In the early 20th century, American psychiatry became increasingly professionalized and medicalized; from the 1930s, it also became significantly psychoanalytic. Psychoanalysis – not Freud’s own writings as much as their elaboration by others – dominated discussions of female sexuality and its problems, frigidity in particular. Too much – or too little – desire figured in this period as indices of developmental psychopathology, where that psychopathology involved the failure to adhere to norms of gender and femininity.
Female sexuality is to be elicited from women’s asexual innocence, but, if too assiduously awakened, threatens to tip into voracious nymphomania – a condition with often tragic consequences such as incarceration in insane asylums. For the woman unable to reach coital orgasm, sitting astride the man ‘is certainly better than titillation of the clitoris’.
Where nothing else can be done, such ‘titillation’ is admissible, for the alternatives are serious: ‘unhappiness in the marriage relationship, possibility of divorce, and even the temptation of the wife to try her luck elsewhere’.
Women who cannot reach coital orgasm but nonetheless have normal or even intense desire are put under a tremendous nervous strain, with resulting neurasthenic symptoms of pain and exhaustion, through the chronic irritation of organs. Insanity is the consequence, then, not only of too much desire, but also of too little pleasure.
In the postwar period, the connotations of female sexual problems as mental disorders continued in part due to the important role played by the American Psychiatric Association’s Diagnostic and Statistical Manual.
The Diagnostic and Statistical Manual of Mental Disorders’ (DSM’s) first edition in 1952 contained, under the rubric of Personality Disorders, the category of Sexual Deviation (including homosexuality, transvestism, pedophilia, fetishism, and sexual sadism).
Problems such as impotence and frigidity belonged to a separate category of ‘Psychophysiological autonomic and visceral disorders’ (under a larger group of ‘Disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain’), of which a ‘psychophysiological genitourinary reaction’ was an instance.
These disorders represented the visceral expression of affect that is often ‘prevented from being conscious’.
The DSM merely states that psychophysiological genitourinary disorders include ‘some forms of menstruation disruption, dysuria, and so on, in which emotional variables play a causal role.’ Formalized paraphrase.
The DSM-II of 1968 is similar, but it adds ‘dyspareunia and impotence’ to the list of instances. There is little detail provided, and the types of diseases listed are not meant to be exhaustive. An etiological process is proposed, and it is the process itself that is important, rather than its various manifestations.
This changed dramatically with the publication of the DSM-III in 1980, which is largely regarded as signalling a transition from psychoanalysis to biological psychiatry.
The DSM has received much criticism, however, on the grounds that it brutally evicted psychodynamism, is deeply intertwined with the interests of the pharmaceutical industry, and has fostered an American hegemony in world psychiatry.
In DSM-III, instead of separate categories for Sexual Deviations and Psychophysiological Genitourinary Disorders, there is an overarching chapter on ‘Psychosexual Disorders’.
This is broken down into gender identity disorders (transsexualism and gender identity disorders), paraphilias (fetishism, transvestism, pedophilia, voyeurism, and so on), and psychosexual dysfunctions. The latter include (for women) the following:
Inhibited sexual desire
Inhibited sexual excitement
Inhibited (female) orgasm
Atypical psychosexual dysfunction.
The DSM-III-R of 1987 changed ‘Psychosexual Dysfunctions’ to ‘Sexual Dysfunctions’, listing the following:
Sexual desire disorder
Female sexual arousal disorder
Inhibited female orgasm
Sexual dysfunction not otherwise specified
In DSM-IV, this remains the same, except that Inhibited Orgasm becomes Orgasmic Disorder. It also adds Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction.
FSD’ is a generic, descriptive – rather than diagnostic – term. And yet it has come to be treated, rhetorically, as if it were in itself a condition, despite the different diagnostic categories constituting it.
Literature throughout the century has privileged problems of desire and orgasm; ‘arousal’ became more important through Masters and Johnson. Marital advice dealt with pain, often as a mechanical problem to be medically, surgically, or educationally addressed; in the recent debate, however, the literature on pain gets somewhat short shrift.
The fact that Viagra, licensed for Erectile Dysfunction in 1998, seemed to work so well was repeatedly invoked as proof that Erectile Dysfunction was not a psychological problem, but merely a mechanical problem.
Medical, pharmaceutical, and public discussions of FSD increased in its wake, with much of the scientific and indeed popular discourse about female sexual problems emphasizing their medical nature – where medical is understood to exclude the psychiatric.
Claims about what influences diagnostic categories and etiological narratives are repeatedly interpreted as claims about the reality of symptoms, with the fraught status of mental illness creating a divisive public discourse.
Many critics have argued that the inclusion of FSD in the manual is inappropriate because the DSM is in the business of pharmaceutical medicalization of sexuality. Prevalent medical FSD discourse, they suggest, understands sexual problems as reductionistically biological, ignoring the contextual (social, cultural, personal) factors shaping sexuality and its difficulties.
To sum it up, the true reason behind the diagnosis of FSD seems to benefit everyone except the one who actually needs it. To feed the pharmaceutical oligarchs, new and confusing illnesses are either cooked up or brought into existence. Understanding what the DSM has had to say about the female sexual problems clearly marks a chronological timetable of how misjudged women have been.
The DSM is sort of a history book of Psychology where one can see how the world changes its view depending on the current need they have. But thankfully, measures have been set in place to ensure that the classification and categorization are just and right.