In recent years, publicity about new treatments for men's erection problems has focused attention on women's sexuality and provoked a competitive commercial hunt for "the female Viagra." But women's sexual problems differ from men's in basic ways which are not being examined or addressed.
We believe that a fundamental barrier to understanding women's sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association (APA) for its Diagnostic and Statistical Manual of Disorders (DSM) in 1980, and revised in 1987 and 1994.2
It divides (both men's and) women's sexual problems into four categories of sexual "dysfunction": sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. These "dysfunctions" are disturbances in an assumed universal physiological sexual response pattern ("normal function") originally described by Masters and Johnson in the 1960s.3 This universal pattern begins, in theory, with sexual drive, and proceeds sequentially through the stages of desire, arousal, and orgasm.
In recent decades, the shortcomings of the framework, as it applies to women, have been amply documented.4
The three most serious distortions produced by a framework that reduces sexual problems to disorders of physiological function, comparable to breathing or digestive disorders, are:
1) A false notion of sexual equivalency between men and women. Because the early researchers emphasized similarities in men's and women's physiological responses during sexual activities, they concluded that sexual disorders must also be similar. Few investigators asked women to describe their experiences from their own points of view. When such studies were done, it became apparent that women and men differ in many crucial ways. Women's accounts do not fit neatly into the Masters and Johnson model; for example, women generally do not separate "desire" from "arousal," women care less about physical than subjective arousal, and women's sexual complaints frequently focus on "difficulties" that are absent from the DSM.5
Furthermore, an emphasis on genital and physiological similarities between men and women ignores the implications of inequalities related to gender, social class, ethnicity, sexual orientation, etc. Social, political, and economic conditions, including widespread sexual violence, limit women's access to sexual health, pleasure, and satisfaction in many parts of the world. Women's social environments thus can prevent the expression of biological capacities, a reality entirely ignored by the strictly physiological framing of sexual dysfunctions.
2) The erasure of the relational context of sexuality. The American Psychiatric Association's DSM approach bypasses relational aspects of women's sexuality, which often lie at the root of sexual satisfactions and problems--e.g., desires for intimacy, wishes to please a partner, or, in some cases, wishes to avoid offending, losing, or angering a partner. The DSM takes an exclusively individual approach to sex, and assumes that if the sexual parts work, there is no problem; and if the parts don't work, there is a problem. But many women do not define their sexual difficulties this way. The DSM's reduction of "normal sexual function" to physiology implies, incorrectly, that one can measure and treat genital and physical difficulties without regard to the relationship in which sex occurs.
3) The levelling of differences among women. All women are not the same, and their sexual needs, satisfactions, and problems do not fit neatly into categories of desire, arousal, orgasm, or pain. Women differ in their values, approaches to sexuality, social and cultural backgrounds, and current situations, and these differences cannot be smoothed over into an identical notion of "dysfunction"--or an identical, one-size-fits-all treatment.
Because there are no magic bullets for the socio-cultural, political, psychological, social or relational bases of women's sexual problems, pharmaceutical companies are supporting research and public relations programs focused on fixing the body, especially the genitals. The infusion of industry funding into sex research and the incessant media publicity about "breakthrough" treatments have put physical problems in the spotlight and isolated them from broader contexts. Factors that are far more often sources of women's sexual complaints--relational and cultural conflicts, for example, or sexual ignorance or fear--are downplayed and dismissed. Lumped into the catchall category of "psychogenic causes," such factors go unstudied and unaddressed. Women with these problems are being excluded from clinical trials on new drugs, and yet, if current marketing patterns with men are indicative, such drugs will be aggressively advertised for all women's sexual dissatisfactions.
A corrective approach is desperately needed. We propose a new and more useful classification of women's sexual problems, one that gives appropriate priority to individual distress and inhibition arising within a broader framework of cultural and relational factors. We challenge the cultural assumptions embedded in the DSM and the reductionist research and marketing program of the pharmaceutical industry. We call for research and services driven not by commercial interests, but by women's own needs and sexual realities.
Sexual Health and Sexual Rights: International Views
To move away from the DSM's genital and mechanical blueprint of women's sexual problems, we turned for guidance to international documents. In 1974, the World Health Organization held a unique conference on the training needs for sexual health workers. The report noted: "A growing body of knowledge indicates that problems in human sexuality are more pervasive and more important to the well-being and health of individuals in many cultures than has previously been recognized." The report emphasized the importance of taking a positive approach to human sexuality and the enhancement of relationships. It offered a broad definition of "sexual health" as "the integration of the somatic, emotional, intellectual, and social aspects of sexual being."6
In 1999 the World Association of Sexology meeting in Hong Kong adopted a Declaration of Sexual Rights.7
"In order to assure that human beings and societies develop healthy sexuality," the Declaration stated, "the following sexual rights must be recognized, promoted, respected, and defended":
- The right to sexual freedom, excluding all forms of sexual coercion, exploitation and abuse;
- The right to sexual autonomy and safety of the sexual body;
- The right to sexual pleasure, which is a source of physical, psychological, intellectual and spiritual well-being;
- The right to sexual information...generated through unencumbered yet scientifically ethical inquiry;
- The right to comprehensive sexuality education;
- The right to sexual health care, which should be available for prevention and treatment of all sexual concerns, problems, and disorders.