Monday, July 2, 2012

Rethinking asexuality as a disorder

This post was inspired by an essay by Natalie Reed explaining why she thinks Gender Identity Disorder is a disorder, and the subsequent comments by Crip Dyke.

Asexuality shows some superficial similarity with Hypoactive Sexual Desire Disorder (HSDD) in the DSM-IV.  It's a similar situation to when homosexuality was classified as a mental disorder in the 70s.  Many asexuals argue that HSDD should be more narrow so as to definitively exclude asexuals.  Others argue that the validity of HSDD itself should be questioned.

I largely agree with these arguments, but I want to discuss one line of argument which is wrong.

"Categorizing asexuality as a disorder means asexuals are dysfunctional and broken, but we're not."

The basic problem presented by HSDD is the following equation: Asexuality = pathologization = stigmatization.  The above argument seeks to break the connection between asexuality and pathology, but takes for granted the connection between pathology and stigma.  This does a disservice to all other people with stigmatized mental disorders and medical conditions.  People with AIDS don't have the privilege of being able to excuse themselves from the medical category just so they can avoid the stigma.  Nor do people with bipolar disorder or OCD.

As a practical matter, breaking the connection between asexuality and pathology may reduce stigmatization. If we truly believe that asexuality is not a pathology, then this is a reason to make our case forcefully.  But the stigmatization is not in itself a reason to believe that asexuality is not a pathology.

Mental disorders are not really meant to stigmatize.

Roughly speaking, the purpose of the mental disorder category is to say, "The best response to these things is through the caregiver/patient paradigm, and possibly through public accommodations."  For example, if a person has seizures, this can be treated with drugs, and if they can't drive we can provide public accommodations such as mass transit.

There is some disagreement over what things are best treated with the caregiver/patient paradigm, but one guideline is that it should cause an impairment in an essential function, or marked distress.  But note that this is not the same as saying people are "broken" or "dysfunctional", since these terms are tools of stigmatization.

I do not think asexuality is best treated through caregiver/patient models.  Asexuality itself is not a problem to be solved.  Asexuality may interact with society and culture to cause problems, but the best response is an education campaign and new community structures.  That's the real reason why asexuality is not a disorder.*  That's the real reason homosexuality is not a disorder either.

*Mind you, there are additional more subtle reasons beyond the scope of this post.

Politics should follow facts.

We should not start with "Asexuality needs to be destigmatized" and immediately go to "Asexuality is not a disorder".  Rather, we should consider the question, "Is asexuality a disorder?" and then in light of its answer choose the best political strategy.  If the answer were "Yes," then we should campaign for destigmatization of disorders.  But the actual answer is "No," so we should campaign for the depathologization of asexuality, while keeping in mind that people with disorders should not be stigmatized either.


Larry, The Barefoot Bum said...

Really really good point about breaking the link between pathology and stigma. But, in general, psychological conditions are usually not even pathologized when they do not cause distress in the patient.

Since I'm a student, I have easy web access to the DSM-IV. And indeed, the diagnostic criteria for HSDD include the requirement for distress:

302.71 Hypoactive Sexual Desire Disorder

A. Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life.

B. The disturbance causes marked distress or interpersonal difficulty. [emphasis added]

C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Note criterion B, which occurs frequently in the DSM: If a patient is not distressed about something he or she feels (or doesn't feel) then it is usually not classified as a disorder. (There are exceptions.) Furthermore, removing the distress, rather than changing the condition that causes the distress, may be the best course of treatment.

Note too that the DSM goes on to note "a lack of normative age- or gender-related data on frequency or degree of sexual desire." Whether we take "normative" in this case in the moral or descriptive sense (I'm not too familiar with psych jargon), we don't know what's normative.

Larry, The Barefoot Bum said...

Also, there may be people who have "persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity," who experience "marked distress or interpersonal difficulty," and who want to restore sexual desire. I do not know how frequently professional psychologists, psychiatrists, and sex therapists can successfully restore sexual desire.

I'm not a professional psychologist, but as best I understand it, inclusion in the DSM is necessary for (or at least greatly facilitates) insurance-paid treatment. Removing HSDD from the DSM would inhibit people who actually are distressed from receiving treatment.

As best I recall, one of the strong arguments for removing homosexuality from the DSM was that ameliorating distress is the only scientifically valid treatment for feelings of distress caused by homosexuality; it is scientifically impracticable to reverse homosexuality. Feelings of distress about "normal" or ineluctable conditions are, I presume, treated in another category.

miller said...

As I emphasized in the post, the mental disorder category is ultimately about designating things to be treated in the caregiver/patient setting. There is some value-judgment involved in the category, since it's about what our response should be. The fact that most disorders have marked distress as a requirement is a statement about what we think is appropriate to treat in the caregiver/patient setting.

A related post is "Homosexuality and the Distress Criterion". As explained in that post, to call ego-dystonic homosexuality a disorder is to state that it is appropriate to either treat the distress, or to treat the homosexuality. I do not agree with this statement, thus I do not agree with the diagnosis.

HSDD is not quite parallel, because it isn't "ego-dystonic asexuality". One could imagine adding an exception to HSDD to exclude asexuals without completely gutting the diagnosis.

The Sociological Imagination article (linked at the top) is very insightful. Hinderliter called the DSM's note on the "lack of normative data" absurd. I am not sure why he thinks it is absurd, but if a certain level of sexual desire is appropriate to treat, then it would seem that it is appropriate to treat regardless of whether it is one or two standard deviations away from the mean.

Larry, The Barefoot Bum said...

the mental disorder category is ultimately about designating things to be treated in the caregiver/patient setting. There is some value-judgment involved in the category, since it's about what our response should be. The fact that most disorders have marked distress as a requirement is a statement about what we think is appropriate to treat in the caregiver/patient setting.

I don't understand what you mean here. Can you clarify?

The distress seems like a component of the diagnosis. If a patient does not feel distress, then his or her condition does not meet that criterion, and he or she does not have a disorder, literally by definition.

miller said...

Yes, marked distress is part of the definition of many disorders, but that's not good enough for the people writing those definitions in the first place. There's a logic underlying the definitions. I think the underlying logic is a value judgment about what things are appropriate to treat in a caregiver/patient setting. This idea comes from the paper I cited in my previous comment.

From there, we can add the additional statement that in most cases, conditions are only appropriate to treat this way if they cause marked distress. Thus most disorders will include distress in their definition, with a few exceptions. I wasn't disagreeing with you, just trying to clarify the rationale behind the distress criterion.

drransom said...

The "causes distress" criterion is also insufficient as it's overinclusive. The distress is often the result of the fact that whatever the condition makes you want to do is stigmatized and considered inappropriate. But you can't just offer the blanket statement that socially induced distress doesn't count, because now you're saying that the desire to have sex with children should never count as a disorder. So now you need some theory of what sorts of socially induced distress should be sufficient and which shouldn't.

In other words, I think labeling these things as disorders is irreducibly tied to some underlying moral theory.