Archives of Sexual Behavior, Vol 39, issue 2, April 2010

371 Pages·1978·3.72 MB·English

by  Kenneth J. Zucker (ed.)

ArchSexBehav(2010)39:213–215
DOI10.1007/s10508-009-9549-8
LETTER TO THE EDITOR
(Self-)Abusive Prophecies, Rigorous Science, and Discursive
Templates: Commentary on Malo´n (2009)
DiederikF.Janssen
Publishedonline:26September2009
(cid:1)SpringerScience+BusinessMedia,LLC2009
In his article entitled ‘‘Onanism and Child Sexual Abuse,’’ outside a dialectic model of controversy.1 An insistence on
Malo´n (2009) proposes a comparative-historical and con- ‘‘objectivity[…]precision,rigorandcoherence,’’accordingly,
structivistreadingoftwoetiologicalplots,withaprospectof may bemistaking thenatureofthebeast. Whatseemsto be
identifyingthelatterintermsofscientific‘‘fallacy,’’theoreti- needed is a sociology of science, not a scientific sociology.
cal‘‘hegemony’’and‘‘incoherence,’’‘‘invasive’’propertiesof Deconstructive and critical approaches to psychopathology
hypotheses,andthereignof‘‘apocalyptic,’’‘‘hysterical,’’and (e.g.,Parker,2002;Parker,Georgaca,Harper,McLaughlin,&
‘‘irrational’’views.Malo´n’skeyobjectionisthatthehistori- Stowell-Smith, 1995) ideally reach beyond an insistence on
caltrajectoriesofbothplotspartakein‘‘thesameerrorsand scientificrigor;indeed,thislineofinquiryseemsmostproduc-
excesses’’that,ultimately,informageneral‘‘Western’’contain- tiveifidentifying‘‘clinicalconsensus’’asaconstitutiveforce
ment of eroticism. Although contending that we are ‘‘com- withinspecificdiscursiveconstellations(feministresearchor
pletely immersed’’ in a ‘‘social hysteria,’’ Malo´n’s critique theforensicapparatus,forinstance)andasitrelatestoover-
worksinthedirectionofarevisionistetiologythatliberates archingtheoreticalprojections,suchas‘‘morality’’and‘‘cul-
sexualexperiencefromitstendentiousevaluation. ture.’’GenealogicalsimilaritybetweenOnanismandCSAas
Malo´n should be congratulated both for engaging in this historicaletiologies,assketchedbyMalo´n,maypertaintoa
latemodernquagmireandforhisfocusoninterpretativeprac- generaltemplateofbiomedicaldiscourseformation,butitdoes
tices.Interpretativepractices,Malo´n convincinglysuggests, notnecessarilypointtoacontinuityinsemanticfunction,thatis
constitutethecoresubstrateofbothOnanismandchildsexual tosay,indiscursiveinstrumentality.Ithinkthisisrelevant:ifa
abuse(CSA),requiringasituatingofbothnotionsinvarious critiqueofsexologicalconsensusistobetransformative,itmay
programmatic frameworks. Indeed, the fundamental conun- have to read the technologies of representation against the
drum of the age-intimacy nexus in Western psychological semanticcontingenciesthatpolicethedirectionofthedebate.
theories of trauma, from Freud’s seduction via Ferenczi’s Foucault(2003)atthispointhasfamouslyproposedanim-
confusion of tongues to Laplanche’s (Lacanian) enigmatic portantlyincompletetransitionfroma‘‘symbolicsofblood’’to
signifiers,iswhata‘‘sex’’actcanbesaidtosignify. an‘‘analyticsofsexuality,’’encodinga(correspondinglyincom-
Thereisreasontopause,however,whenfacingdeconstruc- plete)movementfrom‘‘fallengirls’’to‘‘abusesurvivors,’’from
tive approachesto science thatremain within the domain of ‘‘respectability’’to‘‘integrity,’’frommarriageandvirginitypol-
scientific ambition,includingMalo´n’s,Money’s, and Rind’s iticstoaspuriouslygenderlessvictimology.Intimacyviolations
(bothascitedbyMalo´n)amongothers.The‘‘condemnation’’ involvingclassificatoryminorshave,moreover,beenconstrued
of Rind’s meta-analytic work on the subject a decade ago, quitevariablyasacrimeagainstthebody,againsttheperson,
chronicled by Malo´n, warned that whereas CSA in the U.S. againstthefather,againstwiderfilialinterests,andagainstNat-
isimportantly‘‘aboutscience,’’itisatthesametimeplaced ure.Hence,tofocus,asMalo´n,onsexualityasanentitledexpe-
rientialrealm(world,area),withinwhichscienceblundersandas
invadedbyscience’ssymbolicarrogance,mayrequireadisre-
gardingofimportanthistoricaldiscontinuitiesinwhatsexacts
D.F.Janssen(&)
Berg&Dalseweg209/60,Nijmegen6522BK,TheNetherlands
e-mail:[email protected] 1 106Congress,1stSession,H.Con.Res.107(agreedJuly30,1999).
123
214 ArchSexBehav(2010)39:213–215
areallowedtosignify.Moreover,Malo´n’sappealtodiscursive clear to interpretative anthropologists: the mere ambition of
psychologyimpliesacommitmenttodiscourseas delimiting teasingapartacausativesexact,fromanoccasioningsignifi-
whatcancountasviableconsensus,andwhatasanapologist’s cation of it as consequential, may already underestimate the
‘‘cognitivedistortions.’’IfMalo´n’sperspectiveresonateswith constitutivefunctionofvalidation.Aclosereadingof‘‘CSA,’’
Foucault’s(2003)inidentifyingmodernsexualityasanexclu- inanycase,mayhavetoconcentrateontraumawhereandas
sionarygrammarofdomesticsociality,itdoessobecauseno itreallyoccurs(wemightventure:whereitsoccurrences are
‘‘sexual’’actcanmake‘‘proper’’senseoutsideofthisnormative investedwithnotionsofconsequentiality),ifitistoelucidate
projection(foranangrycritiqueofthis,seeEdelman,2004).But theagencyof‘‘faultedandfailing’’sciences.
thisobservationrequiressomethingelsethanadiagnosisofbad Toconclude,mayIsuggestMalo´n’shistoricalthesiscanbe
science;itrequiresananalysisofhowscienceisdeployed,ex- deliveredtoacomparativeanthropologicalapproachtosexol-
actlyhowitrelatesto‘‘public’’sentiment,andwhyhypotheses ogyasaninstanceofetiologicalpractice.Outsidethecircum-
shouldbedeployedthewaywefindthemsoubiquitouslyde- Atlantic world, we frequently encounter hypotheses contrary
ployed.‘‘Sexuality’’cannotberescuedfromtendentioussex- tooccidentaltraumatology,hypothesesthatprojectthesexact
ologyorfromthehistoricallyprogressivedomesticationofinti- asasinequanon,anecessaryantecedent,anaccelerator,ora
macies:itisco-extensivewiththese.Thismaywellevaporate secondarybenefactorofchildren’sdevelopment.Theideathat
muchofthecritiqueofanydiscourseas‘‘obviouslyextrinsicto ‘‘coituscausesmenarche’’hasbeenattestedprevalentatsome
achild’sexperiences.’’ pointinhistoryamongTrukese,OngeAndamanese,Australian
WhileMalo´n’scomparativeappraisalofhistoricalappear- Aborigines (e.g., Walbiri, Murgnin, Anbarra, Tiwi, possibly
ancesiskeytothedebate,whatMalo´nidentifiesasa‘‘forcibly Kukatja),NewGuineans(e.g.,NewIrelandersandDani),Lep-
orchestratedstrategy[…]adeliberateconfounding’’wouldas cha,Chewa,Tahitians,Indonesians(Adjehers,ToBada,Bauzi),
yetonlytentativelytranslatetoapoliticalmotifunderlyingall SandwichIslanders,Bororo´,Apinaye´,Kayapo,Ramkokamer-
sexualversatilities.Homosexuality,Onanism,andCSA,ithas kra,EasternandWesternTimbira,Wari’(PakaasNovas),Pau
beenproposed,allgravitateontothedomesticfamily—apre- d’Arco,Tepoztecans,Alkatcho(AlkatchoCarrier)(BritishCol-
cariousemotionalecologyandanincubatorofsocialviability— umbia),Kaska,Azande,KisanganiWagenia,Nyamwezi,Ye-
encodingasemanticcontractionthatrenderssexualitylegibleas menites, and was found prevalent in medieval to nineteenth
amoralfunctionandasaprivileged,specific,symbolicreper- centuryEuropeandinselectedancientmedicaltreatises.Fur-
toirethatforciblyimplicates‘‘thechild’’byexcludingit.2CSA, thermore, coitus was documented as considered to be a pre-
moreacutelythanOnanism,figuresinacontemporaryarticu- requisiteforbreastdevelopment(i.e.,asthelopoetic)amongthe
lation of that function and repertoire. Illustratively, since the TanzaniaParakuyo,Maasai,Trukese,Tiwi,andBororo´;some
1980s,anthropologicaldebatesaboutincest(betweenco-resi- Karuguassumedcoitustobesecondarilythelopoetic.Pubertal
dentkin)havebeenreformulatedbyfeministsasapsychiatry developmentwasbelievedtobenecessarilyprecededbysexual
of‘‘CSA’’(involvingminors),andthroughthisreformulation activityamongtheArapesh,Hopi,andIfaluk(NewCarolines),
feminist anthropology has sought to recalibrate the clinical asinmedievalEurope.Illustratively,mythologicalreferences
symptomatologyfeministsociologistssoughtto‘‘expose’’inthe to‘‘koitogenic’’menarchearefoundinThailand,India,New
late1970s.Whatthisimpliesisthat‘‘childhood,’’‘‘sexuality,’’ BritainandMexico,asamongtheMataco,Cubeo,andTukano.3
and political maturity are interlocking rhetorical vectors that Acriticalreadingoftheseconvergentassumptionswillun-
importantlyprecede‘‘sexualexperience,’’suchthattheremay doubtedly‘‘uncover’’abusiveexperiencesandoppressivesex-
hardlybe‘‘essentiallybenignorevenmeaningless’’experience ologies.Regardless,etiologyseemstobeanexerciseininscrip-
thatcanbesaidtoescapethesymbolicviolenceofsexological
consensus.Hereisperhapstoodeepan‘‘immersion’’(of‘‘child’’ 3 Unpublisheddata;citationlistavailablefromauthor.Researchsug-
in‘‘society’’)thancanbeundonebyarestorationofscientific gestthatCSAisindependentlyandnegativelyassociatedwithageof
honesty. menarcheinindustrialwesternsettings(Romans,Martin,Gendall,&
Herbison,2003;Vigil,Geary,&Byrd-Craven,2005;Zabin,Emerson,&
Whatis,inotherwords,impliedisthat‘‘CSA’’maywellbe
Rowland,2005).Itisgenerallyhypothesizedincurrentliteraturethat
acontestablediscursivetemplatebutperhapsmoreimportant-
CSAevents,ratherthantheinstitutionalandwidersocietalresponseto
lyitisanhistoricizeable,normativeproclamationcateringto them, is causing the stress associated with protracted development.
culturallyandhistoricallyspecificobjectives.Ifso(andMalo´n While Zabin et al. take into account household characteristics often
relatedtoCSA,theydonotextendthesetomoreoverarchingmachin-
agreeswithacultural-historicalreading),hypotheticalprojec-
eriesofsignificationthatincreasinglyprecedeandcontainCSAasan
tionsanswertotheculturalefficiencyofsuchaproclamation,
‘‘experience’’or‘‘exposure.’’Consequentlytheirhypothesisseemsto
nottofalsifiability.Malo´nsuggestswecandisentangleCSA’s standorfallwithdefiningCSAbyinterviewees’admittanceto‘‘being
websofsignificance—analluringoptimism.Butthismuchis sexuallytouched’’beforemenarcheby‘‘anyoneolder.’’Reports(Ed-
gardh,2000;Vigiletal.,2005)suggestthatCSAiscorrelatedwithmen-
archeage,coitaldebutage,andreproductivedebutage,butunsurpris-
2 Foucaultspeaksofepistemophilicincestthatwould,infact,beconsti- inglynostudysucceedsinteasingapartabuse,stress,andsexualexpe-
tutiveofthenuclearfamily. rienceperse.
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ArchSexBehav(2010)39:213–215 215
tion,notindeduction.Inthissense,itcannotproductivelybe Edgardh,K.(2000).Sexualbehaviorandearlycoitarcheinanationalsam-
criticized as failing empirical standards. Studies that coura- pleof17yearoldSwedishgirls.SexuallyTransmittedInfections,76,
98–102.
geouslytrytodefamiliarizetheobvious,suchasMalo´n’s,align
Foucault, M. (2003). Abnormal: Lectures at the Colle`ge de France,
with the classical anthropological stance; yet, anthropology, 1974–1975.NewYork:Picador.
ashistory,hasproveditselfanarchiveforopportuneandpro- Geertz,C.(1983).Localknowledge:Furtheressaysininterpretivean-
grammaticreadings(feminism,gayandlesbianpolitics,family thropology.NewYork:BasicBooks.
Malo´n,A.(2009).Onanismandchildsexualabuse:Acomparativestudy
values), and has otherwise remained peculiarly silent on the
of two hypotheses. Archives of Sexual Behavior, doi:10.1007/
issue.Otherthangenderequityorsexualrightsdiscourses,the s10508-008-9465-3.
CSAthesisseemstowarrantagenuinelyradicalcritiqueofsex- Parker,I.(2002).Criticaldiscursivepsychology.London:Palgrave.
uality/sexologyasaregulatoryidiom,anidiomthatwedsdo- Parker,I.,Georgaca,E.,Harper,D.,McLaughlin,T.,&Stowell-Smith,
M.(1995).Deconstructingpsychopathology.London:Sage.
mesticandpsychiccoherence:forbetterorworse.Thisidiom
Romans,S.E.,Martin,J.M.,Gendall,K.,&Herbison,G.P.(2003).Age
hasneverbeenunscientific—ithasratherdeliveredtheorder- ofmenarche:Theroleofsomepsychosocialfactors.Psychological
ingofintimaciestoaspecificallysuccessful‘‘skeletonization Medicine,33,933–939.
offact’’(Geertz,1983,p.170).Tocontestitistocontestmore Vigil,J.M.,Geary,D.C.,&Byrd-Craven,J.(2005).Alifehistoryas-
sessmentofearlychildhoodsexualabuseinwomen.Developmen-
thanascientificscam.
talPsychology,41,553–561.
Zabin,L.S.,Emerson,M.R.,&Rowland,D.L.(2005).Childhoodsexual
abuseandearlymenarche:Thedirectionoftheirrelationshipandits
References implications.JournalofAdolescentHealth,36,393–400.
Edelman, L. (2004). No future: Queer theory and the death drive.
Durham,NC:DukeUniversityPress.
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ArchSexBehav(2010)39:216–216
DOI10.1007/s10508-009-9567-6
LETTER TO THE EDITOR
An Explanation for the Shape of the Human Penis
EdwinA.Bowman
Publishedonline:23October2009
(cid:1)SpringerScience+BusinessMedia,LLC2009
The present form of the human penis, reached over several butvaginalsecretions,whicharethenabsorbedbytheencom-
millionyearsofevolution,wasorchestratedbythevaginaof passingforeskin.Themucousmembraneoftheforeskinad-
thehumanfemale.Themultifunctionalvaginaservesasabirth jacenttotheglansishighlyabsorbent,asevidencedbythe
canal, a component of the structural support for the internal increasedsusceptibilityoftheuncircumcisedmaletoHIV.
pelvicorgans,andasacoitalorgan.Inthislastfunction,ithas It has been suggested that there may be a glans protecting
had an evolutionary effect in shaping male sexual anatomy. featureoftheforeskin,butitisentirelypossiblethatitspri-
Hominidfossilssofardiscoveredshowthatthefemalepelvis maryfunctionistoabsorbbehaviormodifyingchemicalmes-
evolvedtoaccommodatetheincreasingsizeofthebrainofthe sengersfromthefemale.Numerousstudieshaveshownthe
humaninfant.Largercranialcapacitynecessitatedalargerbirth vaginalmucosatobesecretory.Intheprimaterear-approach
canaland,asaresultofsexualselection,anincreaseinthesize coitalposition,thecoronarubsagainsttheanatomicallypos-
ofthepenis.Comparedtothatoftheothergreatapes,thehuman teriorwallofthevagina,themostdependentsurfacewhen
penisisconsiderablylarger,andevidencesuggeststhatitsun- thewomanisstanding,andthereforetheplacemorelikelyto
iqueconfigurationmayalsobearesultofvaginalinfluence. collectvaginalsecretions.Thedeepestendoftheposterior
It has been proposed that the shape of the glans with its vaginaistheculdesac,whichcommonlycontainsasmall
distinctive corona facilitates the scooping out of previously amountoffluid.Ananalyticalstudyofthevaginalsecretions
depositedsemen,enablingthesubsequentdepositionofother ofanovulatingfemaleforneuropeptides,suchaspitocinand
geneticmaterial.Thisisnotalikelyoccurrence.Thehealthy vasopressin,knowntoenhancepairbondingandprotective
vagina has a low pH toprotect it frominvadingorganisms. behaviorinthemale,couldberevealing.Sexualintercourse
Thisintenseaciditywillkillallspermnotpromptlyreaching maybeamediumofcommunicationbetweenhumansolder
the safety of the cervical mucus. I suggest the evolutionary thanlanguageitself.
functionoftheglansanditscoronaisnottoscoopoutsemen
E.A.Bowman(&)
515HollyPointRoad,Freeport,FL32439,USA
e-mail:[email protected]
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ArchSexBehav(2010)39:217–220
DOI10.1007/s10508-009-9548-9
EDITORIAL
Reports from the DSM-V Work Group on Sexual and Gender
Identity Disorders
KennethJ.Zucker
Publishedonline:16September2009
(cid:1)AmericanPsychiatricAssociation2009
DSMProlegomena takeninDSM-IIIwithregardtoetiologyisthattheinclu-
sionofetiologicaltheorieswouldbeanobstacletouseof
SincethefirsteditionoftheDiagnosticandStatisticalManual: themanualbycliniciansofvaryingtheoreticalorientations,
Mental Disorders was published in 1952 by the American since it would not be possible to present all reasonable
PsychiatricAssociation(APA),themanualhasgonethrougha etiologicaltheoriesofeachdisorder….BecauseDSM-IIIis
seriesofrevisions:DSM-IIin1968,DSM-IIIin1980,DSM-III- generallyatheoreticalwithregardtoetiology,itattemptsto
Rin1987,DSM-IVin1994,andatextrevisiontotheDSM-IV describecomprehensivelywhatthemanifestationsofthe
in 2000. For those with a sharp eye, one will note that, sub- mentaldisordersare,andonlyrarelyattemptstoaccountfor
sequenttoDSM-I,themanualhashadaslightlydifferentname: howthedisturbancescomeabout…Thisapproachcanbe
DiagnosticandStatisticalManualofMentalDisorders. saidtobe‘‘descriptive’’inthatthedefinitionsofthedis-
Anyclinician,researcher,orpolicymakerwithaninterestin ordersgenerallyconsistofdescriptionsoftheclinicalfea-
psychiatricnosologyiskeenlyawarethatthepublicationofthe turesofthedisorders.(AmericanPsychiatricAssociation,
DSM-III in 1980 was a watershed moment in contemporary 1980,pp.6–7)
psychiatry.Bythattime,theintellectualandinstitutionalhege-
Apsychiatricnosologythatwas,byandlarge,agnosticwith
mony of psychoanalysis that had dominated the psychiatric
regardtounderlyingcausalmechanismswasdeemedpreferable
landscapehadlostsome,ifnotmost,ofitsgrip(seeGrob,1991;
to a theoretical model that was no longer satisfying to many
Paris,2005;Wilson,1993).Sketchypsychoanalyticmodelsof
researchersandpractitioners.Advancesinbiologicalpsychia-
atleastsomepsychiatricdisordersthatweredescribedinthe
try,theemergenceofcompetingpsychologicmodelsofdevel-
DSM-IandDSM-IIwereabandoned.Therathervaguediag-
opment and disorder, and the increasing availability of alter-
nosticdescriptorswerereplacedbymoredetailedcriteriaand,
nativeapproachestotherapeuticsallcontributedtoaparadigm
for the majority of conditions described in the DSM-III, an
crisisinthediscipline’snosologicalmanual.Since1980,one
atheoreticalapproachpredominated.AsnotedintheIntroduc-
overarching vision was that the manual, if organized around
tiontotheDSM-III:
descriptivelyneutraldiagnosticcriteria,couldbeutilizedbya
For most of the DSM-III disorders…the etiology is un- diverse array of clinicians and researchers from many disci-
known….TheapproachtakeninDSM-IIIisatheoretical plines.Acommonandtransparentlanguage,soithasbeenheld,
withregardtoetiologyorpathophysiologicalprocessex- shouldfacilitatecommunicationinarapidlydevelopingfield
ceptforthosedisordersforwhichthisiswellestablished (seeSpitzer&Klein,1978).
andthereforeincludedinthedefinitionofdisorder….The There was also anothervery crucial issue thatserved as a
majorjustificationforthegenerallyatheoreticalapproach backdrop to the substantive changes that occurred with the
publication of DSM-III, namely the concern that the prior
manualslackedsufficientdetailtoproducereliableandvalid
K.J.Zucker(&)
GenderIdentityService,Child,Youth,andFamilyProgram, diagnosticcategories.Thiswasalreadyapparentinthe1960s
CentreforAddictionandMentalHealth,250CollegeSt.,Toronto, (e.g.,Spitzer,Cohen,Fleiss,&Endicott,1967;Spitzer,Fleiss,
ONM5T1R8,Canada Burdock,&Hardesty,1964;Stoller&Geertsma,1963),butwas
e-mail:[email protected]
123
218 ArchSexBehav(2010)39:217–220
broughttotheforebytheseminalworkbyateamofpsychia- forfieldtrialstotestreviseddiagnosticcriteria;and(6)revi-
tristsatWashingtonUniversityinSt.Louis(e.g.,Feighneretal., siontothetextthataccompanieseachdiagnosis.
1972; Goodwin & Guze, 1979; Robins & Guze, 1970). The Inaddition,theTaskForcewillexaminesomeothermajor
importance of reliability and validity has remained a central issues:(1)themeta-structureofthemanual,i.e.,disordergroup-
concerninallofthepost-DSM-IIImanuals(see,e.g.,Blashfield, ings;(2)measurementofdistressandimpairment;(3)thepos-
Sprock,&Fuller,1990;Nelson-Gray,1991;Pincus,Frances, sible inclusion of dimensional diagnosis as a complement to
Davis,First,&Widiger,1992;Tsaung,1993;Widiger,Frances, categorical diagnosis; (4) the possible inclusion of common
Pincus, & Davis, 1990; Widiger, Frances, Pincus, Davis, & dimensionalassessmentthatwillbeusedacrossdifferentdiag-
First,1991)andwillcontinuetodosowiththepublicationof nostic categories; (5) further consideration of developmental
DSM-V. parametersfordiagnosis;and(6)furtherconsiderationofcul-
Forthelast30 years,itwouldbeveryreasonabletostatethe turalfactorsandgendervis-a`-visdiagnosis.Fortheseissues,the
obvious:theDSMhashadanenormous(international)impact interestedreadercanconsultthefollowing:Andrews,Charney,
onclinicaltraining,thedeliveryofclinicalcare,andprogramsof Sirovatka,andReiger(2009),Beachetal.(2006),Dimsdaleetal.
research(bothbasicandapplied).Ithasalsoservedasaspring- (2009),HelzerandHudziak(2002),Helzeretal.(2008),Hyman
boardforcontinuedandconsideredreflectiononthecontem- (2007),Kraemer(2007),Krueger,Skodol,Livesley,Shrout,and
porary concept of mental disorder (see, e.g., Decker, 2007; Huang(2007),Kupfer,First,andRegier(2002),Kupfer,Regier,
Fabrega,1994,2006,2007;Horwitz,2002;Horwitz&Wake- andKuhl(2008),Narrow,First,Sirovatka,andRegier(2007),
field,2007;Houts,2002;Jablensky,2007;Jensen,Knapp,& Phillips, First, and Pincus (2003), Regier, Narrow, First, and
Mrazek, 2006; Kendell, 2001, 2002; Kendell & Jablensky, Marshall(2002),Regier,Narrow,Kuhl,andKupfer(2009),and
2003;Kendler,1999;Lane,2007;Lewis,2006;Lilienfeld& Tackett,Balsis,Oltmanns,andKrueger(2009).
Marino,1995;Luhrmann,2001;McNally,2001;Paris,2008;
Scotti,Morris,McNeil,&Hawkins,1996;Silk,Nath,Siegel,&
Kendall,2000;Spitzer,1999;Spitzer&Endicott,1978;Wake- TheSexualandGenderIdentityDisordersWorkGroup
field,1992a,1992b,1993,1997;Widiger&Clark,2000;Zachar
& Kendler, 2007). At the time of completing this Editorial ItwasanhonorandprivilegeformetobeappointedasChairof
(August30,2009),thesimplesearchterm‘‘DSM’’inPubMed thisWorkGroupbytheDSM-VTaskForceandtheAmerican
yieldedamere28,223entries! PsychiatricAssociation.Myfirsttaskwastoconsultwiththe
Task Force regarding candidates for the Work Group. There
was,ofcourse,arestrictiononhowmanymemberscouldbe
BacktotheFuture appointed to the Work Group. Vetting nominees is a time-
consumingprocess.Italsocostsmoney,asdoesparticipationin
On April 13, 2006, the APA announced the appointments of face-to-facemeetingsandconferencecalls.Thus,forourWork
David J. Kupfer, M.D., as chair, and Darrel A. Regier, M.D., Group,asforothers,itwasimpossibletoconsiderallqualified
M.P.H., as vice chair, of the DSM-V Task Force (American candidates. Apart from consideration of scholarly qualifica-
PsychiatricAssociation,2006).AndonMay1,2008,theAPA tions,itwasalsoimportanttoadheretotheconflictofinterest
announced the appointments of the entire ensemble of the guidelinessetforthbytheTaskForce,includingaceilingseton
DSM-VTaskForce(AmericanPsychiatricAssociation,2008), theamountofpersonalincomereceivedfromthepharmaceutical
includingthe13WorkGroupChairsforthecurrentgroupingsof industry(seeCosgrove,Krimsky,Vijayaraghavan,&Schneider,
psychiatric disorders in the DSM-IV, its cross-cutting Work 2006),anissuethat was particularly relevantforour Sexual
Groups,othermembersoftheTaskForce,andsoon.Sincethen, Dysfunctionssubworkgroup.TheWorkGroupthatmaterial-
manyadvisorshavebeennominatedandapprovedbytheTask izedincludedthefollowingindividuals:FortheSexualDys-
ForcetoconsultwiththeWorkGroups,resultinginanevenlarger functionssubworkgroup,R.TaylorSegraves(Chair),Yitzchak
cast.TheanticipatedpublicationoftheDSM-Vis2012,fiveyears M. Binik, Lori A. Brotto, and Cynthia Graham; for the Pa-
laterthanpredictedbyBlashfieldandFuller(1996).Forfurther raphilias subworkgroup, Ray Blanchard (Chair), Martin P.
informationontheDSM-V,thereaderisencouragedtoconsult Kafka,RichardKrueger,andNiklasLa˚ngstro¨m;fortheGender
www.dsm5.org. Identity Disorders subworkgroup, Peggy T. Cohen-Kettenis
TheDSM-VTaskForcehas,asitsmission,anumberof (Chair), Jack Drescher, Heino F. L. Meyer-Bahlburg, and
majortasks.Theseinclude,butarenotlimitedto,thefollow- FriedemannPfa¨fflin.MembersofeachWorkGroupnominateda
ing: (1) literature reviews of current diagnostic entities; (2) number of advisors, many of whom are acknowledged in the
literaturereviewsofproposednewdiagnosticcategories;(3) literaturereviewsthatarepartofthisSpecialSectionofArchives.
incorporation of feedback from advisors and the scientific Inthisissue(andalreadyavailableviaadvanceonlinepub-
communityatlarge,aswellasotherinterestedstakeholders; lication),thereaderwillfindatotalof16reviewswrittenbyour
(4)examinationofrelevantsecondarydatasets;(5)proposals WorkGroup.ReviewsbyTaylorSegravesonthemalesexual
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ArchSexBehav(2010)39:217–220 219
dysfunctionswillbepublishedintheJournalofSexualMedi- Blashfield,R.K.,Sprock,J.,&Fuller,A.K.(1990).Suggestedguide-
cine. Most of the reviews focus on a critical appraisal of the lines for including or excluding categories in the DSM-IV.
ComprehensivePsychiatry,31,15–19.
relevant diagnoses that appeared in the DSM-IV (or earlier),
Cosgrove,L.,Krimsky,S.,Vijayaraghavan,M.,&Schneider,L.(2006).
withproposedsuggestionsforreformandrevision.Thereisalso FinancialtiesbetweenDSM-IVpanelmembersandthepharma-
onereviewthatconsiderstheadditionofanewdiagnosis(Hyper- ceuticalindustry.PsychotherapyandPsychosomatics,75,154–160.
sexuality)andtworeviewsongenderidentitydisordercon- Decker,H.S.(2007).HowKraepelinianwasKraepelin?HowKraepel-
inianaretheneo-Kraepelinians?—fromEmilKraepelintoDSM-III.
sider conceptual and sociopolitical/historical parameters.
HistoryofPsychiatry,18,337–360.
Each review was subject to internal feedback by the Work Dimsdale, J. E., Xin, Y., Kleinman, A., Patel, V., Narrow, W. E.,
Group and, in some cases, from feedback by advisors. It Sirovatka,P.J.,etal.(Eds.).(2009).Somaticpresentationsofmental
shouldbemadeclearthattherecommendationsandoptions disorders:RefiningtheresearchagendaforDSM-V.Arlington,VA:
AmericanPsychiatricAssociation.
embeddedinthesereviewsarejustthat.Innowayshouldthe
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isamulti-layeredprocessthatwillinvolveadditionalfeed- Fabrega,H.(2006).Whypsychiatricconditionsarespecial:Anevolu-
backandcertainlywillbeinfluencedbytheresultsfromfield tionaryandcross-culturalperspective.PerspectivesinBiologyand
Medicine,49,586–601.
trials.
Fabrega,H.(2007).Howpsychiatricconditionsweremade.Psychiatry,
PublishingthesereviewsintheArchivesispartofthetrans- 70,130–153.
parencyprocessthatisofcriticalimportancetotheDSM-VTask Feighner,J.P.,Robins,E.,Guze,S.B.,Woodruff,R.A.,Winokur,G.,&
Force.Itallowsinterestedmembersofthescientificcommunity Munoz,R.(1972).Diagnosticcriteriaforuseinpsychiatricresearch.
ArchivesofGeneralPsychiatry,26,57–63.
and other stakeholders to scrutinize the thinking of our Work
Goodwin,D.W.,&Guze,S.B.(1979).Psychiatricdiagnosis(2nded.).
Groupandtoprovidefeedback.Inourpost-modernera,wherea NewYork:OxfordUniversityPress.
micro-thoughtisjustatwitteraway,thescientificperiodicalis,I Grob,G.N.(1991).OriginsofDSM-I:Astudyinappearanceandreality.
hope,stillausefulforumforreflection,critique,anddialogue. AmericanJournalofPsychiatry,148,421–431.
Helzer,J.E.,&Hudziak,J.J.(Eds.).(2002).Definingpsychopathologyin
Commentariesthatarenomorethan1500wordsinlength
the21stcentury:DSM-Vandbeyond.Washington,DC:American
willbeconsideredforsubsequentpublicationintheArchives. PsychiatricPublishing.
Commentaries should be submitted to Kenneth J. Zucker, Helzer,J.E.,Kraemer,H.C.,Krueger,R.F.,Wittchen,H.-U.,Sirovatka,
Ph.D.,Editor,ArchivesofSexualBehavioratKen_Zucker@ P.J.,&Regier,D.A.(Eds.).(2008).Dimensionalapproachesin
diagnosticclassification:RefiningtheresearchagendaforDSM-
camh.net.Thecommentaryshouldbesubmittedasane-mail
V.Arlington,VA:AmericanPsychiatricAssociation.
attachmentusingWORD,shouldcontainabrieftitle,theau- Horwitz,A.V.(2002).Creatingmentalillness.Chicago:Universityof
thor’scompletemailingaddress,andtheuseofthereference ChicagoPress.
styleoftheAmericanPsychologicalAssociation. Horwitz,A.V.,&Wakefield,J.C.(2007).Thelossofsadness:How
psychiatrytransformednormalsorrowintodepressivedisorder.
Oxford:OxfordUniversityPress.
Acknowledgment TheauthoristheChairoftheDSM-VWorkGroup
Houts,A.C.(2002).Discovery,invention,andtheexpansionofthemodern
onSexualandGenderIdentityDisorders.Reprintedwithpermissionfrom
Diagnostic and Statistical Manual of Mental Disorders. In L. E.
theDiagnosticandStatisticalManualofMentalDisordersVWorkgroup
Beutler&M.L.Malik(Eds.),RethinkingtheDSM:Psychological
Reports(Copyright2009),AmericanPsychiatricAssociation.
perspectives(pp.17–65).Washington,DC:AmericanPsychological
Association.
Hyman,S.E.(2007).CanneurosciencebeintegratedintotheDSM-V?
NatureReviewsNeuroscience,8,725–732.
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ArchSexBehav(2010)39:221–239
DOI10.1007/s10508-009-9543-1
ORIGINAL PAPER
The DSM Diagnostic Criteria for Hypoactive Sexual Desire
Disorder in Women
LoriA.Brotto
Publishedonline:24September2009
(cid:1)AmericanPsychiatricAssociation2009
Abstract HypoactiveSexualDesireDisorder(HSDD)isone women.Thisreviewwillalsodiscusscriticismsoftheexisting
oftwosexualdesiredisordersintheDiagnosticandStatistical DiagnosticandStatisticalManualofMentalDisorders(DSM-
Manual of Mental Disorders (DSM) and is defined by the IV-TR;American Psychiatric Association,2000) criteriaand
monosymptomatic criterion ‘‘persistently or recurrently defi- summarizepriorattemptstoofferalternatediagnosticcriteria
cient(orabsent)sexualfantasiesanddesireforsexualactivity’’ and taxonomies. The issues to be considered for DSM-V in-
thatcauses‘‘markeddistressorinterpersonaldifficulty.’’This clude:(1)theutilityofincludinglackofsexualfantasiesinthe
article reviews the diagnosis of HSDD in prior and current criteria;(2)whetherornot‘‘responsivedesire’’shouldbeadded
(DSM-IV-TR)editionsoftheDSM,critiquestheexistingcri- tothecriteria;(3)howtocapturerelationalinfluencesandcon-
teria,andproposescriteriaforconsiderationinDSM-V.Prob- sequences; (4) the overlap between sexual desire and sexual
lemsincomingtoaclearoperationaldefinitionofdesire,thefact arousal/arousability;and(5)whetherornotassociateddistress
that sexual activity often occurs in the absence of desire for shouldbepartofthediagnosticcriteria.
women,conceptualissuesinunderstandinguntriggeredversus Itisimportanttofirstclarifyterminologyused.Intheprofes-
responsivedesire,therelativeinfrequencyofunprovokedsexual sionalliterature,thetermssexualdesire,drive,motivation,inter-
fantasiesinwomen,andthesignificantoverlapbetweendesire est,libido,hunger,andappetiteareoftenusedinterchange-
andarousalarereviewedandhighlighttheneedforrevisedDSM ably.IntheDSM-IV-TR,whereasthedisorderitselfandthe
criteriaforHSDDthataccuratelyreflectwomen’sexperiences. associatedcriteriafocusonsexual‘‘desire,’’the‘‘Associated
Thearticleconcludeswiththerecommendationthatdesireand FeaturesandDisorders’’sectionalsousestheterm‘‘sexualin-
arousalbecombinedintoonedisorderwithpolytheticcriteria. terest.’’Thisreviewwillconcludewithonerecommendation
thatthephrase‘‘sexualinterest’’replace‘‘sexualdesire.’’
Keywords Hypoactivesexualdesiredisorder(cid:1) ThecategoriesofsexualdisordersintheDSMsince1980
Sexualinterest(cid:1)Sexualdesire(cid:1)DSM-V (DSM-III;AmericanPsychiatricAssociation,1980)havebeen
basedonthehumansexualresponsecycleasoriginallycon-
ceptualizedbyMastersandJohnson(1966).Shortlyafterthe
Introduction releaseoftheirbookontreatment,HumanSexualInadequacy
(Masters&Johnson,1970),itbecamereadilyapparentthatthe
Thegoalofthisreviewistoprovideanoverviewonthehistory primarycomplaintforwhichpatientssoughttreatmentwasnot
andcurrentstatusformakingadiagnosisofhypoactivesexual problems with sexual performance or genital excitement, as
desiredisorder(HSDD).Inlinewiththerecommendationby MastersandJohnsonhadassumed.Instead,problemsrelatingto
Segraves,Balon,andClayton(2007)thatcriteriasetsbelisted alackofsexualinterestwerethemostcommonpresentations
separately by sex, this article will focus on sexual desire in amongwomen.Today,wewouldrefertothisasalackofsexual
desire.Inthelate1970s,Kaplan(1977,1979)andLief(1977)
independently suggested that desire is a necessary separate
L.A.Brotto(&)
phase of the human sexual response cycle and Masters and
DepartmentofObstetricsandGynaecology,UniversityofBritish
Johnson’smodelwasexpandedtoacknowledgetheimportant
Columbia,2775LaurelStreet,Vancouver,BCV5Z1M9,Canada
e-mail:[email protected] roleofsexualdesire.Theresultingtriphasicmodelemphasized
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222 ArchSexBehav(2010)39:221–239
Kaplan’sandLief’sviewthatsexualdesirewasthefirstand methodologiesemployed—inparticular,whetherdistresswas
most important component, which triggered the rest of the assessedandconsideredindeterminingprevalencerates.The
sexualresponsecycle.Thistriphasicsexualresponsecycleof NationalHealthandSocialLifeSurvey(NHSLS)isoneofthe
desire,excitement,andorgasm(andresolution),servedasthe mostwidelycitedstudiesontheprevalenceofsexualproblems
basisforhowsexualdisorderswerecategorizedintheDSM: inwomen(Laumann,Paik,&Rosen,1999).Between27and
Sexual Desire Disorders, Sexual Arousal Disorders, and Or- 32%ofwomenaged18–59whohadbeensexuallyactiveover
gasmDisordersmappedontothefirstthreephasesofthesexual thepastyearrespondedwith‘‘yes’’tothequestion:‘‘Duringthe
responsecycle,andtheSexualPainDisorderswereaddedasa last 12 months has there been a period of several months or
fourthcategoryofdysfunctionwithnoapparentjustificationfor morewhenyoulackeddesireforsex?’’IntheNationalSurvey
theiradditionineithertheDSM-III,DSM-III-R,DSM-IV,or of Sexual Attitudes and Lifestyles (NATSAL) conducted on
anyoftheDSMSourcebooks.Thedisorderoflowsexualdesire 11,161Britishmenandwomenaged16–44whoparticipatedin
intheDSM-IIIwaslabeled‘‘InhibitedSexualDesire’’andwas acomputer-assistedself-interview,lowsexualdesirewasthe
definedasapersistentandpervasiveinhibitionofsexualdesire. mostcommoncomplaintinwomen(Merceretal.,2003).The
TheDSM-IIIstipulatedthatthediagnosiswouldrarelybemade prevalenceoflowdesire‘‘lastingatleastonemonth’’was40.6%
unlessthelackofdesirewasasourceofdistresstoeitherthe and‘‘lastingatleastsixmonths’’was10.2%.IntheGlobalStudy
individualorapartner. ofSexualAttitudesand Behaviors(GSSAB),13,882women
TherevisededitionofDSM-III(DSM-III-R;AmericanPsy- across 29 countries took part either in a computer-assisted
chiatricAssociation,1987)droppedtheterm‘‘inhibited’’because telephoneintervieworaface-to-faceinterview(Laumannetal.,
ofitsassumedpsychoanalytic(andpotentiallyambiguous)con- 2005).Lackofinterestinsexwasthemostcommonproblemin
notationanditwasreplacedwithhypoactivesexualdesiredis- women,rangingfrom26to43%.Distresswasnotassessedin
order(HSDD).Replacementoftheterm‘‘inhibited’’alsoallowed thesethreestudies.
forsexualdesiredisordertobedefinedinthesamewayformen
andwomen(Graham&Bancroft,2006).TheDSM-III-Rdefined
HSDDas‘‘persistentlyorrecurrentlydeficientorabsentsexual PrevalenceofLowSexualDesireandAssociatedDistress
fantasiesanddesireforsexualactivity.’’Subtypes(psychogenic
orpsychogenic/biogenic;lifelongoracquired;andgeneralizedor Researchershavealsoattemptedtoquantifytheprevalence
situational) were introduced to further define the HSDD syn- of low sexual desire (DSM-IV-TR Criterion A) versus the
drome.ThenameandcriteriaforHSDDremainedthesamein prevalenceoflowsexualdesireandassociateddistress(DSM-
DSM-IVexceptthatthecriterionofhaving‘‘markeddistressor IV-TRCriteriaAandB).
interpersonal difficulty’’ was added. Thus, the individual with In a Swedish study of 1,335 women aged 18–74, 34% of
deficient(orabsent)sexualfantasiesanddesireforsexualactivity womenreportedthattheyexperienceddecreasedsexualinterest
whowasnotdistressedbythesesymptomsdidnotmeetcriteria quiteoftenormostofthetime.Amongthisgroup,43%viewed
forHSDD. thelowdesireasaproblem(Fugl-Meyer&Fugl-Meyer,1999).
Criterion A for HSDD requires ‘‘persistently or recurrently Bancroft,Loftus,andLong(2003)conductedtelephoneinter-
deficient(orabsent)sexualfantasiesanddesireforsexualactivity’’ viewswith987Americanwomenaged20–65andexaminedthe
and Criterion B requires that ‘‘the disturbance causes marked prevalenceofsexualdysfunction,personaldistress,anddistress
distressorinterpersonaldifficulty’’(AmericanPsychiatricAsso- abouttherelationship.Womenaged20–35weremorelikelyto
ciation,2000).Indeterminingwhetherthelackofsexualfantasies view their lack of sexual thoughts as distressing to the rela-
ordesireforsexualactivityareclinicallysignificant,theDSM-IV- tionshipandtotheirownsexualitycomparedtowomenaged36
TRinstructsthat‘‘thejudgmentofdeficiencyorabsenceismade andolder.Theprevalenceoflowdesireinthisstudywasop-
by the clinician, taking into account factors that affect sexual erationalizedbyaskingwomenthefrequencywithwhichthey
functioning, such as age and the context of the person’s life.’’ thoughtaboutsexwithinterestordesireoverthepastmonth.
CriterionCindicatesthatthelackofsexualdesireisnot‘‘better Responseoptionswere:notatall,onceortwice,onceaweek,
accountedforbyanotherAxisIdisorder(exceptanotherSexual severaltimesaweek,andatleastonceaday,with7.2%ofthe
Dysfunction)andisnotdueexclusivelytothedirectphysiological womenreportingnosexualinterestoverthepastfourweeks.
effectsofasubstanceorageneralmedicalcondition.’’ Bancroft et al. found that negative mental state was the best
predictorofmarkeddistressabouttherelationshipaswellas
markeddistressaboutthewoman’sownsexuality(althoughthe
PrevalenceofLowSexualDesireinWomen authorsrecognizedthatthereverseorderofcausationwasalso
feasible butless likely). Moreover, mental state(e.g., feeling
Over the past decade, there have been numerous attempts to calmandpeaceful)wasmorepredictiveofrelationaldistress
documenttheprevalenceoflowdesireandHSDDinwomen. thanwasphysicalhealth,whereasphysicalhealthwasmorerele-
Therehavebeensomeinconsistenciesinthefindingsand vanttodistressaboutawoman’sownsexuality.Interestingly,
123