Why is absent/low sexual desire a mental disorder (except when patients identify as asexual)?

ABSTRACT

This analytic essay challenges the psychiatric practice of treating absent/low sexual interest/desire/arousal as a mental disorder. It does so by calling attention to the fact that asexuality is treated differently than other non-heterosexual orientations. The current DSM contains no psychiatric diagnosis which has, as its primary symptom, same-sex sexual desire. Yet, the same DSM offers diagnoses such as male hypoactive sexual desire disorder and female sexual interest/arousal disorder which have, as their primary symptom, absent/low sexual interest/desire/arousal. One of the unfortunate consequences of treating absent/low sexual desire as a mental disorder is that it perpetuates the false belief that those who experience their sexuality differently than the heterosexual ‘sexusociety’ norm are less healthy and more dysfunctional. It is also troubling because of the implied gender bias: women are more likely to experience absent/low sexual interest/desire/arousal than men and more likely to be diagnosed with a sexual interest/desire/arousal disorder. Women’s sexual desires, or the absence thereof, are, thus, more likely to be seen as abnormal. Since that judgment has long been used to pressure women to engage in sex they do not want, the unavoidable inference is that the psychiatric tradition of diagnosing absent/low sexual desire as pathological has placed, and continues to place, women at greater risk of sexual exploitation and abuse. The remedy: stop treating absent/low sexual desire as pathological. Recognize that people are sexually different and are entitled to desire sex a lot, a little, or not at all—whatever feels right for them.

KEYWORDS:

• Asexuality
• sexual identity
• sexual orientation
• gender
• psychiatry

The Diagnostic and Statistical Manual for Mental Disorders (APA) has consistently assumed that the absence of sexual desire is not normative (MacNeela & Murphy, 2015; Prause & Graham, 2007, pp. 341–342). The DSM has treated absent/low sexual desire as a pejorative – a sign of dysfunctionality (Cerankowski & Milks, 2010, p. 653). Heterosexual desire, by contrast, has never been treated as inherently pathological. While homosexual desire had been defined as a mental disorder in the DSM-II (American Psychiatric Association, 1968), in 1973, the members of the American Psychiatric Association voted to remove homosexuality from their diagnostic manual. A residual diagnosis ‘sexual orientation disturbance’ was retained for those who experienced their homosexuality as distressing. That diagnosis would go through two more name changes – from ‘homodysphilia’ to ‘homosexual conflict disorder’—until finally settling on ‘ego-dystonic homosexuality’, but that too was dropped from the DSM in 1987 (American Psychiatric Association).

These diagnoses (sexual orientation disturbance, homodysphilia, homosexual conflict disorder, and ego-dystonic homosexuality) were eliminated as part of psychiatry’s efforts to normalise homosexual desire, which raises the questions: Why hasn’t psychiatry made similar efforts to normalise absent/low sexual desire, and why has psychiatry consistently promoted the idea that absent/low sexual desire is pathological? These questions are concerning because the sexual interest/desire diagnosis is disproportionately assigned to women (Brotto & Velten, 2020; Krasnow & Maglio, 2019; Laumann et al., 1999; Meston & Stanton, 2017; Shifren et al., 2008) and because individuals with absent/low sexual desire are often denigrated as psychologically and functionally impaired (Brunning & McKeever, 2021; Gupta, 2017a,b).

In this essay, I argue that treating absent/low sexual desire as a psychiatric symptom is wrong – wrong whether patients identify as asexual or experience distress in relation to their absent/low sexual desire. However, before I begin, for the sake of transparency, I first explain how I came to do this research and take these positions.

My research primarily involves using historical materials to critically reframe contemporary issues – what Foucault (1971, 1977b, 1977a) calls ‘genealogy’. That may explain how my discovery, several years ago, of an article in the British Journal of Psychiatry (Cooper, 1969) launched this study. The article from the British Journal describes how a behavioural sex therapist – a psychiatrist – advised a husband how to deal with a wife who found intercourse profoundly unappealing. The psychiatrist suggested that the husband use force: he advised him to rape his wife. This surprising discovery prompted me to explore mental health journals from the Victorian era to the present to see if there were more articles like this. I found there were: many case studies depicting psychiatrists and other mental health practitioners pressuring sexually reluctant wives and girlfriends, as part of their treatment, to have sex with their presumably normal male partners (Margolin, 2021a, 2021b). These studies helped me understand that treating absent/low sexual desire as a psychiatric disorder had been, and continues to be, an unrecognised form of oppression, particularly the oppression of women.

My second reason for undertaking this research has to do with my background in Freudian psychology. In the 1970s, I trained at a psychoanalytic institute and for years was a passionate follower of Freud. But as time passed, that passion dissolved, except, that is, for one Freudian tenet: the belief that everyone is sexual, the idea that psychological normality is contingent on sexual desire. That belief eventually dissolved too, not only because of the historical evidence that individuals with absent/low sexual desire are oppressed, but because of my experience teaching human sexuality, where many students came out to me and my classes as asexual. My students prompted me to study asexuality and to gather evidence for a formal repudiation of Freud’s (and my former) belief in the importance – the necessity – of sexual desire.

Asexual identity

The DSM-II (1968, American Psychiatric Association) defined homosexuality as a disorder in which individuals’ sexual interests are ‘directed primarily towards objects other than people of the opposite sex, towards sexual acts not usually associated with coitus’ (p. 44). Homosexual pathology, in other words, was to be diagnosed on behavioural evidence alone – strictly on the presence or absence of same-sex sexual interest and activity. That changed in 1973, when members of the American Psychiatric Association voted to drop homosexuality from its list of psychiatric disorders, replacing it with ‘sexual orientation disturbance’ later called ‘ego-dystonic homosexuality’, a psychiatric disorder defined less by behavioural evidence than by the incompatibility between the individual’s sexual identity and their same-sex interests/desires/arousal. To illustrate how this kind of incompatibility should figure into the diagnostic process, the American Psychiatric Association published a case study of a 23-year-old schoolteacher diagnosed with ego-dystonic homosexuality who rejected his homosexual interests and desires: ‘Now, although he has not yet had any overt homosexual experience, he is constantly preoccupied with a physical desire for homosexual contact. Yet, in a social sense, he is repulsed by the idea, finds it totally shameful and unacceptable to his social and cultural goals’ (DSM-III Case Book, Spitzer et al., 1981, p. 82). While this case study does not describe the patient’s sexual identity as either homosexual or heterosexual, it does emphasise the misalignment between his sexual desires and self-image – his belief that homosexuality represents behaviours totally at odds with the ways he imagines himself navigating his life.

We can see a similar concern with the issue of alignment/misalignment between sexual desire and sexual identity in contemporary psychiatry as represented by the DSM-5 and DSM-5-TR (American Psychiatric Association, 2013, 2022), but unlike the psychiatry represented by the DSM-III (1980, American Psychiatric Association) which was concerned with how well an individual’s same-sex sexual desire aligns with their homosexual identity, contemporary psychiatry is concerned with how well an individual’s absent/low sexual desire aligns with their asexual identity. According to the current DSM, ‘self-identified asexuals’ and those who experience a ‘lifelong lack of sexual desire’ are normal – they should not be diagnosed with a mental disorder – relative to ego-dystonic asexuals, individuals who experience absent/low sexual desire but who do not identify as lifelong asexuals. This is consistent with the Asexuality Visibility and Education Network’s (AVEN’s) policy that only individuals can decide for themselves whether they are asexual. In the words of AVEN’s FAQ: ‘Only you can decide to use asexual as a label for yourself’. Thus, those who seek psychiatric treatment to ‘cure’ themselves of their absent or weak sexual interest/desire/arousal – those who do not identify as asexual – fall outside the asexual umbrella.

Distinguishing between asexuality (the sexual orientation) and absent/low sexual desire (the symptom of pathology) represents progress, according to several scholars and clinicians, because: (1) absent/low sexual desire is changeable and treatable when occurring among individuals who do not identify as asexual, but not so among self-identified asexual people (Bogaert, 2006, 2008; Gupta, 2017a); (2) those who identify as asexual, unlike individuals with absent/low sexual interest/desire who do not so identify, do not experience their absent/low sexual interest/desire as distressing (Brotto & Yule, 2011; Brotto et al., 2010, 2015; Prause & Graham, 2007); (3) self-identified asexual people favour maintaining psychiatric diagnoses for those with absent/low sexual desire who do not identify as asexual; they believe the latter may benefit from treatment (Gupta, 2017b); and (4) distinguishing between self-identified asexual people and those with absent/low sexual desire who do not so identify is a method of establishing the legitimacy of asexuality – a method of ‘encouraging people to think about asexuality as a sexual orientation, thereby encouraging people to think about asexuality with terms similar to other non-heterosexual sexual orientations … ’. It is a method of encouraging people to think about asexuality in terms ‘such as the importance of acceptance, understanding, respect, not assuming pathology, not trying to change orientations, etc’. (Hinderliter, 2013, p. 172).

The two-tiered classification system, which treats self-identified asexual people as normal and others with absent/low sexual desire as mentally disordered may seem like progress to some, but it has a serious downside. The main problem is that while it appears to support the normality of self-identified asexual people, it also rejects the normality of those who do not identify as asexual, even though the latter may score similarly low on sexual interest/desire. By implication, under this classification system, other marginalised sexual identities on the ace spectrum who may have low sexual desire but do not identify as asexual (e.g. demisexuals) could be seen as mentally disordered.

By the logic of DSM, clinicians may feel obligated to pathologize opposite-sex desire if their patient does not identify as heterosexual. But so far, concern over the alignment/misalignment between an individual’s sexual desires and their sexual identity has only been used to pathologize sexual minorities: first with ego-dystonic homosexuality (people with same-sex desire who do not identify as homosexual) and now with ego-dystonic asexuality (people with absent/low desire who do not identify as asexual). Consider the wording in both the DSM-5 (2013) and DSM-5-TR (2022): ‘If the man’s low desire is explained by self-identification as an asexual, then a diagnosis of male hypoactive sexual desire disorder is not made’ (pp. 443, 501). That can be translated to mean: ‘If a man’s low desire is not explained by self-identification as an asexual, then a diagnosis of hypoactive sexual desire disorder is made’. Similarly, for women, ‘If a lifelong lack of sexual desire is better explained by one’s self-identification as “asexual”, then a diagnosis of female sexual interest/arousal disorder would not be made’ (pp. 434, 490). To translate: ‘If a lifelong lack of sexual desire cannot be explained by one’s self-identification as “asexual”, then a diagnosis of female sexual interest/arousal disorder can be made’.

A second problem with this two-tiered classification scheme is that it represents a departure from the ways other non-heterosexual sexual orientations are understood and managed. For example, we cannot say we are ‘encouraging people to think about asexuality as a sexual orientation with terms similar to other non-heterosexual orientations’ (Hinderliter, 2013, p. 172), when the quality which most defines asexuality – absent/low sexual interest/desire/arousal – is treated as pathognomonic, as if it is the distinguishing symptom of a mental disorder. Consider that the current DSM contains no psychiatric diagnosis which has, as its primary symptom, same-sex sexual desire; it has nothing that says individuals who are sexually attracted to members of their own sex warrant (or should be considered for) a psychiatric diagnosis. Yet, the same DSM offers diagnoses which have, as their primary symptom, absent/low sexual interest/desire/arousal.

Another difference between asexuality and the other non-heterosexual sexual orientations is that asexuality is a relatively new term. As Brunning and McKeever (2021) note, ‘many people simply haven’t heard of asexuality or ever met anyone who identifies as asexual’ (p. 511). According to one survey, only 25% of respondents were aware that asexual people do not experience sexual attraction (Young, 2019). This suggests that a substantial proportion of those who experience absent/low sexual attraction may not identify as asexual because they are uninformed. Does this mean that these individuals are not asexual? And if they are not – if their absent/low sexual desire is defined as pathological because they lack asexual identity – would treatment consist of helping them identify as asexual? These questions parallel the debate over whether, before the terms ‘homosexual’, ‘heterosexual’, and ‘bisexual’ came into use, it would make sense to say there were no homosexuals, heterosexuals, or bisexuals. Even now, it is likely that some individuals who are sexually attracted to members of the opposite sex may not think of themselves as ‘heterosexual’ or ‘bisexual’ due to their unfamiliarity with these terms, suggesting that the significance of asexual self-identification (and, indeed, the significance of homosexual, bisexual, and heterosexual self-identification) is far from clear (Mustanski et al., 2014; Wilkinson & Kitzinger, 1994, p. 310).

A related problem with using asexual self-identification as a criterion for determining the psychiatric status of individuals with absent/low sexual desire is that asexuality is not an either/or phenomenon. It’s not a uniform category. While Bogaert’s (2004) groundbreaking study of the demography of asexuality defined it in absolute terms as a lifetime absence of sexual attraction ‘to anyone at all’, more recent studies have treated it as a phenomenon that occurs on a spectrum, with asexual individuals experiencing a range of romantic and sexual feelings which differ both quantitatively and qualitatively (Brotto et al., 2010; Dawson et al., 2016; Haefner & Plante, 2015; Van Houdenhove et al., 2014; Vares, 2017). For Chasin (2011), this diversity suggests that ‘it makes more sense to think of asexual as a meta-category, just like sexual, encompassing the same kind of smaller categories’ (p. 721). It also suggests that individuals who experience absent/low sexual interest/desire but who do not identify as asexual should not be denied a place in the asexual meta-category. Lastly, it suggests that a person’s ‘lifelong lack of sexual desire’, as specified in the current DSM, should not be regarded as a more legitimate measure of asexuality than lack of sexual desire which is briefer and more situational, especially in light of research which finds that asexuality, like other sexual orientations, can change over time (Cranney, 2016). To say otherwise – to say that a person who identifies with lifelong asexuality is more genuinely asexual than other asexual types – suggests that asexuality is an essential attribute that does not vary across history and culture (Cowan & LeBlanc, 2018, p. 32). To say self-identification as asexual is fixed, or should be fixed, overlooks the fact that there is little in theory or experience to support the judgement that it is easy for people to attain objective self-knowledge – to know the truth about themselves. As philosopher Harry G. Frankfurt (2005, pp. 66–67) opined, ‘Facts about ourselves are not peculiarly solid and resistant to sceptical dissolution. Our natures are, indeed, elusively insubstantial – notoriously less stable and less inherent than the nature of other things’.

Asexual distress

After ego-dystonic homosexuality was dropped from the DSM, the only sexual orientation that continued to be treated as a mental disorder is asexuality in the form of ego-dystonic asexuality. This is not because the DSM has ever contained a diagnosis titled ‘ego-dystonic asexuality’, but rather because the DSM-5 (p. 433) and DSM-5-TR (p. 489) maintain that individuals who are distressed over a substantial period of time about their ‘absent/reduced interest in sexual activity’ and ‘absent/reduced sexual/erotic thoughts or fantasies’ can be diagnosed with a psychiatric disorder. In other words, according to the DSM-5 and DSM-5-TR, the disorder comes, not from individuals’ lack of sexual interest per se, but from the fact that they are deeply uncomfortable (distressed) about their lack of sexual interest – it feels ego-dystonic – and they want it to change. Following the DSM-5 and DSM-5-TR, then, those who feel clinically significant distress over their absent/low interest in sex, much like those who felt distress over their same-sex attraction between the years 1973 and 1987, can be diagnosed as mentally disordered.

Certainly, there are individuals with absent/low sexual desire who do not identify as asexual and for whom absent/low sex drive constitutes a problem – it feels distressful. But that does not make it a mental disorder. Jack Drescher (2015) and several other psychiatrists (Cabaj, 2009) have argued that using distress as a primary criterion for ego-dystonic homosexuality, or, indeed, as a primary criterion for any other psychiatric diagnosis, makes little sense because it opens up endless possibilities for creating new psychiatric disorders: ‘“Should people of colour unhappy about their race be considered mentally ill”? What about short people unhappy about their height? Why not ego-dystonic masturbation’? (Drescher, 2015, p. 571).

Apart from the seeming absurdity of labelling some human conditions psychiatric disorders based on their association with distress, the American Psychiatric Association removed the ego-dystonic homosexuality diagnosis from the DSM for three main reasons: (1) the lack of evidence that psychiatric treatment can change a person’s sexual orientation, (2) the growing evidence that attempting to change a person’s sexual orientation is psychologically harmful, and (3) the idea that when homosexuals grow up in a homonegative society, as ours is, ‘ego-dystonia, or a period of finding out you’re gay and wishing you weren’t, is quite normal’ (Cabaj, 2009, p. 91). As psychiatrist Judd Marmor (1980) explained, ‘In a society … where homosexuals are uniformly treated with disparagement or contempt – to say nothing about outright hostility – it would be surprising indeed if substantial numbers of them did not suffer from impaired self-image and some degree of unhappiness with their marginalised status’ (p. 400).

Many people who belong to a sexual minority feel distress at some point in their lives due to discrimination. Asexuality is no exception. In a society where those who do not desire sex are treated with disparagement or contempt – where they are rated as less human and less valuable than heterosexuals and other sexual minorities who do desire sex (MacInnis & Hodson, 2012)—it would be surprising indeed if substantial numbers of them did not suffer from elevated distress. In other words, distress among individuals with absent/low sexual interest/desire should not be treated as the deciding factor in diagnosing them as mentally disordered given their position in what Ela Przybylo (2011) calls ‘sexusociety’, a virulent pro-sex culture preoccupied with sexual deeds, desires, and thoughts, where, in Dworkin’s (1985) words, ‘there is the nearly universal conviction … that sex (fucking) is good and that liking it is right: morally right; a sign of human health; nearly a standard of citizenship’ (p. 59).

In sexusociety, where everyone is presumed to be sexual, those who deny sexual interest/activity are often seen as fraudulent or sick or both. To illustrate, Przybylo (2011) provided the example of how David Jay, the founder of AVEN, was treated on the ABC talk show, The View. On the one hand, the show’s host, Joy Behar, found it hard to accept that David Jay, or anyone else, could identify as asexual. How is it possible, she asked, if ‘[w]e are, by nature, sexual beings?’ On the other hand, Behar suggested that asexuals such as David Jay must have something to hide:

But maybe it’s repressed sexuality rather than, you know, that you’re just like a normal guy walking around. Maybe it’s repressed because you don’t want to face what the sexuality might look like. Could that be? Lie down. Just lie down. That will be a hundred dollars [Laughs from audience] … Because if you were having sex with yourself, excuse me one more question, that would mean that you had sexual feelings … . I am trying to get to the bottom of this … . So what are you just lazy or what? … But how does that work? I don’t get this. A guy. I could see for a woman. But you? (David Jay, quoted in Przybylo, p. 450.)

The disbelief and cynicism directed at David Jay represents what Miranda Fricker (2007) calls ‘epistemic injustice’, a form of discrimination in which members of a marginalised group are denied the capacity to define who they are – a microaggression in which individuals are rendered less credible than others, less conscious and self-aware. As we will see, epistemic injustice and three other interrelated disadvantages (social isolation, romantic/sexual conflict, and pathologization) are often associated with absent/low sexual desire. While these disadvantages are no more essential to asexuality than homonegativity/homophobia is essential to homosexuality, examining how they correlate with asexuality not only reveals how many individuals who share this trait come to experience elevated distress, but also how it makes little sense to classify them as mentally disordered for this reason.

Epistemic Injustice. Several researchers (Brunning & McKeever, 2021; Gupta, 2017a; Robbins et al., 2016) have found that epistemic injustice endures as a routine part of asexual people’s lives because when coming out, they are often silenced, judged, and patronised. They are often asked, ‘How do you know you don’t like it if you haven’t tried it?’ (Carrigan, 2012). Or they are told that their asexuality is merely a phase, a reflection of their social immaturity, a condition they’ll grow out of (Cerankowski & Milks, 2010; Dawson et al., 2016): ‘You just haven’t met the right guy yet. When you meet the right man everything will work out and you’ll enjoy having sex’ (Robbins et al., 2016, p. 756). As one participant in MacNeela and Murphy’s (2015) study summed up, ‘Most of the time, people find a way to dismiss asexuality so that they can continue to claim that all human beings are fundamentally sexual creatures’ (p. 803).

Anticipating that disclosure of their sexual orientation will be met with bafflement and will be seen as bizarre (MacNeela & Murphy, 2015), many asexual people choose to remain in the closet. As one explained, ‘I have not come out to anyone … because I do not think there is very much acceptance of asexuality as a valid sexual orientation. I am afraid that my friends would think there is something wrong with me … ’. (Robbins et al., 2016, p. 755). That psychiatrists and other mental health professional operate as if there is something wrong with individuals who say they experience little or no desire for sex – that they treat low/absent sexual desire as a mental disorder – represents another expression of epistemic injustice (Fricker, 2007).

Social Isolation. Asexual people’s anxiety over coming out increases the likelihood that they will keep their sexual identity to themselves, creating a barrier between them and others, including close friends and family members (Gupta, 2017a). That barrier – that experience of involuntary social isolation – represents another possible source of distress. Because asexual people are at heightened risk of social isolation, they are at heightened risk of going without a support network of people who can understand who they are and what they are going through (MacNeela & Murphy, 2015, p. 804). They are more likely to be excluded from conversations about sex and from social activities, such as parties, where the goal is to find a sexual partner. And because asexual people are rarely represented in books, movies, and TV – because there are few characters who openly identify in as asexual in popular culture – they often wonder whether they will ever be able to form the kinds of close human connections that non-asexuals have, the kinds that get talked about, celebrated, and prioritised (Jay, 2015).

Romantic/Sexual Conflict. Most asexual people seek companionship in romantic relationships that do not involve sexual activity (Brotto et al., 2010, p. 610), but they often have difficulty finding such relationships. This is largely because asexual people represent a small minority, so small it can be quite a challenge to find a suitable partner in the limited pool of candidates. As a result, asexual people may feel their romantic lives have been effectively reduced to two choices: either give up the ‘dating game’ entirely or settle for a non-asexual partner. Consider how a research subject from an article on asexual dating framed the problem:

Like it gets quite lonely, if you know what I mean and […] I’ve been on Tinder and things like that but it’s difficult to be in the dating game and try and be in a relationship when […] you want to find a partner and not have sex with them because everybody, I just feel like everybody, is out for it, pretty much (Vares, 2017, p. 524).

Because it is so hard to find a partner who wants a romantic relationship but does not want sex, asexual people often mismatch with partners who want a degree of sexual interest/activity that exceeds their comfort level. This results in several possible kinds of distress. One is fear that when the asexual person comes out to their non-asexual partner, the relationship will end (Van Houdenhove et al., 2014). Another is that the non-asexual partner will pressure the asexual partner to seek treatment for what is presumed to be their sexual problem (Gupta, 2017a). A third is that the asexual’s partner will demand more sexual interest/activity than the asexual partner is capable of feeling or giving (Van Houdenhove, et al., 2015, p. 270): the non-asexual partner may nag or threaten, or even use physical force such as ‘corrective rape’ (Mosbergen, 2013). This may explain why women with low sexual desire who are partnered with men report significantly higher levels of distress, as much as 4.63 times higher, than women who are single (Shifren et al., 2008).

The pressure to engage in unwanted sex in a pro-sex society can also come from asexual people themselves; it can be self-imposed, as when they believe their partner won’t like/love them if they don’t feign sexual interest or make some other kind of accommodation to meet their partner’s sexual needs (Fahs, 2010). They may feel it’s their duty to have sex – it’s what they signed up for in having the relationship – even if the sex is unwanted. The diagnostic problem here is, how can we say that these self-imposed efforts to perform unwanted/undesired sexual acts reflect mental health issues: ‘how do we disentangle women’s distress about desire from political and interpersonal pressures to project and enact a socially desirable sexual self?’ (Thomas & Gurevich, 2021, p. 91).

This is how one asexual woman explained why she consented to unwanted sex with her boyfriend:

The guy I lost my virginity to, I had been in a relationship with him for about a year and I guess I just felt like, well, you know, I need to do this … . I should have said no, but I didn’t. I thought that this is what everybody did in their free time, and so I was trying to be like everybody else (Gupta, 2017a, p. 998).

Dawson et al. (2016) correctly assert that consenting to unwanted sex is not unique to asexual people since all couples, to one degree or another, make accommodations for their sexual partners. At the same time, it is important to acknowledge that not all sexual accommodations are equal. Some are significantly less tolerable than others: when, for example, going along with unwanted sex does not feel like a choice – when it feels like something you must do or else—a mode of accommodation particularly common among women (Gavey, 2005, p. 136; Impett & Peplau, 2003), which may explain why women are more likely to fake sexual arousal and orgasm (Fahs, 2011; Muehlenhard & Shippee, 2010; Wiederman, 1997), tolerate sexual pain (Elmerstig et al., 2008); and prioritise a partner’s pleasure over their own (Elmerstig et al., 2013; McClelland, 2011; Nicholson & Burr, 2003).

Pathologization. This source of distress can be traced back to the first half of the twentieth century when mental health professionals began to promulgate the idea that everyone has an omnipresent and innate need for sex, and that those who do not express that need – those who deny, repress, or suppress their libido – are neurotic and require treatment (Freud, 1905/1962), an idea that continues to have great deal of currency. So that when Erik, a participant in Haefner and Plante’s (2015) study of asexuality, came out to his family, their reaction, ‘You should see a shrink. That can’t be normal’, not only pathologized and invalidated him, it also, presumably, increased his sense of social isolation (p. 280). To compound the problem, according to a study by Foster and Sherrer (2014), when asexual people go to mental health professionals for help, they anticipate that the professionals will reflect the same cultural bias: the belief that everyone is (and should be) sexual; they anticipate that professionals will see them as psychologically impaired and will attempt to treat their asexuality with some kind of intrusive, unwarranted therapy. Thus, one self-identified asexual person wrote, ‘It seems like therapists might be more interested in “fixing” my asexuality rather than just allowing me to explain how I feel’ (Foster & Sherrer, 2014, p. 426).

To summarise, if people with low/absent sexual desire are more likely to be silenced, excluded, misrepresented, and denigrated because of their sexuality – if they are more subject to negative judgement – they can be expected to experience more distress. Their distress, then, should not be seen as a sign of psychiatric dysfunction. It should be seen as a sign of social dysfunction – a sign of undue cultural, political, and interpersonal discrimination.

A presumption of pathology

Psychiatry has long promoted the idea that people with absent/low sexual interest/desire/arousal are mentally disordered whether they experience distress or self-identify as asexual. This section illustrates how this bias against absent/low sexual desire operates by examining two case studies – the only case studies – published by the American Psychiatric Association to serve as guides in diagnosing absent/low sexual interest/desire/arousal.

Case Example 1. This case study was originally published in the APA’s DSM-III Case Book: A Learning Companion to the Diagnostic and Statistical Manual in 1981 (Spitzer et al.), and was reproduced, word for word, in the 1989 DSM-III-R Case Book (Spitzer et al.), the 1994 DSM-IV Case Book (Spitzer et al.), the 2002 DSM-IV-TR Case Book, and the fifth edition of Comer’s Abnormal Psychology (2003). The case study concerns a married couple, Mr. B. and Ms. B., who ‘presents with the complaint that Ms. B. has been able to participate passively in sex “as a duty” but has never enjoyed it since they have been married’ (2002, p. 251). What should be noticed about this case study is that it consists almost entirely of a listing of the many ways that Ms. B. is indifferent to and/or repulsed by sex:

Although she periodically passively complied with intercourse, she had almost no

spontaneous desire for sex. She never masturbated, had never reached orgasm,

thought all variations such as oral sex as completely repulsive, and was

preoccupied with a fantasy of how disapproving her family would be if she ever

engaged in any of these activities (2002, p. 251).

The information contained in this excerpt – the documentation of Ms. B’.s negative feelings about sex – was the only information factored into her psychiatric diagnosis. Thus, the case study concluded, ‘The persistent absence of sexual fantasies and desire for sexual activity justify the diagnosis of Hypoactive Sexual Desire Disorder … . When she does have sexual intercourse, she probably does not become sexually excited, so the additional diagnosis [should be considered] of Female Sexual Arousal Disorder’ (2002, p. 252).

The most noteworthy feature of this case study is that it includes no information on (or inquiry into) how disliking sex impairs Ms. B.’s mental or social functioning. The case study simply assumes that absent/low sexual desire represents an abnormal behaviour variant and contains no discussion of how disliking sex increases Ms. B.’s distress or keeps her from performing life-enhancing activities outside of sex. And, despite the evidence of friction between Mr. B. and Ms. B. around the topic of sex (‘Her husband, although extraordinarily tolerant of the situation, is in fact very unhappy about their sex life’), at no point does the case study reflect the possibility that Ms. B.’s negative feelings about sex arise from the ways she and her husband interact. Was M. B. a difficult sex partner? Was he sexually inconsiderate or offensive in some ways? While Thomas and Gurevich (2021) argue that ‘It is important to consider whether low interest and arousal cause decreased satisfaction or whether less satisfying relationships lead to decreased interest and arousal’ (p. 83), the case study fails to acknowledge those distinctions. At no point does the case study reflect the possibility that Ms. B.’s unsatisfying relationship with her husband or with anyone else may have limited her capacity to enjoy sex. All that appeared to matter, in determining Ms. B.’s psychiatric diagnosis, is the absence of sexual interest/desire/arousal.

Case Example 2. This case study was published in the APA’s DSM-5: Clinical Case Studies (2014) and features an engaged couple, Ms. Olsen and Mr. Nelson, who have been bickering over the frequency of sexual activity. According to Ms. Olsen, her fiancé’s sexual needs are excessive: he wants sex every time they get together, often twice in the same night. On the other hand, he complains that she needs to get drunk before she can tolerate intercourse. Try as he might, nothing he does succeeds in bringing her to orgasm or arousing her sexually.

The case study concludes that Ms. Olsen does not meet the DSM-5 guidelines for female sexual interest/arousal disorder or female orgasmic disorder because, on the one hand, she has never enjoyed sex (‘her sexual issues have been lifelong, as opposed to acquired’) and because, on the other hand, ‘all these diagnoses’, according to the DSM-5, ‘require distress’ (Graham, 2014, p. 232). Mr. Nelson may feel unhappy about Ms. Olsen’s lack of sexual interest, but she does not. She appears to accept her status as a person with absent/low sexual interest – it feels ego-syntonic to her – and thus does not meet the DSM-5 threshold for a mental disorder. From a feminist perspective, this looks like progress. Ms. Olsen’s absent/low sexuality did not seem to warrant a psychiatric diagnosis. Her partner’s complaint was not treated as the final word on how to judge her sexuality.

At the same time, it is important to consider that while Ms. Olsen never complained about her own sexuality, the case study’s author always treated her sexuality as questionable or marginal. Indeed, the entire case study was devoted to sifting through the available evidence to confirm or disconfirm the possibility that Ms. Olsen suffers from ‘female sexual/interest/arousal disorder’. She was always treated as potentially dysfunctional/mentally disordered. While Ms. Olsen appeared to have had as many complaints about her fiancé’s sexuality as he had about hers, only she was considered for a psychiatric diagnosis.

From a diagnostic perspective, the most obvious issues surround Ms. Olsen … .

Looking at her issues from a DSM-5 perspective, Ms. Olsen has diminished

interest in sexual activities and reduced enjoyment of sex, which indicates the

possibility of female sexual interest/arousal disorder. She also does not

experience orgasm during sexual activity, which could indicate the possibility of

female sexual interest/arousal disorder (Graham, p. 232).

Consistent with the way psychiatry has assessed absent/low sexual desire for the past century, in this instance, the absence of sexual desire was treated only as a pejorative – as a sign of dysfunctionality. Mr. Nelson, the individual who wants sex every night and sometimes twice a night, was considered normal from the outset. His sexual behaviour was never questioned as a possible sign of a mental disorder, while the sexual behaviour of the one who found his sexual demands excessive and objectionable was treated as highly suspicious, requiring close psychiatric scrutiny.

Discussion

Psychiatry, as represented by the DSM-5 and DSM-5-TR, now accepts absent/low sexual interest/desire/arousal as normal when it occurs among individuals who identify as asexual. It also accepts absent/low sexual interest/desire/arousal as normal among individuals who, like Ms. Nelson, do not express dissatisfaction/distress about their sexuality. What remains unclear is why psychiatry continues to consider absent/low sexual interest/desire/arousal as an indicator of treatable abnormality in individuals who express dissatisfaction/distress and do not identify as asexual.

To be sure, psychiatrists and psychologists have long assumed that sexual desire can be influenced by psychotherapy (see Hitschmann & Bergler, 1936, Frigidity in Women: Its Characteristics and Treatment). Nonetheless, mental health professionals recognise that efforts to change an individual’s sexual orientation or implant sexual desire through psychotherapy have little or no scientific foundation (Haldeman, 1994). Even Masters and Johnson (1976), founders of the sex therapy discipline, asserted that the reflex pathways of sexual interest/desire/arousal are innate and cannot be instilled or taught: ‘This is like believing that we can be taught how to sweat or make our hearts beat’ (p. 549). Similarly, Brotto and Luria (2014) found little scientific basis for attempting to treat sexual desire: ‘Although the nonpharmacological treatments such as sensate focus, CBT, and mindfulness skills have a long history, evidence of their efficacy in the scientific literature is minimal’ (p. 35). Ter Kuile et al.’s (2012) assessment of the knowledge base for treating sexual interest/desire/arousal problems is even more guarded. Citing the almost complete absence of controlled outcome studies, randomised trials, and single subject and group experimental designs, the authors concluded there are no evidence-based psychological interventions for treating disorders of sexual desire (p. 421). Why, then, do psychiatrists and other mental health professionals continue to regard absent/low sexual interest/desire/arousal as a treatable mental disorder, particularly when assessing women’s sexual health?

One answer is that it represents a tradition – a time-honoured theoretical and clinical bias. Since Freud, mental health professionals have regarded sexual experience as natural, necessary, and healthful, and those who abstain, either because they lack interest, find sex aversive, or cannot become aroused, have been defined as either physically ill or psychologically repressed. As Flore (2014, p. 17) put it, ‘At the heart of scientific research and documentation of human sexuality is the presumption of a hidden, yet discoverable innate sexual desire … . Hence those individuals whose sexualities or absence thereof, do not fit into a scientific model of sexual normalcy appear in psychiatric frameworks … as disordered and pathological’.

A second reason why absent/low sexual desire continues to be regarded as a treatable psychiatric disorder, despite scientific evidence to the contrary, is that many people – particularly women – identify, and are identified, with it. It is a problem for which there is no shortage of clientele, with an estimated prevalence rate among women of thirty to fifty-five percent (Krasnow & Maglio, 2019). As Brotto and Velten (2020) explain, ‘A lack of interest in sexual activity that creates personal distress and strains relationship satisfaction is the most common reason women seek sex therapy’ (p. 14). While women are much more likely than men to see a therapist for absent/low sexual interest/desire/arousal, it is important to consider that they do so, only rarely, when single. According to Both et al. (2017), ‘Usually the complaint comes from women in a steady [heterosexual] relationship and is related to differences in sexual desire between her and her partner’ (p. 12). Apparently, heterosexual women who seek help with absent/low sexual desire feel obligated to coordinate their sexual needs and responses to those of their male partner. This is consistent with the DSM-5’s and DSM-5-TR’s (pp. 433, 489) stance that a woman’s lack of sexual responsiveness – the fact that she is ‘typically unreceptive to a partner’s attempts to initiate’ sex – should be seen as a reason for diagnosing her with ‘female sexual interest/arousal disorder’. By contrast, neither the DSM-5 or DSM-5-TR assume that a man’s lack of sexual ‘receptivity’ or ‘responsiveness’ should be seen as a sign of pathology. Women’s sexual normality, according to these guidelines, thus derives from their willingness to respond to their partner’s sexual demands, but men’s sexual normality does not.

We can see how this gender bias operates in clinical practice: in studies of sex therapy involving couples who show a discrepancy in sexual interest (where one partner wants more sex and the other less), therapists typically affirm men’s right to abstain from sex with their female partner but do not extend that right to heterosexual women seeking to abstain from sex. Instead, sex therapists often pressure women to be responsive/receptive to men’s sexual needs. The psychiatric stance which measures a woman’s sexual health by how receptive she is to her partner’s sexual needs may not have been designed to extort women’s sexual conformity, but that may be how it works. Therapists seem to assume that it is reasonable to ask a woman who shows little or no interest in sex to adjust to her male partner’s sexual expectations (Margolin, 2021a, 2021b).

Why does psychiatry and other mental health professions continue to treat absent/low sexual desire as a mental disorder, especially when the presumed disorder concerns women’s lack of desire? Leonore Tiefer (2002) provides one possible answer: ‘I think one can make a compelling argument that the main outcome has been to preserve “expert” authority over the new sexual opportunities being constructed by modern changes in gender, worklife, leisure and the self (cf. Cushman, 1995), and that medicalisation serves primarily to benefit practitioners and medical industries’ (p. 128). Hare-Mustin and Marecek (1990) provide another possible answer: ‘As long as male behaviour remains the standard in culture, women’s differences from men will be regarded as deficiencies’ (p. 14). To redefine asexuality as a normal psychological variant – to say that, other things being equal, among heterosexual couples, the partner who does not want sex is no less healthy and no more mentally disordered than the partner who wants sex – would require a potentially radical break in the way women’s and men’s sexual obligations and privileges are defined. In sex, like other domains of life in which men set the standard, more often than not, women are judged normal to the degree they match men’s expectations.

Conclusion

This historical comparison between how psychiatry has treated same-sex sexual desire and how it has treated absent/low sexual desire reveals that, while same-sex interest/desire/arousal was once seen as symptomatic of mental disorder but no longer is, absent/low sexual interest/desire/arousal continues to be treated as a diagnosable mental disorder. This inconsistency is troubling in and of itself but especially because it perpetuates the false belief that those who experience their sexuality differently than the heterosexual ‘sexusociety’ norm are less healthy and more dysfunctional. It is also troubling because of the implied gender bias. Women are more likely to experience absent/low sexual interest/desire/arousal than men and are more likely to be diagnosed with a sexual interest/desire/arousal disorder (Brotto & Velten; Krasnow & Maglio, 2019; Laumann et al., 1999; Meston & Stanton, 2017; Shifren et al., 2008). Women’s sexual desires, or the absence thereof, are, thus, more likely to be seen as abnormal. Since that judgement has long been used to pressure women to engage in sex they do not want, the unavoidable inference is that the psychiatric tradition of diagnosing absent/low as pathological has placed, and continues to place, women are at greater risk of sexual exploitation and abuse.

The remedy: stop treating absent/low sexual desire as abnormal. Put to rest the Freudian myth that someone who enjoys sex is healthier and more normal than someone who does not. Recognise that people are sexually different and are entitled to desire sex a lot, a little, or not at all – whatever feels right for them.

Disclosure statement

No potential conflict of interest was reported by the author.