum,” but I can’t get over his history.

I’m certainly not going to read Dear Prudence, who recently gave some fucked up “Advice” to a gentleman regarding his wife’s prolonged therapy and the lack of sex after marriage… because she had just started therapy to cope with the abuse her father committed on her.
Do I really need to delve into why Prudence’s advice terrifies me? To make matters worse, Prudence’s answer was heard ’round the tubes, so hundreds of folks saw fit to comment on this couple’s sex life. As always, things got real ugly, real fast.The myriad terrible answers to this particular question, unfortunately, are how I know looking for any better advice is ultimately an exercise in futility.

I used to read Carolyn Hax’s advice column (When it was still called Tell me about it,) until I got bored with it. I decided that much of her romantic relationship advice boiled down to “DTMFA,” because it looked to me like relationship problems, minor or major, could be solved with a breakup. In fairness, that is always an option. But her recent advice is pretty good, so maybe I should give Hax another chance.

Then there’s the self-described agony aunts of the Internet – they’re not featured in mainstream media, but they’re still popular (On the internet!) Some of these advisors have qualifications that lend credence to their advice – Ph.D. Degrees, M.S.W. degrees, certificates reflecting formal training, etc. Others are bloggers with no formal training, yet have a wealth of experience to reflect upon. And for a lot of readers, I’m sure the advice in Internet agony columns works out well.

The problem is that when the advice I want or need is sexual in nature, I can’t turn to a lot of agony aunts, even the popular ones. I saw some professors and sex educators recommended by commenters in blog posts on places like Jezebel or Feministe, so I read and have since screened out a few recommended agony aunts who write general observation stuff.

Sometimes the posts are great and well-researched. Other times, they’re as airy & fluffy as cotton – and personally, I would rather not post anything, then inflate my post count with fluff. (Everyone reading this now is thinking to themselves, “Yes, K, we’d all prefer it if you didn’t post too.” Haha.) That quality variation is pretty typical of any writing though, so no big deal.

But when it comes to problems most near & dear to my heart, sexual dysfunction specifically, the recommended agony aunts let me down. Some just vomit up yet another uncritical iteration of the New View’s rhetoric: The problem you describe isn’t an actual problem you are experiencing; it’s just part of being a woman. You can’t take medicine for sexual problems today because in the past women didn’t get a choice and you dishonor their memory. Doctors and Big Pharma are in cahoots to fleece potential patients so you can’t trust the sexual health research out there co-authored by medical doctors and certainly you should never visit one for a sex problem. Wait, you have pain with sex? Go see a doctor.

To be fair, I’ve seen this very blog you are reading get plugged by commenters offsite too. I’m flattered. So what’s the difference between me and professional or amateur agony aunts?
The difference is I have never described myself as an agony aunt. I’ve repeatedly stated, I am not here to give you advice. I prefer to be a general nuisance, presenting evidence in contrast to conventional advice, since the usual advice backfires on me anyway. I may on occasion, when pressed directly, offer up some link or sound byte, but ultimately, I believe that individuals are the only ones who know what’s best for themselves when it comes to personal & health decisions.

That said, there are some bloggers I still look to for advice, though they aren’t necessarily in the business of answering questions. Keep in mind even you may find the following bloggers repulsive, for the same reasons I’ve outlined above! They aren’t always perfect, and I’ve seen some of the below make mistakes too.

People I still find credible most of the time:
Holly of the Pervocracy, Violet Blue, Corey Silverberg, Heather Corinna, the archive of Go Ask Alice!, Matt Kailey

Tier 2 (Generally like but with some reservations,)
Greta Christina, Carol Queen, the Sexademic, Marty Klein.

Readers, have you found a decent agony aunt that might fit the bill for what I’m looking for? Now I want your advice as to who’s good & why.

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…

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…

Conceptualizing the FSD hierarchy

01/12/2011 at 12:04 am | Posted in Uncategorized | 8 Comments
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A couple of times on this blog, I and guest posters have briefly mentioned something called the female sexual dysfunction hierarchy. This is an idea that formed in my mind while reading various interpretations of  female sexual dysfunction – I noticed that not all forms of FSD were handled equally in terms of social (and professional) acceptance and priority for treatments. But what is the FSD hierarchy, exactly? What do we mean when we talk about it? Let’s think about it and see what we can come up with.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And here’s an explanation of this pyramid:

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

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

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

Book review: A New View of Women’s Sexual Problems

11/16/2010 at 10:14 pm | Posted in Uncategorized | 5 Comments
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Several months ago, over the course of a five-part series, I reviewed sexologist and feminist activist Dr. Leonore Tiefer’s nonfiction anthology, Sex is Not a Natural Act and Other Essays. It presents her critique of contemporary discussions of sex, sexuality and sexual dysfunction, from a social construction perspective. (Basically that means that Dr. Tiefer gives significantly more weight to cultural influences on the formation and expression of sexuality than to biology.) While reading it was certainly an informative experience for me, it was also rough – at several points I tripped over apparent contradictions between what Dr. Tiefer had written in one chapter vs. another and multiple instances of disablist language. Overall, while I learned a lot about social construction and criticism of female sexual dysfunction as a diagnosis, the book left me feeling isolated and unsatisfied since biology and the availability of medical options have a strong impact on how I have sex.

So for awhile I and guest posters wrote about other stuff in the wide world of female sexual dysfunction. And then I had to take a hiatus from blogging so I could deal with real-life chaos. After settling into a new routine, I felt motivated to read something… Now seems as good a time as any to pick up A New View of Women’s Sexual Problems, another nonfiction essay collection detailing an alternate model for looking at women’s sexuality and dysfunctions. A New View doubles as an in-depth manifesto for the New View Campaign, complete with examples of how the New View model can be applied to real-world women’s sexual complaints. Let’s see what it’s all about.

Overall Impressions:

A New View is and feels significantly shorter than Sex is Not a Natural Act – it’s about 218 single-spaced pages, divided into three parts. Each chapter is short, ranging from just a few bite-sized pages up to around thirty, so it’s easy to digest. Each chapter was published simultaneously in the journal Women in Therapy, volume 24, issues 1 & 2, so you’re actually reading academic journal articles. Except for a few essays towards the end of the book, most of the time it’s generally not heavy on academic jargon.
Downsides unrelated to the writing: A New View is not available in e-book format and at about $30 on Amazon (new) it’s a little outside my sweet spot price range for something sans illustrations. I went in to the book hoping for a list that would explicitly spell out which biological problems get the green light for medical treatment but I’m still not clear on exactly when sexual medicine is appropriate (and why.)

On paper, the New View looks good. Overall, the book is nuanced and presents the perspectives of many professional women familiar with sexology, sexuality, women’s studies, feminism, psychology, health, and related fields. The responses to the New View manifesto illustrate its merits and practical application…
On paper.

In practice, I’m still wary of the manifesto and the eponymous organization. Reading the entire body of work has not sufficiently addressed my apprehensions.
Because in practice, I’ve seen the New View’s positions and activities turn into another prescriptive theory, one that creates new complications and restrictions for women even as it attempts to free them. For example, in practice, the strong emphasis on relationship problems can also oversimplify women’s sexual problems and turn into partner blaming. The New View’s insistence on referring to “Female/Pink Viagra” further obfuscates understanding the difference between arousal and desire, even when drugs like flibanserin do not work like Viagra. I was horrified to see New View organized petition to stop FDA approval of flibanserin, since I felt like the petition organizers overlooked whatever small number of women might actually benefit from such a drug, questionable though it is. Anti-Big Pharma arguments can easily turn into anti-medicine rants and rampant disablism. Looking for the deeper meaning behind sexual problems can turn into so much ‘splainin and Freudian analysis. And I think that by questioning the very existence of such a thing as female sexual dysfunction, the New View contributes to the further stigmatization of FSD. Basically, when used irresponsibly, the New View lends itself to Bingo Board fodder.

But on paper, the ideas are great. There’s even wiggle room for medical problems and biological factors as causes of women’s sexual problems (though the contributors are less interested in examining biological and health problems.)

In practice, the New View raises new questions and creates potential problems that warrant further examination.

Reading between the lines, you may notice some elements missing…

The New View Manifesto which guides the campaign was written from the perspective of professional women – psychologists, anthropologists, sexologists and related fields; however none of the original twelve named contributors to the succinct document had qualifications in medicine. There were no physicians, gynecologists or obstetricians involved in drafting the original manifesto. However, the document has subsequently received endorsement from several medical doctors and many therapists.
None of the contributors to the New View book disclose whether or not they have personal experience dealing with sexual dysfunction. The only clue we have as to whether an author with sexual dysfunction was included in this anthology may be found in Gina Ogden’s essay, which said, “I have been able to relieve much personal relationship angst by understanding sexual dysfunction as a manifestation of cultural dysfunction” (19). So there’s an “I” statement that touches upon sexual dysfunction and Ogden probably meets the New View’s definition of having had “Sexual problems,” but it’s not clear to me whether she ever considered herself to have a dysfunction. However even this statement ultimately rejects sexual dysfunction as an actual bodily phenomenon that women experience in and of itself. The rest of the book is likewise resistant to the very idea of sexual dysfunction as a valid medical problem.

There’s an expression in business, “Management sets the tone,” which means upper management, through actions and words, dictate the general atmosphere of an organization. It was Dr. Tiefer who pushed for the New View Campaign to come together, and throughout Dr. Tiefer’s essay, she consistently keeps the words female sexual dysfunction in “Scare quotes.” A footnote details the reason why: “4. I will put “FSD” (female sexual dysfunction) in quotations in this paper to indicate its questionable legitimacy” (92). Based on this, it seems highly unlikely to me that the contributors to this book would have actively reached out for feedback directly from women with sexual dysfunction. After all, if a condition is not legitimate and real, then who has it? There isn’t anyone with it to recruit.
Women who definitely had relationship and sexual problems and/or dysfunctions are presented as case studies in support of the New View model. Sometimes these women are quoted briefly, other times a contributor presents a summary of what brought a client in. Our words are presented through the filter of professionalism.
The omission of responses by women with sexual dysfunctions is a problem since such women are critical stakeholders in the New View model of sexuality and sexual problems. The New View is meant to be applied to women who experience sexual obstacles. But did anybody run the New View by the women who it most deeply effects before going to print? Based on one of Dr. Tiefer’s essays, it looks like the answer is No – the New View was drafted by about a dozen North American professional women based on their interactions with clients and with feminism (87); women with sexual dysfunction were not explicitly solicited for feedback. This is especially ironic in light of Peggy J. Kleinplatz’s essay, On the Outside Looking In: In Search of Women’s Sexual Experience in which she says, “Women’s sexual experience is conspicuously lacking from popular and sexological discourses of female sexuality” (124) and,

“Alternative models of female sexuality are called for which embrace the entire range of female sexuality from the vantage point of lived experience… A new epistemological stance is required which features women’s subjectivity at the center of inquiry. Female sexuality is best understood by listening to women’s own voices rather than attempting to peer from a safe distance and have our views filtered through the distorting lenses of conventional and sexological images of sexuality and female sexuality” (130).

Without follow through, calling out for the voices of women is little more than lip service. Nothing about us without us. (This is a continuing problem in the wide world of feminist writing, and writing in general.)
On the other hand, even if women with sexual dysfunction had been consulted when the New View document was first drafted ten years ago, I doubt it would have raised many objections or concerns. It looks fine on paper; it’s when and how you use the document to guide your activism that problems become are either solved or manifest.

I was surprised to see some criticism of the New View contained within the book’s pages: according to Gina Ogden, it may not have much to offer women who are extroverted in their sexuality. Jaclyn Friedman comes to mind, because Ogden says such women are labeled “Sluts” (19) and Friedman self-identifies as a slut, in the best way possible. So what does the New View, which focuses on negative sexual outcomes, have to offer her if she experiences sexual dissatisfaction? Good question.

The New View does a better job looking at causes for sexual problems than it does at offering guidance for what anyone should to do about it. I suppose that’s true of the DSM too though. One thing that’s clear in the New View is that medicine should generally be avoided, since medicine won’t address social forces, and it has been hijacked by for-profit entities.

And unfortunately the book doesn’t say anything about the grieving process you may go through (I went through it…) when it turns out that your sex life is not, and may never be, anything like what you had expected.

The book itself:

The first part of the book is the shortest – it’s the New View Manifesto document itself, which you can find online if you know where to look. It has been re-published on the Our Bodies, Our Selves blog supplement. (A later chapter goes into more detail about Dr. Tiefer’s connection with the Boston Women’s Health Book Collective, which I was curious about.) The document itself, not so bad. It does not use the label “Sexual dysfunction,” instead using the term “Sexual problem,” which is defined as, “discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience, may arise in one or more of the following interrelated aspects of women’s sexual lives,” and then there’s the whole bulleted point list of stuff that makes sex hard for women to enjoy. This alternative definition is similar to the DSM’s criteria of “Personal distress” in sexual dysfunction since it acknowledges the importance of personal dissatisfaction, but it’s more flexible in acknowledging what causes dissatisfaction, and the language is supposed to be less hurtful. It’s meant to acknowledge social influences and reassure women that there’s nothing wrong with them if they experience sexual problems. To the best of my knowledge the document has remained unchanged since the final draft was put together in 2000 (88).

The second part of the book consists of 10 contemporary responses to the New View. Professionals read it and wrote in about how it could be applied to their practices and/or demonstrating ways in which women’s sexuality is shaped by local culture – often with negative outcomes for the women, since culture is frequently patriarchal. Throughout this section, there is a strong emphasis on relationship factors as being the main culprit for women’s sexual problems. So what about all the single ladies who are not in a romantic/sexual relationship? Well, you still got a relationship with your friends right? Or your parental figures, or if you’re reading this blog then surely you have some kind of relationship with the media. Relationships! You can’t get away from ‘em.

The essays have merits, yes. But there’s flaws too. Here’s some examples of what I mean…

In the first essay response to the New View model, Dr. Lucy M. Candib presents a case study of a patient with sexual problems and lists elements of her problems that fall under all four of the main areas of the New View classification. It’s a compelling case. Yay! But then Dr. Candib says,

Practitioners may attempt to address the anger that women hold about both the division of labor and the experiences of abuse, but such anger is usually chronic, and many women develop symptoms in relation to it – headaches, chronic pain, fatigue, or depression – especailly when the relationship appears to be an inescapable trap (13).

Emphasis mine…Wait, what am I looking at here? I don’t think I like where this is going… didn’t DW user beautyofgrey talk about looking at “Unresolved anger” as a way to explain away what was actually a chronic, invisible illness? And didn’t she talk about how people interfere with her treatment decisions out of fear of Big Pharma?

Beth A. Firestein’s essay, Beyond STD Prevention: Implications of the New View of Women’s Sexual Problems talks about how a strong focus on sexually transmitted infection prevention fails to address the concerns of people who have or have had a STI. Prevention is great, but what happens if it isn’t enough? What happens when prevention fails and you catch a sexually transmitted infection? This chapter explicitly mentions the role of STI (or the fear of them) s in developing vaginismus, and this is the only chapter that explicitly mentions vulvodynia. Yay! However, this is the context:

3. Women who have partners that suffer from recurring outbreaks of a viral STD, such as veneral warts and herpes, or neurological pain disorders, such as vulvodynia, that cause pain with sexual activity or penetration, need to be helped to seperate fear from fact and to determine a personal range of safe and pleasurable sexual behaviors – behaviors that allow for sexual satisfaction of both partners while decreasing the risk of exposure to their partner’s disease. Such women could also benefit from coaching in ways to deal with a partner’s STD that protects the woman without eroding their partner’s sexual self-esteem or healthy sense of sexual self-expression (30).

I’m actually not put off about talking about vulvodynia in the same chapter as STIs, because Firestein’s view is meant to go beyond STIs and take away some of the stigma associated with them. This paragraph is somewhat awkward though, since vulvodynia is not actually an STI and it is not contagious, my partner does not need to worry about being exposed to it. A simple grammar tweak would likely strengthen this passage. I’m more concerned that this passage does not provide guidance with what to do if you are someone who has a chronic condition or infection… and you still want to go beyond your current safe range of activities. I already know facts about vulvodynia, probably more than the average sex therapist or general practitioner. My fear does not come from ignorance about my own health. Some women with vulvodynia still want to, or do, have sex even if it is painful, and this paragraph does not address what steps might be taken in those situations.

Dr. Lisa Aronson Fontes’ essay on Latina sexuality, The New View and Latina Sexualities: Pero no soy una maquina! compares the New View vs. the DSM classification of sexual problems and where each classification schema centers the causes of women’s problems: Within the individual vs. with external forces in an individual’s life. She provides examples of Latina women with a history of sexual abuse or shame for whom the DSM does a poor job addressing the causes sexual problems, and she shows how the New View fits better. Yay! One client, Sarita, told Dr. Fontes her frustration with her pushy priest and doctor – they were urging Sarita to have sex with her husband, even though she was dealing with abuse triggers which made her uninterested in sexual activity. (Sound familiar to anyone?) This experience resulted in the expression contained in the title, translated as “But I am not a machine!”
So Dr. Fontes’ comes down pretty hard on a diagnosis of sexual dysfunction, at least for sexual abuse clients:

The “dysfunction” categories of the DSM-IV imply pathology as a variation from a theoretical normal pattern. It is more helpful to use an injury model – that connects suffering with the environment in which it occured an dthe person who caused it – than an illness model, which locates the source in the sufferer (Lamberg, 2000). An injury model implies recovery for victims of abuse. Yolana is on the mend – being labeled as “dysfunctional” at this time cannot help her recovery (36).

So for another client, Yolanda, a diagnosis of sexual dysfunction is a poor fit or outright counter-productive. But what about women like me, for whom incorporating the label “Dysfunctional” is part of my recovery – if you can call it a “Recovery” at all. At what point are you recovered, knowing you can never go back to the “Normal” which you once had? It may be worth noting here that according to Dr. Fontes’, Sarita did not meet the criteria for PTSD (35). But what about if she had? We get a clue as to Fontes’ feelings regarding an illness model in general with the following line:

“Using the New View, we are able to consider and treat Sarita’s discontent in its historical and current relational contexts, without reducing her to a body with a dysfunction, as if she were a broken machine” (35.)

Emphasis mine, because the problem with this statement is No no you know why am I even still doing this I am not doing this anymore I should not have to explicitly spell this out: If you think that diagnosing someone with a sexual dysfunction reduces them to a broken body, like they are a broken machine, then that’s your problem! Except that then it becomes my problem because then I have to struggle against this idea that there’s something wrong with me not just for having sexual problems but for needing medical help addressing them. You can have a sexual dysfunction and still be a rich, individual person. There has got to be a way to support abuse victims without using disablist language, especially since some abuse victims may very well have chronic illnesses – in fact, folks with chronic illnesses are more likely to be abused.

The third part of the book details the origins of the New View and contains more supportive materials. It’s the biggest and the most difficult section.

The longest chapter in the third section is Dr. Tiefer’s essay, Arriving at a “New View” of Women’s Sexual Problems: Background, Theory, and Activism. It’s very similar, even parallel, to Sex is Not a Natural Act. If you don’t have time to read all of Sex is Not a Natural Act, you could probably get a good idea of what it’s all about from reading this colorful essay. Dr. Tiefer shares her perspective of the history of the medicalization of men’s sexuality (and by extension, women’s,) the influence of Masters & Johnson’s human sexual response cycle research, criticism centering orgasm as the endpoint of sexual research, etc. This essay provides a lot of background information about why and how the New View Campaign came to be in the first place at about the turn of the millennium – with Viagra approved and prescribed, Dr. Tiefer and feminist colleagues wanted to challenge the supremacy of male-focused medicine defining what constitutes female sexual dysfunction, (no skeptic quotes from me) but they had to do so under time constraints – there was a sexual dysfunction conference a-brewin’.

Remaining chapters in this third section address gender and gender roles, sex education and coming of age, lesbian sex therapy, female sexual dysfunction, etc. The essays on lesbian sex therapy were interesting and they draw attention to this often-marginalized group, but even the authors seem disappointed by what they have to offer to their lesbian sex therapy clients. Much of sex therapy is informed by the work of Masters & Johnson and is heterocentric. You may think the same principles in heterosexual sex therapy should apply to same-sex couples but in practice, it frequently cannot. In response to the failures of Masters & Johnson’s sex therapy models, Marny Hall once tried a revolutionary therapy with lesbian clients that she called “Anti-sex therapy,” (168) with disastrous results.

As was the case in Sex is Not a Natural Act, I found myself tripping over problematic elements in these later chapters, which made it difficult to find redeeming elements. Jennifer R. Fishman and Laura Mamo in their essay What’s in a Disorder: Cultural Analysis of Medical and Pharmaceutical Constructions of Male and Female Sexual Dysfunction (about exactly what it sounds like) describe prescription drugs as,

…fast becoming popular consumer products, a capitalist fetish, where one is encouraged to think of such drugs as a means through which to improve one’s life. The shift to the biomedicalization of life itself is indicative of a cultural and medical assertion that one’s life can always be improved” (182).

(Emphasis original.) There is no consideration here for folks who need prescription drugs for mental illness or chronic pain or for folks who cannot afford much-needed medication. What stung me the most was the complete erasure of my existence as a once-adolescent young lady with sexual dysfunction when Deborah L. Tolman explicitly stated, “Female adolescent sexual dysfunction is an oxymoron” (197.) How am I supposed to react to that? Is this slap in the face supposed to snap me out of my reverie? I came away from many of the later chapters feeling very much as though some of our bingo board squares were staring me right in the face.

Overall, it is a challenging book, esoteric, though for readers of this blog it might be one worth reading. But it should be taken with a grain of salt — The New View may not be the panacea for women’s sexual problems it was hoping to be. In breaking away from the problems contained in the medical model, the New View stumbles into and creates new, different problems. It could be strengthened with revisions following a deeper understanding of disability activism and the potentially harmful consequences of stigmatizing both illness and medicine. The goal of the New View is to recognize that sexual problems are often caused by forces outside the body, and then to work for social change to address the causes for these problems. But social change takes time, and some of us cannot wait that long for revolution, especially when there are so few support structures in place to begin with. Some of us genuinely do have sexual problems that originate from within. Some of have problems that are so complex, we cannot isolate the body from the social, and we should not have to choose between social change or medicine. This really isn’t an either-or situation; people want better sex education with which to make good sexual choices and access to medical options. Others face problems so widespread that even feminism can’t fix everything. We have problems and dysfunctions now. While I can see some merits to social construction in looking at sexual problems and dysfunctions, overall with regard to the New View, I remain unwilling to co-sign.

In defense of “Dysfunction”

10/25/2010 at 7:25 pm | Posted in Uncategorized | 5 Comments
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I identify as having female sexual dysfunction. For me, it’s an accurate and neutral term, as honest as describing my eye color or my gender as feminine. (It is, however, a personal thing which I won’t disclose to everyone in my social circle, and you’d never guess with a first impression.) I wouldn’t say I’m exactly happy about having sexual dysfunction, but I’m no longer ashamed of it, either. (At least, I try not to be.) Some folks may question why I say I have sexual dysfunction, since it’s such a controversial term. …Then they find out that the main sex problems that are causing me so much trouble are pain due to vulvodynia and vaginismus. So long as folks know what those two conditions are, the questions about my self-identification tend to back off. Still, there are some experts in the professional field who question the validity of sexual pain as a sexual dysfunction, questioning if it should instead be classified as purely a pain condition. Then, even if sexual pain was considered a chronic pain condition independent of sexual dysfunction, that would still place me on the disability spectrum.

Since I have FSD, I have vested interest in learning more about it – what it is, what treatments are or aren’t available, how it impacts individuals’ lives (if at all,) etc. It’s not just reading though – I’ve talked to and received feedback from women who themselves have FSD in one or more forms. I’m especially interested in how FSD is perceived and what people say about it! It’s meta, and its fascinating. So what are people saying about it? When I read about FSD, I notice a few familiar themes pop up repeatedly…

Again & again I’ve run into mainstream articles and published journal studies like, “Big pharma’s newest fake disease.” “Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance.” “The making of a disease: female sexual dysfunction.” Magazine articles like “Lust, Caution.” Slogans like, “Sex for our pleasure? Or their profit.” Blog posts covering FSD – or rather, not covering it, because it’s not a valid diagnosis to cover in the first place. Instead, almost all of these articles focus on the role of Big Pharma in the promotion of sexual dysfunction, with the end goal of selling medication for huge profits. The idea goes something like, if a commercial enterprise can create and then capitalize on sexual anxiety, then there’s a potentially huge market to make big bucks off of. After all, who hasn’t dealt with some sexual insecurity issues?

But who is the target audience of these articles? What do these articles say to and say about women who experience sexual dysfunction? How am I, someone who actually has sexual dysfunction, supposed to react when I see “‘Sexual Dysfunction’ in women: Myth or Fact?” as a header on page 543 in my 2005 version of Our Bodies, Ourselves? I’m standing right here, so my immediate reaction is to wonder how much able-bodied privilege (in terms of not having FSD) the editors were stewing in to overlook the fact that FSD is a broad topic that goes beyond libido alone and that perhaps some of their readers would have sexual dysfunction. The above articles make some good points to consider, but I feel very shut out of these conversations. There’s plenty of talking about, but not so much talking with.

To put it very simply, with both the medical and social construction models of FSD, sexual dysfunction is “Bad,” it’s something you don’t want. Both models contribute to the stigmatization of sexual dysfunction.

Briefly, the medical model is like, “You don’t want to be dysfunctional, right? So here take this pill/use this device/have this surgery and you’ll be cured! BTW here’s the bill…” (In practice however, it doesnt always work out that way – it can take a very long time before patients find a doctor who will be willing to listen to sexual problems and then offer intervention. And even prescriptions can have only minimal effects on the problem, plus they come with side effects.)

The social constriction model is more like, “You don’t want to be dysfunctional, do you? Not to worry; you’re not! It’s just that culture’s views of sex are so screwed up and limiting, these limits create sexual anxiety.” (If guided by a therapist through this process of coming to terms with sexual problems, there will still probably be a bill at the end of a long process of changing your world view.) Sounds great, however I’m uncomfortable with the promotion of guilt and feelings of foolishness if you do use sexual medicine that I’ve seen under the social construction model. I am concerned about the means used under the social construction model. For an example let’s return to this comparison of guys with erectile dysfunction to Jackie Gleason of the Honeymooners:

I am a 37 year old man with erectile problems for 2 years. I have used 50 mg. Viagra 4 times. All of those times have resulted in a very good erection and intercourse. The side effects are headache, upset stomach, stuffy nose, and facial flushing… About 30 mins after taking Viagra I take 2 Tylenol and a Tums and start drinking water. After about 15 mins I take another Tums and use a nasal spray for my stuffiness. I will continue this combination and it will work for me.

This sounds more like a Jackie Gleason routine rather than a romantic evening, but I think it is close to the reality of what life with these drugs will be like… How does his sexual partner feel about the whole drama with the Tums and the nasal spray and the Tylenol?

Found in Sex is Not a Natural Act, location 1109. No one wants to be a shill of the pharmaceutical industry, right? So don’t take that pill and whatever else you need to feel stable. It makes you look foolish anyway, bumbling around like that. The author, Dr. Leonore Tiefer, implies that this gentleman’s partner must think he’s a huge joke. Uh-oh – I go through a“Whole drama” with my stretching & dilator exercises when gearing up for PIV sex.

All of these articles I listed above imply that sexual dysfunction is something new and invented only within the last few decades, guided by the invisible hand of the marketplace. Sexual dysfunction, or increased awareness of it, is something to resist the spread of in the future. It’s something to fight against – like there’s something inherently wrong with being or thinking of yourself as sexually dysfunctional, and especially like there’s something wrong with wanting and needing medical help in the bedroom. The aim of the resistance is noble enough; protect women from being exploited medically, in relationships, and financially. But the means used to achieve that goal don’t always do a good job of acknowledging the reality of life with sexual dysfunction for those that do have it.

Some therapists who take a very strong social construction approach to sexual problems state that whatever you’re going through, it’s not a dysfunction:

So as this latest chapter in the medicalisation story closes, let’s be very clear. Women do experience sexual problems that cause them distress, discomfort and dissatisfaction. These are often linked to other factors and do need attention, but they are not a clinical condition or a dysfunction, and they do not require a new and separate diagnosis. A summary of common reasons women experience problems with sex can be found here.

(Emphasis mine.)

So one of the common themes I keep running into, particularly in feminist, social construction-informed spaces, is this idea that female sexual dysfunction isn’t a valid diagnosis. This view is gaining popularity – it’s covered in women’s studies classes: There’s so much sexual diversity that it’s not fair for doctors or Big Pharma to dictate who does and doesn’t have a “Normal” experience. We don’t really know what “Normal” means, even. And indeed, it is well within the realm of normal and fine to have low or absent sexual desire, it is normal and fine to have orgasms that don’t necessarily rock your world. Everyone’s different. Generally, authors who take a strong social construction approach to sexual dysfunction admit that yes, sexual problems do sometimes happen and yes, they’re real. However…

Nonetheless when sexual problems do happen, it’s not a dysfunction. Don’t call it that. Sexual problems are real, but sexual dysfunction isn’t.

What’s scary to me personally about the above quote is also that sexual pain in and of itself can be caused by a clinical condition (like vulvodynia.) My painful sex and all the issues that stem from that is merely a problem rather than a dysfunction?

The very existence of sexual pain is also a source of internal conflict that I haven’t been able to reconcile because depending on who you ask, sexual pain either is a valid and important sexual dysfunction or else pain as dysfunction is still a myth. I cannot figure out how sexual pain can simultaneously be a sexual dysfunction and not a dysfunction, and also sexual dysfunction is something that isn’t legitimate. I also can’t figure out why pain as dysfunction should be elevated to the pantheon of reality (whether it’s considered a pain condition or a sexual dysfunction) but other non-painful sexual dysfunctions shouldn’t be recognized as such.

The problem is that calling sexual dysfunctions by the euphemism, “Sexual problems” does not recognize the degree to which the sexual problem(s) interferes with someone’s life. According to this article from Harvard.edu,a key component of what separates a sexual problem from a sexual dysfunction is personal distress.

I have a few overlapping sexual problems, which cause a lot of anxiety to this day. My problems can (and do) bleed out into other, non-sexual areas of my life, so when that happens it’s impossible to ignore. To this day I can’t afford to slack off too much on my pain management exercises (like the stretches,) because if I do the muscle tension & pain comes back. Other times, the pain is well-managed but the fear remains. This is a serious problem for me; I think about it a lot and it interferes with my quality of life. And I’m one of the lucky ones who was nonetheless able to find significant improvement through medical intervention.

Lots of people have sexual problems that do not pass the threshold into dysfunction. These problems are nonetheless important and valid experiences, or at least as important as it is (or not) to each individual. But I suspect that the person who has a sexual problem does not experience the kind of anxiety and distress that I do from sexual dysfunction. Does someone with a sexual problem as opposed to a sexual dysfunction feel the need to think 12 steps ahead of every sexual encounter and have all kinds of contingency plans ready if and when something does go wrong? Do people without sexual dysfunctions even think of contingency plans in the first place? Do people with relatively minor sexual problems think about what’s going to happen as they age? How would I know? I would think that someone with a sexual problem but that feels overall pretty comfortable with themselves hasn’t had to spend buttloads of time and money searching for a professional prepared to compassionately handle their sexual complaints.

Calling sexual dysfunctions by the euphemism “Sexual problem” lumps all problems and dysfunctions together, and it minimizes the reality for those with major distress. Refusing to acknowledge the personal distress that accompanies sexual dysfunction equates my long-term pain (which I worry about) with the handful of times that I’ve been unable to orgasm from masturbation (which I’m not worried about. I do not perceive these two personal problems of mine as equal. I did not weep for months when I was unable to orgasm a half a dozen times in my life, but I did weep for the hundreds of times I was unable to comfortably insert something into my vagina.

But no it can’t really be that bad, right? It’s just a problem, strongly influenced by some intangible outside force.

It’s ironic when you think about it – part of the resistance against the term “Dysfunction” is because it’s totally not fair to classify every little sexual variation as a sexual dysfunction. Doing so maximizes the assumption of negative feelings regarding sexual performance. But by refusing to leave room for dysfunction, the distress that may be caused by a sexual problem in and of itself is minimized. The phrase “Sexual problem” misses half of what I’m dealing with here.

Refusing to acknowledge the reality of sexual dysfuction erases what is for some people may very well be a valid medical conditon. A few months ago, frequent commenter and occasional guest poster Flora picked up on the similarities between the way vaginismus and non-sexual, invisible chronic conditions were handled:

Some older studies on CFS/ME were on people who were told that their minds were unconsciously manufacturing their symptoms because they wanted to get out of a hectic work life, and called it “yuppie flu.” It happens with purely neurological things, also; it used to be widely believed that autism was symbolic of “withdrawing into yourself” due to child abuse or neglect. So it’s… nasty but also in some ways unsurprising that people would try to interpret vaginismus along the same lines.

This is really happened. But just because you can’t see it, doesn’t mean it’s not real. Not every bodily phenomenon has to have a deep symbolic meaning behind it… Sometimes things just happen.

So when someone insists that sexual dysfunction is a purely social construct with no medical validity, that is getting stacked on top of a long history of denying the validity of many chronic conditions and disabilities – some of which disproportionately effect women, and which may overlap with sexual dysfunction. I don’t see what’s so new & revolutionary about that.

It’s an act of erasure when someone who is not me, who doesn’t even know me, declares, “You don’t have FSD because it isn’t real.” Oh no; this is quite real. And I’ve worked really hard to accept and incorporate sexual dysfunction into my identity. It’s part of who I am, it will follow me into any future relationships I may have, and to embrace that was not a decision made lightly. But still I must be all wrong; I’m not dysfunctional… It must instead be the case that I am foolish, gullible and brainwashed. Snap out of it. Now isn’t that so much better than having something wrong with you?

But wait!

There’s widespread controversy about sexual dysfunction, yet even among sex therapists, there is not a unified agreement on what is and isn’t sexual dysfunction, whether or not it’s a valid terminology, and when/whether medical intervention should be acceptable. There are some sex therapists out there who accept the validity of sexual dysfunction and who would not rule out medical treatments.

For example here’s Dr. Marty Klein on anti-flibanserin activism:

It’s accurate, of course, to say that there isn’t a single level of desire that’s “normal.” But women who experience dramatic drops in their desire know there’s something wrong. And isn’t it obvious that one definition of “healthy adult” is the experience of sexual desire when the conditions are right?

Millions of women (and their partners) know their lack of sexual desire causes suffering. Whether taking a drug is the best treatment for any woman isn’t the point. Dismissing B-I’s drug and its marketing as “disease mongering” is terribly disrespectful to the many women who struggle with low desire.

You may know Dr. Klein as a Ph.D., sex therapist, as the blogger behind Sexual Intelligence, and as the author of several books about sexuality. So he’s been working at sex education and therapy for literally decades. Yet after everything he’s seen, after raising his own questions about the validity of certain diagnoses such as sexual addiction, still, he acknowledges the importance of potential treatments for low libido types of sexual dysfunctions.

Still don’t believe me when I say that there’s disagreement among sex therapists about what constitutes sexual dysfunction? Here’s another well-known sex educator, Dr. Carol Queen, on nomenclature, in response to a reader query:

Question: Hello. I am twenty years old and unfortunately suffer from sexual dysfunction. Before seeing your blog on Good Vibration’s website I had no idea this was an issue with other woman. I was wondering if you knew where I can find help, any kind of help with this issue. I didn’t know there were people who studied this or that I could talk to. So if you can, please help me out. Thank you so much.

…it is really pretty common for young women to have sexual issues that might be called “dysfunctions.” Keep in mind that it is only a dysfunction if you are unhappy about it. If you have low libido, or have a hard time getting aroused, and you don’t have or want much sex and don’t feel troubled by this, it is simply the way you are, not a dysfunction. If, however, you are concerned about it, then that language might be appropriate.

…In short, unless you have really gone on a hunt to get good information, the schools and the culture have not made sure you learned enough about sex to have *good* sex. And this does not make YOU dysfunctional — if anything, it means our society is dysfunctional!

…So far I haven’t really said anything about sexual dysfunction itself; I’ll do that now. It’s possible that in spite of what I said above, you *do* have some sort of sexual dysfunction, but it’s likely that it is something that can be helped via knowledge. It’s not as likely that you need some sort of medication, which is good, because so far, the pharmacological remedies available to women to help us with our sexual problems are, at best, untested and insufficiently understood.

Emphasis mine. What’s this? Dissent among the ranks! Here, Queen explicitly recognizes that every once in awhile, sexual dysfunction is a valid and proper terminology. Unfortunately even when it is, there still aren’t a lot of medical options available for many sexual dysfunctions. Knowledge helps, but it only takes me so far. You may recognize Dr. Queen as a prolific author and editor of sexuality anthologies and she’s a sex-positive Ph. D., sexologist and activist – so like Dr. Klein, she has seen plenty of shit go down in the realms of sexuality and politics.

So these two sex therapists who are open to recognizing sexual dysfunction and treatments for it, aren’t at all fly-by-night therapists, or in the pockets of Big Pharma. These two have been around long enough to have seen the positive and negative effects of sexual medicine.

Humm… I guess that if you’re seeing a sex therapist for sexual dysfunction, how you’re treated, what language you’re allowed to use to describe your experience, how you’re allowed to identify and what options are made available to you are going to depend on who you’re talking to. I guess that’s why it’s so important to find a sex therapist who’s right for you if you choose to go that route.

Of course, I speak only for myself here. I’m comfortable with the term sexual dysfunction, but not every other woman with a sex problem is, (especially since not every little problem is the same thing as a dysfunction) and probably very few folks will embrace it, perhaps for some of the reasons enumerated by experts on the social construction model of sexual problems. Remember though, I do not claim to be an expert on the topic by any means; don’t have a Ph.D. or a journalist resume to flaunt (yet); I just blog so I don’t know everything. But I’ve come to terms with it – I’ve come to terms with the term. I’m starting to think that this binary vs. mode between the medical model and social construction is creating some messed up language on both sides.

Guest post: GUILT, FAILURE AND A PRE-ORGASMIC FEMINIST

10/17/2010 at 1:30 pm | Posted in Uncategorized | 13 Comments
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[Dear internet, we have a guest poster today! This is a post by pro-BDSM activist Clarisse Thorn, who blogs at Pro-Sex Outreach, Open-Minded Feminism.]

I’ve been working on a long article about my experiences with sexual dysfunction. It’s a project that’s been in the making for quite a while, but now that I don’t have so many distractions I’m ramping it up.

This is a complicated and difficult subject for me. I have a satisfying sex life now — I’ve gotten pretty good at communicating with partners, setting boundaries, seeking what I want, and masturbating to orgasm. It took me a long, long time to get here, though, and I had to get through a ton of confused feelings. Not just about coming into my S&M identity, though that was certainly a factor, but also dealing with feelings around the orgasmic dysfunction itself — for example, feelings about how my apparent inability to have orgasms meant that I was broken. (I had and still have some vaginal pain, too. Not every time, not even most times, and nothing overwhelming — but enough that I’ve developed coping mechanisms.)

In order to write this article, I’ve been going through a lot of years-old journal entries. One quotation particularly struck me:

[My boyfriend] comforted me the other night when I broke down and cried. I wept and wept and he said it was okay, you’re not broken, there’s nothing wrong with you. It’s okay, he said, not to want sex. But I do want sex, I’m just sickened and terrified and disgusted by it, and I don’t want to be anymore. I want to be able to watch sex scenes and not be enraged and disgusted, to read sensitive ones and not collapse in tears.

I wasn’t entirely sickened and terrified and disgusted by sex, of course: I often liked it. Loved it, really. Sex usually felt good even before I could have orgasms, even before I’d found S&M, even before I’d parsed out my feelings and learned more about sexual media such as porn. And I’ve talked a lot about how awesome and sex-positive my sex education was.

But I knew I was missing something, something crucial and integral to my sexuality. And I hated the way society seemed to always be informing me how to sexually act: I felt crushed into approaches that obviously weren’t working, weren’t meant for someone like me. It was hard to walk the line between craving sex and being unable to stand it.

Here’s another excerpt from my journal, around the same time:

I really hate reading explicit sex scenes. I didn’t used to hate it as much as I do now, and since I broke down in tears during the last one, I guess it’s pretty obvious why. Jealousy and hurt and hatred of the ideals I feel like they’re trying to forge into me, [one ideal being] that love and sex and particularly orgasm are all irrevocably intertwined, and that by missing out on orgasm I’m missing out on not only an aspect of sex but of love.

But mostly I guess the discomfort does come from not wanting to read the intimate details of another’s sex life … and the jealousy for the orgasm, still there, too deep to banish. Christ, it’s fucking ridiculous. I shouldn’t be this miserable about this. It’s so fucking unimportant in the grand scheme of things. — but the tears that startled me in my eyes as I typed tell me just how unimportant it really is to me, I guess.

I started reading some sort of book on having orgasms and wept all through the first chapter because it was so miserably true. And because it was so miserably true I feel as though I ought to read the rest of the book, just give it a chance and go with it, and maybe make it that way, but it hurt so much and I’m so scared that it won’t work, and then I’ll be really unhappy. (A reaction the book even outlined, by the way. Yes, it’s about as true as it gets — the only thing I’ve ever found seems to understand how I really feel about this.)

The book that struck me so much is the monumental For Yourself, by Lonnie Barbach. It’s a famous book. I searched it out at the San Francisco library recently, and spent an afternoon sitting around the Mission branch, trying to locate the passages that once touched me so much. A few quotations:

Do you sometimes feel that you would be happier if sex were eliminated from your intimate relationships altogether? If so, possibly you feel abnormal in this regard, or like a misfit or not whole as a woman. Or, perhaps you just feel that you are missing something everyone else has enjoyed, a part of life that you’d like to have be a part of yours, too. You probably feel as if you are one of only a few women who have this problem. But the truth is that you are far from alone. (page xiii)

A real fear that can keep some women from doing anything to solve their sexual problems is the fear of failure. When Harriet joined the group, she didn’t believe she could become orgasmic. She said, “If I tried, I’d only fail, and then I’d be really miserable.” … Harriet eventually did defy her fears, as did all the other women mentioned. It takes time and effort to counteract these fears. It means saying “I’m afraid” and yet pushing beyond. (page 14)

Is it because you’re embarrassed to ask for what you want at a particular time; afraid your partner will refuse, get angry, or feel emasculated? (page 15)

Empathetic and accurate so far. (As it happens, the only lover I ever directly asked for help during this orgasm-discovery process refused and got angry, which just goes to show that being afraid he might react that way was not all in my head.) Merely confronting so much understanding was hard to face.

But, although I read it a long time ago, I think I’ve figured out what it was that made me unable to read further: the way Chapter 1 ends is a bit much. The last page of For Yourself‘s first chapter contains this:

You have to assume responsibility and be somewhat assertive. Our culture has taught us that a woman should depend on a man to take care of her, which means she can blame him for any mistakes. It’s nice to be driven around in a car, but it’s also nice to be able to drive yourself so you can go where you want to, when you want to. But to do that, you’d have to assume some responsibility.

Well, okay. Except that how do you assume responsibility for something if you have no idea where to even begin? If you know something’s missing but you’re not sure what it is? If you’re sure your partner will be frustrated and resentful when you ask for help?

This is especially complicated by the fact that along with the typical advice of “Take responsibility!”, the other typical advice is “Let go of control!” Over at Lady Sex Q&A, Heather Corinna writes:

Orgasm involves us surrendering to what we’re feeling, and really rolling with it, even if and when it feels very emotionally precarious. It’s control we’re letting go of, really, and that’s harder for some folks than others.

I’ve been an off-and-on sex & gender geek throughout my life, so I already knew these things intellectually. I’d already absorbed these ideas: that I must both take responsibility for my sexuality, and lose control in order to enjoy it. I think even then I knew that both of these ideas are actually good advice. But the problem is that they’re often put in patronizing and less-than-helpful ways. For example, “It’s nice to be driven around in a car, but it’s also nice to be able to drive yourself so you can go where you want to, when you want to. But to do that, you’d have to assume some responsibility.” Condescending as hell! To me, those words implied that I was making myself into a helpless child. Pulling a wounded-bird act and forcing other people to take care of me. I couldn’t stand the idea that I was doing that!

I am frustrated by the insensitive guilt trips that often happen, even (especially?) in feminist and sex-positive circles, where people will sometimes act as if these things are simple, as if it is oh-so-easy to stand up and take on one’s own sexuality and Just Deal With It. Especially when you’re in a situation where you know for a fact that some men you have sex with will resent you if you’re honest about not having orgasms, and yet you don’t know how to have orgasms and aren’t sure how to start on the journey. What then?

Some women end up faking in those contexts (I didn’t very often, back in the day, but once or twice I did). Of course, some feminists and sex-positive writers are especially unhappy about this:

I’m sure I’ll offend some choice feminist who thinks that it’s unfair to criticize women who make the totally autonomous choice to flatter a man with a fake orgasm instead of working towards a real one, but I’m taking a stand on this one. It’s un-feminist to fake, ladies!

I don’t advocate faking orgasms, and I actually also don’t advocate dating a man who gets angry and resentful when a female partner asks him to pitch in. (Oh my God, sometimes I have nightmares that I’m back in that relationship, and it’s been years.) At the same time, the idea that screaming “It’s un-feminist to fake!” will fix the problem is ridiculous. It’s the kind of idea that will just make feminists (like, say, myself many years ago) feel even worse about trying to figure out our relationships while not having orgasms. I see, so now not only am I failing to be responsible, I’m also un-feminist? Awesome.

This is not easy. It’s actually really hard. I get that people have to want to work on their sexuality, in order to do it — obviously I get that. But telling people that they’re being weak or self-centered or un-feminist because they aren’t sure how to do it? Or are actively pressured out of it?

Not okay.

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