What's 'normal' sex? Shrinks seek definition Controversy erupts over creation of psychiatric rule book's new edition

By Brian Alexander

MSNBC contributor

updated 3:33 a.m. PT, Thurs., May. 22, 2008

This month the American Psychiatric Association announced the names of “working group” members who will guide the development of the new Diagnostic and Statistical Manual of Mental Disorders, or DSM, the codex of American psychiatry.

Not surprisingly, given the DSM’s colorful history, particularly when it comes to sex, controversy erupted within days of the announcement, especially over membership of the Sexual and Gender Identity Disorders working group, which will wrestle with questions such as: Are sadomasochism or pedophilia mental disorders? Are dysfunctions like female hypoactive sexual desire disorder (low sex drive) psychiatric issues, or hormonal issues? Perhaps the most important question is whether, when it comes to many sexual interests and issues, it’s even possible or desirable to create diagnostic criteria.

At least one petition, spearheaded by transgender activists, is being circulated to oppose the appointment of some members to the Sexual and Gender Identity Disorders work group and its chair, Kenneth Zucker, head of the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto, Canada. The petition accuses Zucker of having engaged in “junk science” and promoting “hurtful theories” during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy.

Zucker rejects the junk-science charge, saying that there “has to be an empirical basis to modify anything” in the DSM. As for hurting people, “in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.”

That sex is controversial comes as no surprise to Dr. Darrel Regier, the vice-chair of the APA’s DSM-V Task Force, based in Arlington, Va.

Sex, he says, in an understatement, “is an area that obviously has lots of emotion attached to it.” But the APA, he says, is doing its best to put science and evidence first, both in who it appoints to working groups and in the process it will use to create the DSM-V (so called because it is the fifth complete version). Each working group will accept input from many experts with varying views, reach a consensus on DSM content, and then put that work group’s product before the board of trustees of the APA and the APA assembly.

All that may be true, but Regier does not expect such reassurances to quell the forces already swirling around the DSM-V as it moves toward a 2012 publication date. Currently, the DSM-IV includes sex-related activities as varied as paraphilias like voyeurism, klismaphilia (erotic use of enemas) and sadism, and functional disorders like dyspareunia (pain with intercourse), erectile disorders and premature ejaculation.

'A set of scientific hypotheses'
The first DSM was issued in 1952. The idea was to create a more standardized way of talking about psychiatric disorders. As psychiatrist Dr. Gail Saltz, a TODAY Show contributor who also practices in New York, explains, the DSM is best viewed as “a language we have chosen to speak, a talking point we mental health professionals have created to communicate as well as we can with each other and with other professions.”

It is not a final arbiter of who’s crazy and who’s not. Saltz, who says she thinks the DSM can be limiting in clinical practice, prefers to take a holistic approach and look at each patient’s collection of symptoms and concerns without being restricted by the DSM’s various criteria.

Regier agrees that’s how doctors should use it, arguing that the DSM “really needs to be seen as a set of scientific hypotheses.” It is, he believes, “a living document” changeable with new research.

But if the DSM is a book of “hypotheses,” why the fuss? Does the DSM matter?

Yes. A lot.

The first reason why is prosaic. If you want your insurance to reimburse your visit to a mental health professional, you are probably going to need a DSM code signifying a diagnosis.

But the more profound reason is that it shapes how doctors, even the rest of rest of society, view sexuality.

“A psychiatric diagnosis is more than shorthand to facilitate communication among professionals or to standardize research parameters,” wrote Dr. Charles Moser and Peggy Kleinplatz in a 2005 paper published in the Journal of Psychology and Human Sexuality. “Psychiatric diagnoses affect child custody decisions, self-esteem, whether individuals are hired or fired, receive security clearances, or have other rights and privileges curtailed. Criminals may find that their sentences are either mitigated or enhanced as a direct result of their diagnoses. The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas. A review of this area is not only a scientific issue, but also a human rights issue.”

A problem for whom?
There is no shortage of opinion on what ought to be changed, deleted or included in the new DSM-V. Sandra Leiblum, formerly a professor at New Jersey’s Robert Wood Johnson Medical School and an expert in female sexual health who is now in private practice in Bridgewater, N.J., says she wants to see a revision of diagnoses of female hypoactive sexual desire disorder, other female arousal disorders and sexual pain like dyspareunia. For example, she wants language that would separate arousal disorders into genital (more biological in origin) and subjective subtypes.

Carol Queen, a sexologist, sexual rights activist and co-founder of San Francisco’s Center for Sex and Culture, believes the new DSM should stress that sexual variances are only a problem “if they are problems in the life of the person showing up” in a psychiatrist’s office “so that when somebody is eroticizing something, or doing something in a consensual way, that’s not a problem” even if it may seem odd to most of us.

She also proposes an addition, a diagnosis of “absexual” (“ab” meaning “away from”). This would include those who appear to be “turned on by fulminating against it.” Examples could include state governors who crusade against prostitution even while paying hookers for sex, and religious leaders who wind up trying to explain engaging in the sex acts they preach against.

Moser, who is affiliated with the Institute for Advanced Study of Human Sexuality in San Francisco, and Kleinplatz, from the University of Ottawa, argue that all paraphilias, like sexual sadism, sexual masochism, transvestism, should be removed from the DSM, insisting that “the DSM criteria for diagnosis of unusual sexual interests as pathological rests on a series of unproven and more importantly, untested assumptions.”

This does not mean, as opponents of this idea have suggested, that they somehow approve of sex between adults and children. “We would argue that the removal of pedophilia from the DSM would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes," they wrote. "Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred.”

Most of these suggestions are inherently political, as much as the APA and most psychiatrists would wish to avoid politics. Sex exists as part of the culture, and it cannot be separated from it.

The DSM has reflected cultural shifts through its revisions and new editions. The most famous example is homosexuality. When the first DSM was created in 1952, homosexuality was declared a mental illness. By 1973, and after much heated debate and over objections from religious conservatives, the DSM-II excluded homosexuality as a disorder with the exception of one variant, and that was soon dropped in an interim revision.

Once deviant, now desirable
“Definitely a change in culture affects diagnoses,” Leiblum says. “We used to think oral-genital sex was deviant and we have embraced that. Masturbation was evidence of out-of-control behavior, now we see it as not only normative but to be encouraged.”

So if enough people start to do it, or are more public about doing it, does that mean it is no longer a disorder? “I think it probably affects the degree to which people are willing to look at scientific evidence,” Regier says.

This fuzziness is why, starting in the 1980s, the field moved toward adding the notion of “distress” to the DSM.

“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” explains Regier. “I would say also if there is no victim involved … this behavior is not imposing a person’s will on another person, that is a critical component when one looks at conditions in this area.”

If you aren’t distressed, and everyone is a consenting grown-up, then there probably isn’t a disorder. But things won’t be that simple for the creators of the new DSM.

“How do you make a criteria that does not pathologize low desire?” Leiblum asks rhetorically. You add the need to be distressed about it. “But then whose distress should be looked at?” she asks, referring to a sexual partner. “You can have hypertension and not feel any distress because there is objective criteria for what is high blood pressure. But there is none of that for sexual diagnoses, even premature ejaculation. What constitutes premature?”

(At a press conference Monday, the International Society of Sexual Medicine made a stab at a definition, saying premature ejaculation is "a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration; and, inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.”)

This problematic lack of clarity, Leiblum argues, is especially acute for the paraphilias. Does the criteria amount to “If it’s mine it’s OK, but if it’s yours it’s kinky? These issues need to be grappled with.”

Brian Alexander is the author of the new book “America Unzipped: In Search of Sex and Satisfaction."

© 2008 MSNBC Interactive

URL: http://www.msnbc.msn.com/id/24664654/from/ET/

interview

Among the Sex Wonks

Bonk: The Curious Coupling of Science and Sex
by Mary Roach
W.W. Norton (2008)

Mary Roach. Photo by Phoebe Rachlis.

By Don Hazen and Tana Ganeva

AlterNet.org

April 28, 2008

It turns out there is quite a bit of variability in the distance between the clitoris and the vagina.

Princess Marie Bonaparte -- great grandniece of Napoleon and an accomplished amateur scientist -- discovered this tidbit of information in her doomed quest for the elusive vaginal orgasm. Bonaparte measured the genitals of 243 women and concluded that women with a shorter span between their clitoris and vagina were more likely to orgasm during sex.

Armed with this information, Bonaparte decided to subject herself -- twice -- to having her clitoris surgically moved.

Alas, it was to no avail. As we learn in Mary Roach's new book Bonk: The Curious Coupling of Science and Sex, the princess's story did not have a happy ending. (Ironically Bonaparte moved on to psychoanalysis and became a devotee of Sigmund Freud, an arch-enemy of the clitoral orgasm).

If informational nuggets like this turn you on, then Roach's hilarious overview of sex research throughout history is for you. Bonk features hundreds of surprising and amazing facts that Roach gathered in her investigation of the science of sex. Here are just a few eye-openers: In the 1970s, Masters and Johnson observed that homosexuals were far better lovers than heterosexuals, perhaps because of gender empathy; women are more likely to have risky affairs when their hormones are peaking; rhesus monkeys climax within five seconds of entering their partner, giving new meaning to the term quickie; more than a few men throughout history have had animal testes grafted onto their genitals in the hopes of increasing their virility.

Let's be clear, though. Sex research is not an exact science, given the mysterious, unquantifiable factors like emotion, attraction and "sexual chemistry" that influence sexuality. But some things are pretty obvious, observable, and predictable nevertheless, and we find out what happens in the laboratories of sex throughout history. It is not always a pretty picture, but one that is often hilarious.

Bonk profiles the great pioneers of the science of sex, like Alfred Kinsey and the aforementioned Masters and Johnson, as well as dozens of lesser lights who undertook brave, creative, or just plain wacky experiments in their pursuit of knowledge.

And the best part in reading this book is that Roach is damned funny. Experiencing Roach in Bonk provides the "full monty" of reading non-fiction. You are titillated, you learn hundreds of new fascinating, and sometimes ludicrous things about sex and human behavior, and you often laugh your butt off. Consider the British study that found 351 terms for penis, including "the one-eyed milkman," but only three for the clitoris, which by the way doubles in size when stimulated and is far more erogenous than the penis.

Roach goes everywhere to learn about sex -- far back into history, to foreign lands, and into territory where sex is not usually on the agenda, like among people with incapacitating spinal injuries. Here Roach highlights the pioneering work of Marcalee Sipski, and we learn that men can have sex with catheters in their penises and that orgasm is sometimes achievable in people with the most serious injuries.

We spoke with Roach over the phone about the science of sex.

How has sex research evolved over the past several decades and how has sexual understanding changed as a result?

"In the '70s you had researchers like Masters and Johnson doing pure physiological sex research. When the basic processes of arousal and orgasm were figured out, or beginning to be figured out, there was less of that type of research. During the AIDS era there was a lot of research directed toward behavioral surveys and figuring out risk taking behaviors and their connection to the transmission of HIV, so a lot of money went into that area. Nowadays there's a lot more money, and a lot of sex research is devoted to coming up with therapies for sexual dysfunction, whether it's pharmaceutical or otherwise. So that's a general look at how sex research has changed since the '60s."

Much of the first few chapters are about the female orgasm and the persistent myth of the vaginal orgasm. Does the myth still persist? Do men still cling to it?

"I don't know if the myth still persists. Hopefully not. It was interesting for me to see how even figures as large as Masters and Johnson came out saying 'No! There's no such thing, it's all just indirect stimulation of the clitoris, and there's no such thing as a vaginal orgasm, the clitoris is always involved.' Then came that study by Alzate where women came in and he was sort of frictioning the front wall of the vagina and reliably producing orgasms without any contribution at all from the clitoris. To me it's silly because there's not . . . there are nipple orgasms, there are dream orgasms, there are people who can think themselves into orgasm. Kinsey met a woman who . . . stroking her eyebrows made her have an orgasm. Everybody's wired differently. So I hope people aren't still clinging to that particular myth."

What about the G spot or as you say "that other erogenous zone?" Is there research about that, and what should the lovers of women know about it?

"Clearly the front wall of the vagina is an erotic area and there still persists some sort of discussion about whether there is a separate structure. Can you differentiate the tissue of the G spot from the rest of the front wall of the vagina? There are people who bicker back and forth about that. But clearly, whether or not it's a separate structure, the front has an erogenous area. If it didn't, those rabbit-style vibrators wouldn't be the terrific sales item that they are."

You state that erections are all about blood and that impotence has moved from the realm of the psychological to the physical. What is your take on the psychological versus the physical in terms of sexual dysfunction?

"With men, clearly when you age there's an age-related change in the tissue of erectile chambers and that can be helped; Viagra is very useful for that. In somebody who doesn't have any age-related changes in their tissue and is able to get an erection while they're sleeping (which is how they determine if it's psychological or physiological), they look for nocturnal erections. In somebody who has no trouble getting an erection in their sleep, it's an indicator that it's a psychological issue. And sometimes these men are given Viagra anyway. I asked a urologist, "Why are you giving these people Viagra if it's clearly a psychological issue?" He said that what happens when somebody starts being unable to get an erection is that the anxiety sets in and then they really can't. It's sort of a vicious cycle. They try to break that vicious cycle by giving them Viagra and at the same time suggesting they have therapy. I thought, fair enough."

The belt and suspenders approach.

"Exactly. Sometimes I think it's several issues when it comes to libido and differences in a couple's interest in sex and how often they want to have sex. That's a situation where pharmaceutical solutions aren't enough. There isn't anything right now for women in terms of raising libido. There is in Europe. I think there's a testosterone patch that is available there. But even with all of these pharmaceutical solutions, I think that open communication and conversation should also play a critical part."

There's a new study out that suggests that sex takes from 3 to 13 minutes. It treats sex pretty mechanically. Of course 3 to 13 minutes is a lot longer than some monkeys take time to orgasm . . .

"Your chimpanzees take about five seconds to get there. There was a statistic that I saw that said from two to five minutes. But what they're talking about is just from penetration to orgasm, so they were leaving out, say, a 20 minute sensual massage, and foreplay . . . it could be an hour of really fantastic foreplay before you get to the part where their stopwatch starts going. So it's kind of a misleading figure. The statistic I saw, they were just talking about from the time of penetration to orgasm, not the entire sexual encounter. Hopefully your statistic also is that; hopefully that wasn't the whole thing."

Hopefully it wasn't. But part of the question is why does society still conflate sex with traditional intercourse?

"True. Exactly. So often with sex research they fail to define their terms. They'll say sex -- well, what do you mean by sex? Are you talking about the film that somebody watched beforehand? Does that go into it too? Or the oral foreplay? What are you calling sex? If you don't define it, people think 'They're just talking about the in-and-out part.' And there doesn't even need to be an in-and-out part. So we need to pay attention to how they're defining things."

At the end of the book you talk about how homosexuals are generally much better lovers because they take the time for foreplay and exploration but heterosexuals generally don't. Can you explain why?

"This was a study done in the '70s. I'm hoping that straight people have made some strides since then. Around that time there were a lot of books like the Hite Report that were very much talking about technique, in a very mechanistic way -- sex manuals and sex tips. For the first time they were putting out all of these 'Here's the way to satisfy your partner,' etc. So people were overly concerned with the mechanic aspects of sex: 'Now I need to do this for 10 seconds and now I have to rub her here.' It was all very goal-directed and not about losing yourself in the whole process of turning each other on.

"Another thing the study mentioned was the gender empathy issue. If you're both of the same gender you have an intuitive sense of what works, whereas straight people have to kind of fumble around and figure it out."

Do you think sex research encourages this sort of goal-oriented attitude towards sex?

"No. I think that women's magazines and men's magazines, which are always saying 'Five tips that will drive him or her wild' and give you a laundry list of things to do encourage that attitude. And people feel incompetent and like they are lacking something because they are not doing that. Sex research for the most part is ignored by the general public. It goes on in labs. Sex research doesn't come out and say 'here's how to have better sex' usually. Often it's in its own abstract world."

There was one Masters and Johnson study that found that the sex fantasies of gay and straight people were similar. And rape fantasies, or forced sexual encounters, rated high on the list for both groups. Do you have a sense of why that is or what that might mean?

"No. I'm just reporting what they found. I'm not a sociologist or a cultural speculator. I don't know why that is. Possibly it's tied to issues of control. They always talk about how it's people in positions of power or control that often like to be sexually rendered helpless and dominated."

Historically most sex researchers were men. Do you think this impacted the research?

"Sure. One example in the book is that when primatologists studied sexual behavior in primates other than people they just assumed female monkeys were releasing some sort of chemical that was making the males act. It never crossed their minds that the females were initiating sex. And they came up with this stuff that they called copulins that the females were supposedly releasing, which would trigger sexual behaviors in the males, and that the females had no idea and were totally passive. I spent an afternoon in a rhesus compound outside of Atlanta. The females avoid the males unless they're ovulating, and then basically they just go up to them and slap the ground like 'Check it out, I'm here, lets have sex.' But they do all the initiating of sex. It was years before the primatologists at the time, who were all male, picked up on that because it wasn't on their radar that females would be anything other than passive receptacles."

Like the young monkey that was having sex for the first time, she was a little more subtle because she had to work around the dominant female.

"Exactly. It was like an eighth grade dance where you go up to the punch table at the same time. But definitely she was taking the initiative and making the overtures. Carefully, subtly, but obviously."

For the five-second copulation.

"Exactly. For what? Is that it? You blink and you miss it. Be thankful that you're not a rhesus monkey."

Are there other examples of wider cultural misunderstandings about sexuality influencing research?

"Well, there was the case of Marie Bonaparte -- the woman who surgically had her clitoris moved. I'm assuming that her surgeon, Josef Halban, suggested moving her clitoris, as opposed to just having her try a different position or something oral. So she resorted to these drastic measures. It was an intercourse-centric view of what sex needed to be, the idea that you had to move the clitoris closer to the vagina so that missionary position intercourse could make her orgasm. I don't know if it was his personal view or the prevailing cultural view that sex is intercourse and nothing else. That's one sad example."

I got a kick out of reading the painful history of the repression of masturbation. And for men, especially, there is actually a biological reason for masturbation.

"If you let it sit around long enough the sperm start getting deformed and are not particularly useful for making their way into an egg. So I liked that Roy Levin had come up with an evolutionary explanation for masturbation -- that it in fact served a valuable purpose."

Another point in the book has to do with the role of hormones in sexual desire. You come down pretty hard on birth control pills.

"When I was working on the book a study came out about how birth control pills lower the amount of freed-up testosterone in the blood (testosterone is what drives up female libido) and what I thought was extraordinary was that this isn't mentioned as a side effect either on the product or by health providers. It's never mentioned to you when you get a prescription for the pill. When you get an anti-depressant, one of the side-effects is that it lowers your libido. But for the birth control pill, the FDA isn't concerned about libido. They're just concerned about medical risks. It seems like something they might want to mention to people."

Any theories about that?

"I think because it's considered a lifestyle issue and it's not on their list of things to check for. If it's not a medical condition, it's thought of as a lifestyle thing. It's why they don't include it for that category of drug."

The last question is something I always like to ask somebody who's on the circuit. How are people reacting to your book and what do they seem to be most interested in?

"This is an interesting book to be on the circuit with because people come up to me and ask questions as if I were a sex therapist. So I'll have someone come up to me and say 'I don't know, my husband wants to have sex with me all the time, and as far as I'm concerned I'd be happy with birthdays and holidays and I'd rather wash dishes than have sex.' So people come up to me and say these outrageous things and then they go 'Am I normal?' A guy came up to me and said 'You know I had a heart attack 10 years ago and I haven't had an erection since, but you know what, it's interesting, you don't really have to have the erection to have the orgasm and I just realized that.'

"And I said 'Yeah, isn't that something.'"