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A Genealogy of Appetite in the Sexual Sciences pp 117–146Cite as

Palgrave Macmillan

The Diagnostic Manual and Technologies of Psychiatry

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Abstract

This chapter historicises the discursive expansion in the classifications and interpretations of “sexual dysfunctions” in contemporary US psychiatry in the late twentieth and early twenty-first centuries. It examines how the turn of the psychiatric gaze towards amounts, degrees and appetites in the Diagnostic and Statistical Manual of Mental Disorders harnesses a range of techniques that, in addition to pathologising the patient, invite her to develop greater awareness of their sexual self. The patient is actively encouraged to use the manual as well as information gathered during the therapeutic process as techniques for managing their sexual imbalances. This chapter thus aims to produce a genealogy of the turn of the psychiatric gaze towards the medicalisation of sexual appetite in the last two decades of the twentieth century, and, in doing so, to approach the development of the diagnostic manual as a technical object both for professional diagnosis and for the care of the self.

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Notes

  1. 1.

    American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, DC: American Psychiatric Association, 1994), 493.

  2. 2.

    See, for example, Arline Kaplan “DSM-V Controversies,” Psychiatric Times 26, no. 1 (2009): 5–10 and Allen Frances, Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (New York: William Morrow, 2013).

  3. 3.

    The DSM is primarily used in the United States, though several countries also utilise it. Beyond the DSM, the International Classification of Diseases , now in its tenth edition, also contains a section dedicated to sexual disorders. The ICD provides standardised codes for diseases and enables the compilation of epidemiological data. It outlines few procedures for diagnosis in its section on sexual dysfunctions, limiting itself to definitions. It lists “loss of sexual desire” with frigidity and Hypoactive Sexual Desire Disorder both included and “excessive sexual drive” with nymphomania and satyriasis named. The DSM has long abandoned the labels provided in the ICD. This applies to sexual orientation too, as the ICD still considers sexual orientation a determinant in certain disorders. For example, Sexual Relationship Disorder: “The gender identity or sexual orientation (heterosexual, homosexual, or bisexual) is responsible for difficulties in forming or maintaining a relationship with a sexual partner.” Physicians and activists have called for sexual orientation to be removed from future versions of the manual; see http://www.who.int/bulletin/volumes/92/9/14-135541/en/. In the ICD, the question of appetite remains pervasive as disorders such as fetishism, lack or loss of sexual desire, excessive sexual drive and sexual aversion are organised around amounts and arousal.

  4. 4.

    Rachel Cooper, Psychiatry and the Philosophy of Science (Montreal and Kingston: McGill-Queen’s University Press, 2007), 94–95. See also Nikolas Rose, Our Psychiatric Future: The Politics of Mental Health (Cambridge: Polity, 2019), 71.

  5. 5.

    The Medical 203 was published in 1946 by the War Department and was specifically designed for use in the army. See Arthur C. Houts, “Fifty Years of Psychiatric Nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203,” Journal of Clinical Psychology 56, no. 7 (2000): 935–967.

  6. 6.

    Robert L. Spitzer and Janet B. W. Williams, “The Revision of the DSM-III,” Psychiatric Annals 13, no. 10 (1983): 808.

  7. 7.

    Rick Mayes and Allan V. Horwitz, “DSM-III and the Revolution in the Classification of Mental Illness,” Journal of the History of Behavioral Sciences 41, no. 3 (2005): 249–275.

  8. 8.

    Jerrold S. Maxmen, The New Psychiatry: How Modern Psychiatrists Think about Their Patients, Theories, Diagnoses, Drugs, Psychotherapies, Power, Training, Families, and Private Lives (New York: William Morrow & Company, 1985), 31.

  9. 9.

    Gerald L. Klerman, George E. Vaillant, Robert L. Spitzer and Robert Michels, “A Debate on DSM-III: The Advantages of DSM-III,” American Journal of Psychiatry 141, no. 4 (1984): 541.

  10. 10.

    Houts, “Fifty Years of Psychiatric Nomenclature,” 947.

  11. 11.

    Melvin Sabshin, “Turning Points in Twentieth Century Psychiatry,” American Journal of Psychiatry 147, no. 10 (1990): 1272. Note that the DSM-III was also designed to closely align with the World Health Organization’s International Classification of Diseases , volume 9. See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (Washington, DC: American Psychiatric Association, 1980), 399–457.

  12. 12.

    APA, DSM-III, 23.

  13. 13.

    Ibid., 23–32.

  14. 14.

    Ibid., 276.

  15. 15.

    American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 1st ed. (Washington, DC: American Psychiatric Association, 1952), 120.

  16. 16.

    American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. (Washington, DC: American Psychiatric Association, 1968), 47.

  17. 17.

    Mayes and Horwitz, “DSM-III and the Revolution in the Classification of Mental Illness,” 251.

  18. 18.

    William H. Masters and Virginia E. Johnson, Human Sexual Inadequacy (Boston: Little, Brown & Company, 1970), 9.

  19. 19.

    William H. Masters and Virginia E. Johnson, Heterosexuality (New York: Harper Collins, 1994), 42.

  20. 20.

    Their work also documented women’s ability to achieve multiple orgasms and this is repeated on page 276 of the DSM-III.

  21. 21.

    See Janice Irvine, Disorders of Desire: Sexuality and Gender in Modern American Sexology (Philadelphia: Temple University Press, 2005). See also chapter three, “The Coital Imperative” in Lynne Segal, Straight Sex: Rethinking the Politics of Pleasure (Berkeley: University of California Press, 1994), 70–116.

  22. 22.

    Leslie R. Schover, Jerry M. Friedman, Stephen J. Weiler, Julia R. Heiman and Joseph LoPiccolo, “Multiaxial Problem-Oriented System for Sexual Dysfunctions,” Archives of General Psychiatry 39 (1982): 615.

  23. 23.

    Helen Singer Kaplan, Disorders of Desire and Other Concepts and Techniques in Sex Therapy (New York: Simon & Schuster, 1979), 9–23.

  24. 24.

    See John D’Emilio and Estelle B. Freedman, Intimate Matters: A History of Sexuality in America, 3rd ed (New York: Harper & Row. 2012 [1988]), 301–343.

  25. 25.

    Segal, Straight Sex, 101.

  26. 26.

    Kaplan, Disorders of Desire, 58.

  27. 27.

    Segal, Straight Sex, 101.

  28. 28.

    Harold Lief, “Inhibited Sexual Desire,” Medical Aspects of Human Sexuality 7 (1977): 94–95.

  29. 29.

    APA, DSM-III, 278.

  30. 30.

    Ibid.

  31. 31.

    Ibid., 276.

  32. 32.

    Ibid., 279 (emphasis original).

  33. 33.

    Ibid.

  34. 34.

    Ibid., 276.

  35. 35.

    Ibid., 279 (emphasis added).

  36. 36.

    Two important exceptions are Janice Irvine’s Disorders of Desire and Leonore Tiefer, Sex Is Not a Natural Act and Other Essays (New York: Westview Press, 2004). The debates over homosexuality and its removal are described in Ronald Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis (Princeton: Princeton University Press, 1987 [1981]).

  37. 37.

    Edward Shorter, Historical Dictionary of Psychiatry (Oxford: Oxford University Press, 2005), 131–132.

  38. 38.

    Bayer, Homosexuality and American Psychiatry, 176.

  39. 39.

    APA , DSM-III, 281 (emphasis added). Note that the ICD-10 lists “Egodystonic sexual orientation” but it bears no connection to levels of sexual appetite: “The gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it.” See http://apps.who.int/classifications/icd10/browse/2016/en#/F66.1.

  40. 40.

    APA, DSM-III, 282.

  41. 41.

    Object choice of course continues to preoccupy science as demonstrated by the search for the “gay gene”. See Simon LeVay, Gay, Straight and the Reason Why: The Science of Sexual Orientation (Oxford: Oxford University Press, 2010) and Robert Alan Brookey, Reinventing the Male Homosexual: The Rhetoric and Power of the Gay Gene (Bloomington, IN: Bloomington University Press, 2002).

  42. 42.

    Mayes and Horwitz, “DSM-III and the Revolution in the Classification of Mental Illness,” 258–259.

  43. 43.

    See Hannah S. Decker, The Making of the DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford: Oxford University Press, 2013), Stuart A. Kirk and Herb Kutchins, The Selling of the DSM: The Rhetoric of Science in Psychiatry (New Brunswick: Transaction, 1992) and Michael Bronski, A Queer History of the United States: ReVisioning American History (Boston: Beacon Press, 2011).

  44. 44.

    See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised (Washington, DC: American Psychiatric Association, 1987).

  45. 45.

    See, for example, Lisa Downing, “Heteronormativity and Repronormativity in Sexological ‘Perversion Theory’ and the DSM-5’s ‘Paraphilic Disorder,’” Archives of Sexual Behavior 44, no. 5 (2015): 1139–1145, Alain Giami, “Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms,” Archives of Sexual Behavior 44, no. 5 (2015): 1127–1138, and Jeffrey Weeks, “Beyond the Categories,” Archives of Sexual Behavior 44, no. 5 (2015): 1091–1097. See also by Jack Drescher, “Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual,” Archives of Sexual Behavior 39, no. 2 (2010): 427–460, and “The Removal of Homosexuality from the DSM: Its Impact on Today’s Marriage Equality Debate,” Journal of Gay & Lesbian Mental Health 16, no. 2 (2012): 124–135.

  46. 46.

    Giami, “Between DSM and ICD,” 1136.

  47. 47.

    Michel Foucault, The Use of Pleasure: The History of Sexuality, Volume 2, trans. Robert Hurley (New York: Vintage, 1985), 40.

  48. 48.

    Ibid., 47. See chapter one of this book for a discussion of aphrodisia.

  49. 49.

    Ibid., 101.

  50. 50.

    Ibid., 97.

  51. 51.

    Ibid., 55–56.

  52. 52.

    Michel Foucault, “Subjectivity and Truth,” in Ethics: Essential Works of Foucault, 1954–1984, Volume 1, ed. Paul Rabinow (London: Penguin Books, 1997), 89.

  53. 53.

    Michel Foucault, “Technologies of the Self,” in Technologies of the Self: A Seminar with Michel Foucault, eds. Luther H. Martin, Huck Gutman and Patrick H. Hutton (Amherst: University of Massachusetts Press, 1988), 239. See also Michel Foucault, The Care of the Self: The History of Sexuality, Volume 3, trans. Robert Hurley (New York: Vintage Books, 1986).

  54. 54.

    Eric Paras, Foucault 2.0: Beyond Power and Knowledge (New York: Other Press, 2006), 131.

  55. 55.

    Nikolas Rose, Governing the Soul: The Shaping of the Private Self (London and New York: Routledge, 1989), 248.

  56. 56.

    See, for example, Annemarie Mol, The Body Multiple: Ontology in Medical Practice (Durham and London: Duke University Press, 2002).

  57. 57.

    Geoffrey C. Bowker and Susan Leigh Star, Sorting Things Out: Classification and Its Consequences (Cambridge, Massachusetts: MIT Press, 1999), 10.

  58. 58.

    American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (Washington, DC: American Psychiatric Association, 2013), 433.

  59. 59.

    “Lifelong” means that the “disturbance has been present since the individual became sexually active” while “acquired” refers to a disturbance that “began a period of relatively normal sexual function.” APA, DSM-5, 433.

  60. 60.

    Ibid., 434.

  61. 61.

    Michel Foucault, The Will to Knowledge: The History of Sexuality, Volume 1, trans. Robert Hurley (London: Penguin, 1978), 18.

  62. 62.

    APA, DSM-5, 434.

  63. 63.

    Ibid.

  64. 64.

    Ibid., 433.

  65. 65.

    See further Ilina Singh and Nikolas Rose, “Biomarkers in Psychiatry,” Nature 460 (2009): 202–207 and Rachel Cooper, “What’s Wrong with the DSM?,” History of Psychiatry 15, no. 1 (2004): 5–25.

  66. 66.

    See by Rose, Governing the Soul, Inventing Our Selves: Psychology, Power, and Personhood (Cambridge: Cambridge University Press, 1998) and The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton: Princeton University Press, 2007).

  67. 67.

    G. Corona, E.A. Jannini and M. Maggi, “Review: Inventories for Male and Female Sexual Dysfunctions,” International Journal of Impotence Research 18, no. 3 (2006): 237.

  68. 68.

    Veronica Harsh, Elizabeth Lloyd McGarvey and Anita H Clayton, “Physician Attitudes Regarding Hypoactive Sexual Desire Disorder in a Primary Care Clinic,” Journal of Sexual Medicine 5 (2008): 640–645.

  69. 69.

    Anita H Clayton et al., “Cutoff Score of the Sexual Interest and Desire Inventory-Female for Diagnosis of Hypoactive Sexual Desire Disorder,” Journal of Women’s Health 19, no. 12 (2010): 2191.

  70. 70.

    Rose, Governing the Soul, 247.

  71. 71.

    See Irvine, Disorders of Desire, 163–183.

  72. 72.

    APA , DSM-III, 283. However, disorders listed under “paraphilic disorders,” for example, “sexual sadism disorder” and “pedophilic disorder,” could be interpreted as “excessive.” Excess as a “standalone” pathology through the proposed category “hypersexual disorder” has not been included in the DSM-5. I maintain that lack of sexual appetite is always in connection with both sexual lack and excess. For instance, the condition of low or absent sexual appetite can be considered excessive in itself since it represents the “pathological” exaggeration of a norm of sexuality, albeit towards lack.

  73. 73.

    See the special issue on “Hypersexual Disorder” of Sexual Addiction & Compulsivity: The Journal of Prevention and Treatment 20, no. 1–2 (2013): 1–153. For a compelling critique of sexuality and “addiction discourse,” see Helen Keane, “Disorders of Desire: Addiction and Problems of Intimacy,” Journal of Medical Humanities 25, no. 3 (2004): 189–204.

  74. 74.

    APA, DSM-5, 423.

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    Jacinthe Flore

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Flore, J. (2020). The Diagnostic Manual and Technologies of Psychiatry. In: A Genealogy of Appetite in the Sexual Sciences. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-39423-3_5

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