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Classifying Sexual Dysfunctions, Their Root Causes, and Historical Evolution
Abnormal Psychology · Chapter 17: Sexual Health, Gender Identity, and Atypical Sexual BehaviorsSection 17.1 · lesson 60 of 9713 min · free with a free account
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In this lesson
Distress, not deviation - and a history that argues for caution.
- Describe the linear and circular models of sexual response
- Explain the shared requirements and the specifiers
- Identify biological, psychological, relational, and sociocultural contributors
- Trace the field's history, and what it teaches
Transcript
Everything said in the video, section by section (1,787 words). Read along, or search it.
Sexual Health, Gender Identity, and Atypical Sexual Behaviors
Classifying Sexual Dysfunctions
Chapter seventeen turns to sexual health, gender identity, and atypical sexual behaviors. This first section is about how sexual dysfunctions are classified. We look at the two models of sexual response used in clinical practice, and at the requirements every category shares. We look at the four domains that contribute to these difficulties. And we trace the history of the field, because that history is the strongest argument there is for using current categories with care.
Before You Begin
Scope and Boundaries
First, the framing. This is educational and clinical material. It is not a basis for self-diagnosis, or for diagnosing anyone else. Anyone with concerns about sexual functioning should speak with a qualified professional, and medical assessment is part of that. Two boundaries are set here, and they hold for the whole chapter. The first is consent. This section concerns consensual adult sexual functioning only. Behavior involving a person who has not consented, or who cannot consent, is never a dysfunction. It belongs to later sections, where consent is the organizing principle. The second boundary is that gender identity has nothing to do with this material. It is developed separately, at the end of the chapter. Everything here is described in clinical terms. That is a professional requirement, and a practical one. A student who can think in clinical language is better placed to have these conversations.
Normal Variation
A Very Wide Ordinary Range
Start with normal variation, because it is enormous. Sexual interest, frequency of activity, and preference vary widely between people, and across a single person's life. Interest rises and falls with health, sleep, workload, mood, relationship circumstances, and age. Very high interest and very little interest are both within the ordinary human range. Asexuality, meaning an orientation with little or no sexual attraction to others, is an orientation. It is not a dysfunction. Its exclusion is written into the diagnostic requirements. And treating it as a difficulty to be corrected is an error with a documented history behind it. So variation alone is never the clinical criterion. Something else has to be present.
The Criterion
Distress and Impairment - but Whose?
That something is distress or impairment. A difficulty becomes clinical when it causes the person distress, or interferes with their functioning. That sounds simple, and it is not, because distress in this area often originates outside the person. Compare two situations. In the first, a person is troubled by a change in their own sexual response, and would like it to be otherwise. In the second, a person is untroubled by their own experience. They are distressed because a partner is dissatisfied, or because they have absorbed an expectation of what is normal. The classification requires the distress to belong to the person. And it explicitly excludes difficulties better explained by relationship distress, or by another significant stressor. So part of the clinical task is establishing whose distress is driving the presentation. Getting that wrong pathologizes one member of a couple for a difference that belongs to the couple. It is a common error, and a consequential one.
Table 17.1.1
How the Field Evolved
Now the history, laid out period by period. In the nineteenth century, sexual behavior outside a narrow norm was taken to indicate disease. What changed that was accumulating evidence that the behavior was common, and the treatments harmful. In the mid-twentieth century, large-scale research described what people actually reported doing. It showed the ordinary range was far wider than the clinical literature had assumed. Later, laboratory research on physiological response produced the first stage model of sexual response, making function something that could be studied, rather than only asserted. Then a distinct field of sex therapy emerged, with brief, focused treatment replacing the assumption that years of general psychotherapy were needed. And the current view, that distress and impairment define a difficulty, followed the removal of homosexuality from classification, and the criticism that came after it. Notice how often the correction came from description, rather than from theory.
The Lesson
Why History Is Not Decoration
This history is not decoration. It should be read as an argument. In the nineteenth century, a wide range of ordinary sexual behavior was classified as disease, and treated accordingly, sometimes with interventions that caused lasting harm. What was really being classified was conformity to social expectation, described in medical language. The removal of homosexuality from classification, covered in chapter eight, is the clearest documented case of a category that encoded social disapproval rather than clinical observation. The lesson is not that the current classification is wrong. It is that this area has repeatedly mistaken social norms for pathology, and that the mistakes were not obvious at the time to the people making them. So a category that pathologizes difference, rather than distress, deserves scrutiny before it is applied.
Models of Sexual Response
2 Models in Clinical Use
Two models of sexual response are in current clinical use, and the difference between them decides who gets described as having a problem. The linear stage model describes response as a fixed sequence of stages, each following the last. Desire was later added as the first stage, and the classification broadly follows this model. Its contribution was real. It gave the field a shared vocabulary, and made it possible to specify which part of a response was affected. Its limitation is that it treats spontaneous desire as the starting point of every encounter. Circular models describe a different sequence. A person may begin from willingness rather than desire. Arousal builds in response to context and stimulation, and desire emerges afterwards. Emotional closeness and satisfaction then feed back into willingness next time. For many people, especially in long-standing relationships, this describes experience better than the linear account does.
Figure 17.1.2
Look at Where Desire Sits
Look at where desire sits in each model. In the linear model, desire comes first, and drives everything after it. In the circular model, it arrives late. Willingness comes first, then context and stimulation, then arousal, and desire emerges after that. Closeness and satisfaction feed back into the next occasion. That single difference determines whether a common experience is read as ordinary, or as a disorder. If a clinician holds the linear model as the norm, they will hear an account of responsive desire as evidence of a deficit. A clinician who holds both models will hear it as one of two ordinary patterns. The next section develops this further.
Table 17.1.3
Classified by What Is Affected
The current classification groups sexual dysfunctions by the aspect of function affected. Desire and interest difficulties affect interest in, and motivation toward, sexual activity. Arousal difficulties affect the physiological and subjective response once activity begins. Both are developed in the next section. Orgasm-related difficulties, and genito-pelvic pain and penetration difficulties, are developed in the section after that. And two further categories cover any of these, when a substance or medication, or another medical condition, accounts for it. Those are assessed medically. Notice the organizing principle. The classification is built around what is affected, not around presumed cause.
Requirements and Specifiers
What All the Categories Share
All of these categories share a common set of requirements, described here by their function, with no threshold values. The difficulty must have persisted for a specified minimum period, and occurred on most occasions. It must cause clinically significant distress to the person. And it must not be better explained by another mental condition, by relationship distress or other stressors, or by a substance or medical condition. Two pairs of specifiers apply across the categories. A difficulty is lifelong if it has been present since the person became sexually active, and acquired if it began later. It is generalized if it occurs across situations and partners, and situational if it is confined to particular circumstances. These are informative. An acquired, situational difficulty points toward something in the current context. A lifelong, generalized one points elsewhere. A clinician who takes only the presenting complaint, and not the specifiers, has lost most of the assessment information available.
Table 17.1.4
4 Domains of Contributors
Contributions fall into four domains. In practice they are almost never separable, and a formulation that names only one is usually incomplete. Biological contributors include vascular, neurological, hormonal, and general health factors, and medication effects, which are named at class level only. A person who notices a change after a change in treatment is describing something real, and worth raising with their prescriber. Psychological contributors include performance anxiety, depressive presentations, stress, and beliefs about what should happen. Relational contributors include conflict, resentment, communication, and pressure. Sociocultural contributors include sexual scripts and misinformation. Notice the first row. Medical assessment is not one option among four. It belongs in every case. And a psychological formulation never removes that requirement.
Mechanisms
Spectatoring, Pressure, and Scripts
Three mechanisms deserve a closer look. Performance anxiety is the most frequently involved psychological contributor, and its central mechanism is spectatoring. That is the shift of attention during activity, away from the experience itself, and toward monitoring and evaluating one's own performance. Attention is a finite resource. What is spent on observation is not available for engagement. And the resulting drop in response confirms the fear that started the monitoring. Pressure is the second. A partner's frustration, however understandable, tends to increase pressure, and pressure is among the most reliable suppressors of sexual response there is. That is why a difficulty within a couple is often best formulated at the level of the couple, rather than located inside one person. And third, sexual scripts, the culturally supplied expectations about how an encounter should go, shape both what people expect, and what they conclude their experience means.
In the Clinic
When a Couple Presents: Who Is Troubled?
When a couple presents, the first question is not what is wrong. It is who is troubled, and by what. Three patterns recur. In the first, one person is distressed by their own experience, and the formulation is largely individual. In the second, both are distressed by a difference between them, and the formulation belongs to the couple. In the third, one person is distressed only because the other is. The clinical task is to say so clearly, rather than accept the referral as framed. Treating the third pattern as though it were the first produces a diagnosis where none belongs. And it confirms to the person that they are the problem.
Assessment
Rarely Raised Unless Someone Asks
Finally, assessment, which starts from a hard fact. People rarely raise these difficulties unless a clinician asks. They expect embarrassment. They expect the clinician to be uncomfortable. And they often do not know anything can be done. So a difficulty of years' standing can sit unmentioned through several consultations. Assessment has three components. Medical assessment, for physical and medication-related contributions. A clinical interview, covering onset, course, context, the specifiers, the person's beliefs, and whose distress is at issue. And, where a partner is involved, assessment of the relationship. The interview needs a stance rather than a technique. Respectful, unhurried, and asked as routinely as any other question. And it must not assume orientation, relationship structure, or practice. Assumptions show in the phrasing of a question, and people answer the question they were actually asked.
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