Doctors debate dyspareunia part 4: The debate continues

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Facepalm Carl Pictures, Images and Photos

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Happy 3rd birthday, Feminists with FSD

09/07/2011 at 6:19 pm | Posted in Uncategorized | 6 Comments
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Today marks the 3rd anniversary of this blog. Three years on the internet, blogging about first-person perspectives of sexual dysfunction and feminism – that’s a long time to blog!

I think this calls for some small celebration and a few more pictures on this mostly-text operation. (We especially need some filler right now because I am still working on part 4 Ina blog post series about doctor’s views of sexual pain.) We already have pictures of cupcakes and unicorns here, but there is one very special type of unicorn I neglected to include during my little April Fool’s prank:

[Description: Unicorn pony Rarity leaning into also-unicorn pony Twilight Sparkle. From the MLP:FIM wiki. You can’t actually see Rarity’s horn in this picture, but it’s there.]

Yes that’s right: It’s a Pony post! Deal with it. This blog needs about 20% more Ponies in order to be cool. (Don’t tell me you didn’t see it coming.) Now let’s get this pony stuff out of our systems pronto.


See more on Know Your Meme

[Description: Animated .gif of Twilight Sparkle jumping mid-air and black glasses landing on her face. She talks and text appears saying, “Deal with it.”]

As is tradition, let’s take a break from usual serious posting to do some retrospective navel-gazing. (See the first-year anniversary here and last year’s post here.)

2011 has been a quieter year for Feminists with FSD than in previous years, because I didn’t write anything during the summer. We lost some time we could have spent blogging. On the other hand, taking time off gave me a chance to recharge and shed some burnout. I may have to do that again next year.

But even with that break, things are likely to remain quieter around here than they have been in the past – you may have noticed the lack of weekly blog link roundups. My excuse for this is that I still work full-time in a completely unrelated field and receive zero compensation for putting anything up on this blog. I cannot offer compensation to guest posters, because I have nothing to give. And since my commute got a lot worse this year than it has been in the past, I don’t have as much time to blog as I used to. But I keep trying to chug along and plug along as much as I can.

There’s still a lot of stuff left to talk about with regards to the intersection of feminism & female sexual dysfunction. I’ve addressed only a few of the outstanding issues I brought up in last year’s anniversary post. Your undying patience with my snail’s pace at getting new content posted is appreciated.

On the other hand, there are new topics posted now that I hadn’t thought of last year – such as our still-continuing series on how doctors think sexual pain should be addressed – as a pain problem, or as a sex problem? Hmm. So much work left to do… and it needs to be done.

I am 100% confident that there is still a need to present these first-person perspectives on feminism & sexual dysfunction. I’m still finding posts online and in articles written by people who present themselves as experts on sexuality – yet articles about sexual dysfunction still fail to speak for me, or even, to me. So many articles by folks who have never experienced sexual dysfunction firsthand, yet claim to know more about it than I and my friends do. The authors don’t talk to me as an equal deserving of respect and with a mind of my own, capable of making thoughtful decisions on what to do about my health and sex life. Instead, what I’m seeing as someone who actually has sexual dysfunction, is condescension and stereotypes presented as helpful “Advice.”

I don’t know about the rest of you, but most of the advice offered in these contemporary articles about and critical of sexual dysfunction do not address my problems. Instead, the advice presented just adds bullshit onto my growing pile of crap I gotta deal with – and makes it harder for me to slog along way to a satisfactory resolution. I’m thinking to myself right now, Oh look, another so-called “Sexpert” just implied that anyone who even considers using medication to manage a sex problem must be a pill-popping shill incapable of critical thought re: the pharmaceutical industry and potential side effects. What do these journalists think we do? I think they think we all go to a big city with fistfulls of cash and bang on the door of the first corporation we can find, saying, “BIG PHARMA TAKE MY MONEEEEY!!!”

[Description: Stylized unicorn with a gold tiara and rainbow wavy hair Princess Celestia shrugging with this look on her face: >:/]

I think to myself, And look over there, another journalist just explicitly stated that women who don’t have orgasms are holding themselves back because of peer pressure brainwashing by the patriarchy. I can’t believe this is still a thing.

Remember, I am not an Agony Aunt. Most of the time I hate giving out advice, because I can never have a complete story of what’s going on in your life, what you’ve already tried, where you want to be in the future, etc. I don’t want to be the one to give you the wrong advice that winds up causing more problems in the end.
And please, for the love of god, no one ever refer to me as a “Sexpert.”

I will proceed to make one exception to my general guideline about not giving advice though. Here’s something that the sexual dysfunction writers to which I am referring need to know:

Protip: if you yourself do not know what daily life with sexual dysfunction is like, yet you still want to write about female sexual dysfunction, maybe find some women who actually have sexual dysfunction ask for their opinions and experiences first. Having trouble finding women who identify as having sexual dysfunction and who are willing to open up to you about it? Then maybe you should read the archives on this blog for examples of why it’s risky to come out as having a sexual dysfunction in the first place. There is still tremendous stigma attached to it as a diagnosis, whether you’ve got a low libido, pain, or any other seriously distressing sexual problem. Is your blog post or magazine excerpt going to be yet another one of these problematic articles?

So instead of copying the way I see most articles about sexual dysfunction, here’s what I prefer to think when I write stuff for this blog. I start off from these general points of view to serve as guidelines:

People with sexual dysfunction are smart.
People with sexual dysfunctions are capable of making rational decisions about what to do about their health and sex lives.
People with sexual dysfunction have probably already sought advice, are currently seeking advice, or will seek advice in the future. That means that whatever advice you as an individual have for someone with a sex problem, it probably isn’t that new or revolutionary. Whoever you’re writing for has probably seen some iteration of your advice, or will see it again in the future. So that’s why I like to take things in a different direction here – I like to show off stuff that I haven’t seen before, or stuff that I’ve only rarely seen.

It’s a different starting point from how I usually see sexual dysfunction patients handled. Most articles and essays about sexual dysfunction start off from a position where the patients are ignorant, gullible and easily manipulated.

Hmm… No, sir, I don’t like it.

What th— wait a minute! This was supposed to be a pony post! Who let Mr. Horse in here?! Get out of here, Mr. Horse. You’re from a different show.

[Description: Mr. Horse from the Ren & Stimpy show standing on two legs and wearing a gentlemen’s coat and tie. Standing in front of an abstract yellow & gray background with a sour look on his expressive face.]

A problem holding me back is that since I am not an Agony Aunt, Sexpert, Ph.D., M.D., M.S.W., or anything other than an ordinary lady with an extraordinary crotch, I still lack something critically important: Credibility. Who is going to listen to a young lady’s views of sex and feminism when she herself has not actually even had any penis-in-vagina activity in over two years, despite being in a long-term heterosexual relationship? Who is going to take seriously a critique of peer-reviewed journal articles, as written by someone with no relevant academic credentials? What publisher would ever take an essay about sex by someone like me seriously? There’s no two-or-three letter acronym before or after my real name, other than the generic “MS.” So although This blog has a decent number of readers – as many as some college classes – I remain painfully insecure about my own perceived illegitimacy. I feel like it doesn’t matter how much research I do or if I do a good job of pointing out flaws in the way people present sexual dysfunction; without something to make me look like I’m important, no one will ever listen.

And that makes me sad.

[Description: Light purple winged unicorn Princess Luna crouching on the ground. She is looking up at something off-screen.]

I suppose the solution to this dilemma is to go back to school to get a two-or-three letter acronym to put in front of or behind my name. Except I already have a Bachelor’s degree in another field, and school costs money. Money and time, which I am also short on. It is a conundrum… Plus, in principle, you shouldn’t need to have professionally recognized credentials in order to talk about what’s going on in your life.

So for some reason I keep on blogging anyway. It’s one of those things where you do it because you have to do it. Not that I’m being compelled by any outside force; just something inside pushing for more. So more comes out – and hopefully, will continue to pour out for the foreseeable future.

Thanks for reading, we shall return to our regularly scheduled non-pony blogging shortly.


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