I am not a doctor. I am not your doctor. This is not medical advice.
The exchange refers to the 5th edition of the Diagnostic and statistical manual of mental disorders (DSM-5). The gist of the exchange is that the DSM-5 allegedly pathologises asexuality, categorising it as a mental disorder under the label hypoactive sexual desire disorder (HSDD).1 What follows is a scathing review of the DSM-5 and its publisher, the American Psychiatric Association, for supposed discrimination against asexuality, based on what I believe is an incomplete or incorrect characterisation of HSDD and the DSM-5.
To be clear, the DSM-5 is very much a flawed document, and its treatment of HSDD could very much be improved – but not for the reasons described in the Tumblr exchange.
What actually is HSDD?
The DSM-5 criteria for (male) HSDD are:
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. […]
B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by […] significant stressors […] or another […] condition.2
The reference to ‘another […] condition’ in criterion D includes nonsexual mental disorders such as depression, and other medical conditions such as hypogonadism. The DSM-5 also notes that:3
If the […] low desire is explained by self-identification as an asexual, then a diagnosis of […] hypoactive sexual desire disorder is not made
Clearly, the DSM-5 does not ‘pathologise asexuality’ per se. On the contrary, the DSM-5 explicitly acknowledges that asexuality in and of itself does not constitute HSDD.
What, then, is HSDD? The answer lies in criterion C: that the low sexual interest must cause ‘significant distress’. The ‘pathological’ part of HSDD is not specifically low sexual interest, it any distress that may be associated with it.
Are there circumstances where an asexual person could be diagnosed with HSDD?
As above, a person who identifies as asexual explicitly cannot be diagnosed with HSDD.
We could imagine, however, a person who has low sexual interest due to or in association with an asexual orientation, but who does not actually identify as asexual, perhaps because they have never been introduced to the concept before. This is not a rare occurrence within the asexual community, nor would be it at all unusual for the person to feel distress as a result of feeling different, ostracised or an outsider.
In this setting – yes, that person could potentially be diagnosed with HSDD. But as before, the diagnosis is not because the person is or may be asexual – it is purely because of the distress. When the distress is significant, the criteria for HSDD simply puts a name to that distress – distress which can be helped. Similarly, as we will see below, applying the label of HSDD does not suggest that the ‘asexuality’ is the problem to be ‘fixed’ – the issue, which we can help with, is the distress.
What does the DSM-5 say about the management of HSDD?
The Tumblr exchange goes on to draw connections between the DSM-5 and the peddling of medications to supposedly treat HSDD.4 Similarly, the Aces, Aros and Enbies post brings up ‘unwarranted “treatment” of […] asexuality’. Does this hold water?
Clearly, the DSM-5 says nothing about ‘treatment’ of asexuality, since, as above, the DSM-5 does not ascribe any disorder to asexuality per se.
What, then, about HSDD?
Recall that DSM stands for ‘diagnostic and statistical manual’. That is exactly the scope of the DSM: it sets out the criteria for diagnosing a listed condition, and supplies statistics about them. The DSM says very little in general about the management of any of the conditions, and the same is true of HSDD – the DSM-5 says not a word about the management of HSDD.
When the management of HSDD is outside the scope of the DSM-5, then responsibility any unwarranted ‘treatment’ of clients with HSDD necessarily cannot be laid solely at the feet of the DSM-5 and APA.
What, then, should be the management of HSDD in the setting of potential asexuality?
The association of a label to distress relating to sexual orientation is not new. Until the DSM-III-R (1987), the condition egodystonic homosexuality was a diagnostic category within the DSM. In the International statistical classification of diseases and related health problems, 10th revision (ICD-10), which is the version in current use at the time of writing, egodystonic sexual orientation is included as a diagnostic category.
The ICD-10 defines egodystonic sexual orientation as where a person's ‘gender identity or sexual preference […] is not in doubt, but the individual wishes it were different’.5 As with HSDD, sexual orientation by itself is ‘not to be regarded as a disorder’ – a disorder only arises when there is associated distress.
Broadly, two possible approaches present themselves: either to attempt to change the person's sexual orientation to conform to their desires (i.e. conversion therapy and sexual orientation change efforts), or to support the person and enable them to find acceptance.
Surprise, surprise, only one of these works.6
Analogously, it seems only reasonable that where HSDD is associated with a sexual orientation (whether or not that person is aware of it at the time), the most ethical and justifiable management is to support that person and enable them to find acceptance. This is entirely appropriate with the DSM-5: if the problem is the distress, then remedy the distress.
So what is the problem, and where do we go from here?
Clearly, the experiences of asexual people are not perfect, as they could be on paper. Significant discrimination and stigma continue to persist.
The DSM-5 has been used as a weapon against asexual people, bolstered by incorrect information perpetuated by websites that do not clearly reproduce the DSM-5's position. It is easy to imagine that someone acting in poor faith could open the DSM-5, or an inaccurate summary of it, read the criteria about low sexual interest, miss or ignore the criteria on distress and specific exclusions on asexual people, and spin this into an attack on asexual people.
We must remember that the DSM-5, however, is not designed for consumption in this setting. In the DSM-5's own words, it is intended ‘to assist trained clinicians in the diagnosis of their patients' mental disorders’. In the hands of trained clinicians, acting in good faith, who are up-to-date on the literature and evidence, the DSM-5 and HSDD criteria can lead to positive outcomes. Discrimination and stigma furthered in connection with HSDD are not an inherent element of the DSM-5 itself, but are primarily consequences of its misuse.7
Even though the DSM-5 may not be the ‘problem’, however, that does not mean that it can't be part of the solution. There are a number of areas in which the DSM-5 can be improved, and from a general perspective, this is well understood within the mental health sector. In relation to HSDD specifically, for example:
Greater clarity could be provided around HSDD criteria. The current DSM-5 speaks apparently interchangeably about ‘sexual thoughts’, ‘desire for sexual activity’, ‘sexual interest’, ‘sexual arousal’ and ‘asexuality’. Within the asexual community, and increasingly in the research context, however, these concepts are regarded as totally distinct. Asexuality is characterised specifically as lack of sexual attraction, irrespective of what ‘thoughts’ or ‘desires’ they may have regarding sexual behaviour, which is again distinct from libido, sex drive or ‘arousal’ in a physical sense.
Greater direction could be provided about the differential diagnosis and assessment of HSDD. During the assessment stage, there may well be diagnostic overlap between HSDD and asexuality that needs to be cleared up. While the DSM-5 acknowledges that self-identification of asexuality precludes a diagnosis of HSDD, it offers no guidance as to how to reach that point. Current literature is also lacking in this regard, typically assuming that the diagnosis of HSDD has already been correctly made.8
The category of HSDD could be removed entirely, provided a suitable alternative is clearly in place to assist clients with distress. While there may be nothing technically wrong with HSDD as a category, its presentation as a distinct entity may have an adverse ‘signalling’ effect. In conjunction with effective broad change in destigmatising asexuality, the removal of the diagnosis may signal this to the community. This mirrors the removal of egodystonic sexual orientation from the upcoming edition of the ICD, ICD-11, on the basis that ‘concerns […] can well be addressed using other ICD categories’.9 The argument then is not so much that it is wrong to have a label, but that this particular label is similar enough to an an alternative less socially loaded label that there is no need to specifically carve out sexual desire as an edge case.
Discrimination against asexual people is clearly real, and changes to the DSM could be part of addressing that. But I contend that to demonise the DSM-5 and make out that this should be because the DSM-5 is supposedly the root of the problem is unjustified.
It is important not only to be right, but to be right for the right reasons.
In the DSM-5, the condition referred to in the previous edition as ‘hypoactive sexual desire disorder’ was split into 2 gender-specific conditions: male hypoactive sexual desire disorder and female sexual interest/arousal disorder. I find this to be extremely questionable and problematic, but that is a topic for another time. I will use HSDD to refer generally to both DSM-5 conditions. ↩
Diagnostic and statistical manual of mental disorders: fifth edition. Virginia: American Psychiatric Association; 2013 [cited 2020 Sep 19]. Sexual dysfunctions. doi: 10.1176/appi.books.9780890425596.dsm13 ↩
There has been some suggestion that print copies of the DSM-5 did not contain these statements. While there have been updates to the references cited, this does not appear to be the case : Hinderliter A. Sexual dysfunctions and asexuality in DSM-5. In: Demazeux S, Singy P, editors. The DSM-5 in perspective. (History, philosophy and theory of the life sciences; vol. 10). Dordrecht: Springer. doi: 10.1007/978-94-017-9765-8_8 ↩
Specifically, female sexual interest/arousal disorder. ↩
International statistical classification of diseases and related health problems. 10th revision. Geneva: World Health Organization: 2019 [cited 2020 Sep 19]. Chapter V, Mental and behavioural disorders. https://icd.who.int/browse10/2019/en#/F66.1 ↩
Guidelines for psychological practice with lesbian, gay, and bisexual clients. Washington (DC): American Psychological Association; 2011 [cited 2020 Sep 19]. https://www.apa.org/pi/lgbt/resources/guidelines ↩
Indeed, in this context, to change the DSM-5 alone would accomplish little. To take the example of egodystonic sexual orientation as an example, without a broader agreement among clinicians that sexual orientations are not mental disorders, removing the diagnostic category alone may make matters worse. If clinicians tend to act in bad faith around egodystonic sexual orientation, then to remove that label as an option may simply lead those clinicians to act in bad faith about a different label – for example, to diagnose those clients instead with obsessive-compulsive disorder. The ‘falling back’ to a less-relevant label would arguably be even worse. ↩
Cochran SD, Drescher J, Kismödi E, et al. Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11). Bulletin of the World Health Organization. 2014 Jun 17; 92: 672–79. doi: 10.2471/BLT.14.135541 ↩