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
Tags: , , , , , , , , , , ,

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

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

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

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

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

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

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

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

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

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

I think the war on women goes something like this:

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

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

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

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

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

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

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

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

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

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

The almighty glass of wine

02/07/2012 at 12:28 am | Posted in Uncategorized | 9 Comments
Tags: , , , , , , , , , , ,

How many readers here have heard a variation of the following statements, with regards to their sex lives?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I hate booze.

I hate all booze everywhere.

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

Hate all the booze!

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

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

hate all the booze?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Good!

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

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

Questions about Vulvanomics

11/17/2011 at 11:45 pm | Posted in Uncategorized | 2 Comments
Tags: , , , , ,

This Friday, the New View Campaign will be protesting cosmetic genital surgery clinics and clinics that perform procedures like laser vaginal rejuvenation. In case you’re new here, the New View Campaign is a feminist grassroots organization developed over a decade ago by Dr. Leonore Tiefer, a sexologist and college professor (among other things.) The group’s goals are to present a form of feminist resistance against female sexual dysfunction (their view is largely recognized as THE feminist answer to FSD,) and pharmacological treatments for the conditions that fall under its umbrella; to eradicate cosmetic genital surgeries (or at the very least, to force more research on procesures,) and offer some alternative, non-medical interventions to improve women’s sex lives. The last item means taking a social construction approach to sexuality, a cerebral topic which constitutes another series of blog posts. (Check my archives, I’ve talked about the New View and social construction before.)

This nationwide protest is visible activism as part of their recent Vulvanomics media blitz. The clinics in question have not been publicly named to my knowledge – the group communicates on a listserv instead. I haven’t joined it, due to a clause on the New View website that states joining the listserv means you endorse the group’s philosophy & actions. The New View Campaign does not represent my views and does not speak for me.

It is not the first time the group has publicly protested against vulvar modification. The intentions are good – draw attention to unnecessary asthetic procedures, which target women, are expensive and carry health risks. In spite of this, I wasn’t comfortable with it the first time around. And I remain uneasy, because I fear that their activism has the potetial for some unintended negative consequences.

Full disclosure: I may be a bit biased, seeing as I’m someone who actually knows what it’s like to undergo genital surgery, and as someone who actually has FSD.

As the campaign gets underway, I want to contribute to the hard conversation by raising a few questions about this planned event.

- I understand vulvar and general cosmetic surgeries to be a symptom of a larger problem – body snarking & policing, fatphobia, misogyny and racism – rather than THE problem. Take away cosmetic surgeries, and there will still be these underlying problems remaining. An example of this would be Austrailia’s practice of censoring naturally large labia in softcore pornography.
What steps is this current campaign taking to address the systemic, more intangible problems that may motivate permanent surgical changes in the first place?

- One goal of this round of activism is to get the FDA to monitor cosmetic and laser surgeries and require more rigorous research, to be made available to end users (clients.) That way, women can do better research and make informed decisions about what they do with their bodies.
However, I doubt this type of activism will end there. I got a feeling I can answer my own question above: Even if the New View gets exactly what it wants – which would be beneficial to women – the anti-surgery and anti-medicine activism is likely to move on to new targets. Perhaps then the New View will shift its focus to censorship vs. idealized & unrealistic body representations in pornography, etc. All of which is certainly eligible for a social construction critique.
However, since these systemic problems will still remain, and are likely to be the next area for activism, that means even if you read the material and wanted to go through with surgery, you’ll probably still have your decision questioned. It will never stop and there is no way to do a cosmetic surgery correctly, so you’re just going to have to deal with the stigma and shame of doing it wrong anyway.
So, the question is – are there any conditions in which it is socially acceptable for a woman to undergo cosmetic or sexual surgery on the genitals? If so, what are these conditons?

- One approach to address women’s insecurity about the appearance is to embrace vulvar diversity. But what do we mean by vulva diversity? In galleries of what normal vulvas look like, how often do we see vulvas with visible (if subtle) health problems? Does vulva diversity, a celebration of the wide range of normal, include vulvas like mine which, pretty much everyone including Dr. Tiefer, agrees, is in fact not normal? (Remember, when vulvodynia acts up, a lot of gentle and sexual touches will register to the vulva owner as pain.) And does the movement to celebrate vulvar and body diversify embrace those women who have already undergone modification?

- I notice that this campaign refers to cosmetic genital surgeries as FGCS – it’s not explicitly defined on the petition but I’m pretty sure the acronym translates to “Female genital cutting surgery,” with the intent of invoking FGC, aka FGM – female genital mutilation.
Recall that the film Orgasm, Inc. did not hesitate to use the term FGM, even though it carries a degree of stigma – the implication is that, if you’ve undergone FGM, then you are a mutilated mutant. FGC is more sensitive term.
But how does the New View respond to critics who claim there is a difference between FGC and vulvar cosmetic surgeries? Some critics here, for example, claim there is a difference between damaging girls’ genitals against their will & without their consent, vs. trained surgeons operating on women who seek such procedures out.

- During a recent Feministe shitstorm, (not actually that recent in blog-time but still to soon for me,) (Google “Feministe ‘don’t do this’ just because I’d prefer to avoid trackback trolls for awhile longer,) several commenters deflected questions about medically necessary genital surgeries. The idea seems to be that medically necessary procedures are exempt from critique. That’s different – and I still don’t understand why.
- So how are we defining medically necessary vs. purely asthetic? What criteria is necessary to justify a surgical procedure to a vulva? How do we quantify the amount of discomfort and danger required? How shall we address the intersection of medical, sexual and cosmetic concerns, for example in reconstructive surgery? To that end, were the current surgical facilities subject to the protest screened to ensure that medical patients will not receive unwanted attention?

- Relatedly, some of the New View’s criticisms, and general feminist critique, of cosmetic surgeries include the fact that surgeries hurt, come with health risks, and cost a lot of money. Genital surgeries carry sexual health risks in particular, and the price tag can reach thousands of dollars – just like my medical surgery, which my insurance dicked around about & didn’t reimburse what they were supposed to.
But these concerns – pain, side effects, and cost – are present with medical surgeries as well. So, again, why are medical surgeries, which carry the same risks, not subject to the same critique? (Basically, if cosmetic surgeries are bad because x, y, and z… and I did a surgery that also involved the same x, y, and z… then what makes my situation any more forgivable? Intent? I thought the intent doesn’t matter.)

- During the same recent Feministe shitstorm, I saw a commenter raise concerns about the impact that anti-cosmetic surgery sentiment and activism might have on trans* individuals. Some transsexual women and men undergo top and/or bottom surgery.
Has the New View taken any steps to clarify the difference between GRS and cosmetic surgery? (Of course I suppose transphobes will look for any excuse to be transphobic – and if that means invoking the spectre of cosmetic surgery with all it’s negative implications, – then we’re gonna need a lot more activism to get that to stop.)

In fairness, most of the problematic comments about cosmetic surgery, including genital surgery, is derived from the New View’s work, rather than explicitly stated by representatives of the group. I’ve noticed that in her writing, Dr. Tiefer by and large is very thoughtful about what she puts in print. In contrast on the Feministe post I’m referring to, Jill & co addressed cosmeric surgery as largely an individual provlem, imploring indivduals not to go through with it. Buried in the comments, there was some effort made to address social problems contributing to the spread of this type of surgery… But I had to wade through a whole lot of crap to find it, to the point where I found the thread exhausting. I give up; you win; I disengaged.

The New View has been around for over a decade, stirring up uncomfortable but necessary conversations – and that, in and of itself, isn’t necessarily a bad thing. But its still largely the same organization it was ten years ago, and it really should take some time to examine & reevaluate some areas for improvement, especially with regard to its internalized ableism re: FSD and mental illness.

So, I just hope that on Friday, I don’t run into a protest group outside of an outpatient cosmetic surgery facility just like the one where my medical surgery took place. As much as I’d like to be a punk and counter-protest, (I’d be the one holding the sign that says, “New View doesn’t speak for me / Ask me about my surgically altered vagina”) I know myself well enough to recognize that a group of women protesting vulvar surgeries – by using props of tools like the ones used on me – will probably just set off a massive anxiety attack.

Feminists with FSD does Orgasm, Inc.

10/12/2011 at 10:51 pm | Posted in Uncategorized | 5 Comments
Tags: , , , , , , , , , , , , , ,

It’s the post you’ve all been waiting for and the one I’ve procrastinated on for far too long.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Orgasm, Inc. final thoughts:

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

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

Doctors debate dyspareunia part 4: The debate continues

09/19/2011 at 10:51 pm | Posted in Uncategorized | 3 Comments
Tags: , , , , , , , , , , , , , , , , ,

“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
Tags: , , , , , , , , , , , , , , , ,

[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
Tags: , , , , , , , , , , , , , , , ,

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…

Conceptualizing the FSD hierarchy

01/12/2011 at 12:04 am | Posted in Uncategorized | 8 Comments
Tags: , , , , , , , , , ,

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.

Compare and contrast

12/02/2010 at 9:16 pm | Posted in Uncategorized | Leave a comment
Tags: , , , , , , , , , , , , , , ,

My last post presented a review and critique of the feminist sexology text, A New View of Women’s Sexual Problems. It’s a different kind of review. The book was inspired by the efforts of the Working Group on the New View of Women’s Sexual Problems, a group of about a dozen North American women who came together to present an alternative view of sexual problems and dysfunctions, just in time for a  medical conference held about 10 years ago. A New View of Women’s Sexual Problems, the book, builds upon the original New View manifesto.

Today I’d like to present to you a different kind of feminist response to sexual dysfunction – a response from another woman who is intimately familiar with gender studies, feminism… and vaginismus.

As I noted in the New View book review post, I felt like some elements were missing from the essays – notably, it remains unclear to me whether any of the contributors to the original manifesto or the book actually know what it’s like to live with sexual dysfunction – to be torn between what you “Know” is the “right and proper” feminist response to sexual dysfunction vs. the daily grind of living with and responding to it, sometimes just managing. It’s possible that one or more of the contributors did have some kind of sexual dysfunction, and just didn’t disclose such status for whatever reason. But since I can’t know for sure, I still feel like I’m left on the outside of a circle of folks who are not me, yet who nonetheless decide my fate for me.

Alas, my time available for blogging is shrinking, and will continue to do so until some time in January! So instead of presenting another dissertation-length blog post, I’m just going show you an essay today and give some reasons as to why I liked it.

The essay is, A certain remoteness telling vaginismus, by Fulvia Dunham. I thoroughly enjoyed this essay. If you usually like what you see here on this blog, then I would strongly recommend that you read it. It’s one essay in the anthology Illness in the Academy, published by Purdue University (whom I would like to thank, along with Google Books, for making A certain remoteness in its entirety available to me as of today. I did have difficulty viewing it on my mobile device, however, and I am not certain if Google Books format can be picked up by all screen readers. Keep in mind, allocate your page previews carefully if you want to read the essay in full online.) According to Amazon, Illness in the Academy:

investigates the deep-seated, widespread belief among academics and medical professionals that lived experiences outside the workplace should not be sacrificed to the ideal of objectivity those academic and medical professions so highly value. The 47 selections in this collection illuminate how academics bring their intellectual and creative tools, skills, and perspectives to bear on experiences of illness. The selections cross genres as well as bridge disciplines and cultures.

Other essays in the book talk about life with chronic illnesses, conditions, and disabilities – to mention a few, some contributors have or are close to someone with diabetes, endometriosis, depression, autism, cancer.

And yet vaginismus – a sexual problem, a sexual dysfunction, a variation of normal, a medical condition, a gynecological disorder, a disability, a symptom of a relationship problem – what is it really? – is included right alongside these more readily-recognized health conditions – though certainly the conditions included have varying degrees of public awareness and social acceptance. The editor of the anthology, Dr. Kimberly R. Myers, did not excise the essay on vaginismus as too titillating due to its sexual nature or as irrelevant due to being a relationship problem. Here, it is unquestioningly given the same treatment as any other medical problem. Seeing vaginismus included in the same place as more readily recognized chronic conditions was a shock to me. And this book was published in 2007, so it’s ahead of the curve! I find myself asking if, because vaginismus was part of this collection, if that means there’s openness to the idea of looking at sexual dysfunction as disability even offline…

Clearly, there is a need to understand vaginismus as a matter of health:

Exchanges with family members were uncomfortable; people were usually tentative and shy, occasionally asking if I’d fixed “my little problem,” implying that it was a bad habit of aversion I had to correct rather than a problem or illness with which I needed help… I think the unspoken assumption in many of their minds was that if you can’t perform normally in sexual terms, you’re unfortunate – but not in need of a hand, as you would be if you had a recognizable illness (151).

All the emphases in the quotes are in the original.

The author of the essay in question talks about how she sought assistance from professionals trained in treating vaginismus, though she herself does not appear to be an expert herself – there’s no pH.D or M.D. or M.S.W. or other certification given next to her name. She’s a regular person, like me. Much of what Dunham writes about appears to have taken place while she herself was a student (which makes sense, given that the anthology is titled Illness in the Academy!)

What I like best about Dunham’s essay is that there’s no filter in A certain remoteness. Dunham was given the opportunity to speak in her own words. No one is presenting snippets of what she said in the greater context of some other theory. She’s just saying: What she did, what she went through, what she saw and heard, and what was on her mind when it happened.
I suppose right now, I’m creating a lens, an artificial filter, just by framing this post the way that I have chosen. But that’s what the link to the essay is for – you can see for yourself.
In contrast, in the New View book, short statements from women with sexual dysfunction were presented by professional women, as case studies in support of the New View manifesto. When someone says or does this, she really means that.

Because there’s no filter, there is a stream-of-consciousness, indicated by italics and bolds in the text, which weaves throughout A certain remoteness; usually flitting under a sea of text, always near the surface,… then *Boom!* it pops out for just an instant, and is gone… only to leap out again a few paragraphs later, a brief flash of uncensored turmoil over a carefully constructed treatsie.

But here and there we can catch a glimpse of it, Fulvia’s free stream-of-consciousness,  jumping out of the formal, the factual, and the philosophical:

and if your body is closed, if you can’t let anyone in, if you can’t talk about it easily because no one knows what you’re talking about, if you’re obligated to remain closeted because people often forget what you’ve told them, then you’re simply repressed – closed – out of the loop – out of circulation – unable to come out because you can’t let anyone in, because there’s no language with which to come out, and because nobody cares (149)

(As a side note, some of my unedited draft posts look like this before going live!)

Another interesting feature of Fulvia’s essay is the way she addresses language. In an eerie coincidence, frequent commenter Flora and sometimes contributor left a note here last night addressing how Dr. Tiefer in particular treats language – it’s a very important tool. It has power. Words mean things. But not everyone thinks that way, and to emphasize language over other modes of communication can create new, unique hurdles.
And sometimes, words have limits. Sometimes, language isn’t as powerful as it should be – because there are no words to express what you are really feeling:

Then they ask me about the man with whom I have parted ways two months before, after having been with him for two years. I say that things are fine; everything’s amicable enough, and he usually calls me every couple of weeks from Los Angeles. when he told me, it was new year’s eve, and then waking up in the middle of the night just after, him near me, trying to tell him that he was all over for me, that i’d never have intimacy with anyone now, because no one would have the patience, that this was the last dance, impossible, that he was relegating me to life among those who remain alone – trying to explain – the words were broken – that although i wasn’t sure i wanted children, i wanted the possibility I say that we’re exchanging emails and phone calls fairly often. and it would never be possible again and doomed and no access cut off a certain remoteness – his looking at his watch to see if it was midnight yet They have to catch me as I begin to fall backward off the chair. (153)

Dunham explicitly says, “The words were broken.” Fulvia was trying so hard to articulate everything she was feeling at the time of her breakup. But she just didn’t have the words available. How do you talk about vaginismus when you’re not even supposed to talk about vaginas, about pain, about sex? So you grope around looking for words, looking for something that comes close to expressing what’s on your mind in a way that another person can understand but the language that’s available doesn’t match what you want to say, so you wind up saying something that maybe has a totally different meaning. Maybe what really conveys the emotion is a scream, or a work of art, or a song, or something that does not yet exist.

Dunham herself may even be familiar with the New View’s work:

Given my later training in gender studies, it became tempting to try to believe that this wasn’t a “problem” or “dysfunction:” it was simply a “difference.” But given the imperative we receive in our culture to express ourselves as sexual beings, the messages we’re sent that suggest we’re incomplete, uptight, wound-up, or repressed if we can’t or don’t, it doesn’t feel like merely a difference; it feels like a defecit. It also doesn’t feel like just a difference when the desire is there, but the means of expression are not. It feels like an insurmountable obstacle. (151)

Being familiar with gender studies and possibly with the New View’s work in combating the medicalization of sex, Dunham struggles with questions about what that means for her, as someone living with vaginismus; as someone who needed and sought medical assistance to address it:

am I succumbing to compulsory heterosexuality, the heterosexual imperative, the pressure to become more valid through an ability to participate legibly in the sexual economy? Their sign says “No passing zone.” Rather than seeking to overcome this, perhaps I should use this with which I have been fated to disrupt the usual equation between “intimacy” and “penetration.” Should I question the usual assumptions about what constitutes sexual success and fulfillment? – challenge the commonplace equation between sexual fulfillment and fulfillment? (154)

She knows. She knows she knows. You know? Dunham is familiar with gender studies and feminism. She’s heard it all before. The critiques of sexual dysfunction from a social construction perspective are there. But she also knows that there’s something more going on… something that even feminist-informed social construction sometimes cannot breach:

Is it wrong to want my vagina to open? (154).

This simple question. This one, simple question… is the same one I find myself asking after reading through books like Sex is Not a Natural Act and A New View of Women’s Sexual Problems. Am I doing something wrong? Am I now obligated to expand my sexual horizons rather than having that available as an option? Is it okay for me to get medical help for vulvodynia & vaginismus, and whatever else I may encounter in the future? In so doing, am I medicalizing sex and making it harder for TAB women to enjoy sex as they are? Or do I have the one and only free pass to sexual medicine, because dyspaerunia is the only valid and important sexual dysfunction? But if that’s the only valid sexual dysfunction, then what about my friends? Dunham seems to understand what it feels like, to be stuck in the middle.

And open her vagina did. Dunham continued to seek help addressing her vaginismus, and eventually, after 15 years, she did find satisfactory resolution through physical therapy in Montreal, Canada. She no longer needs to talk about vaginsmus – “Perhaps I am at the point where I can – and even should – put all this to rest” (154). But Dunham still remembers the whole experience, vividly – and much like Susanna Kaysen, it has left her sexual identity fundamentally changed… Dunham, in the end, came out of the experience, as Q for Questioning, or possibly even Q for Queer, inspired by a definition proposed by Eve Sedgwick. Dunham now has the option to engage in heterosexual PIV intercourse, if she so chooses… will she so choose? Even if she does not exercise this option, Dunham does not express resentment towards the doctors who helped her reach this point; she has nothing but gratitude towards them. I suppose the social system of medicine available in Canada helps – in the USA, she may have faced a different set of challenges with the cost treatment and insurance.

There’s a lot more to the essay I didn’t address here; I just picked a few parts that resonated with me. Reading A certain remoteness alongside A New View presented a refreshing contrast, and I would like to see more essays and creative works like it.

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

11/16/2010 at 10:14 pm | Posted in Uncategorized | 5 Comments
Tags: , , , , , , , , , , , , , , ,

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.

Next Page »

Blog at WordPress.com. | The Pool Theme.
Entries and comments feeds.

Follow

Get every new post delivered to your Inbox.

Join 30 other followers