Overmedicalization, as every feminist, queer, and disability scholar knows, is a cornerstone of oppression. Yet traditional critiques of medicalization also have oppressive effects. For one thing, they typically fail to challenge stigma against sick people, preferring instead to simply move certain groups outside of the category of illness. Also, many anti-medicalization arguments adopt the essentialist position that people should “be true to” the body and mind they are born with, an imperative that renders medical and technological interventions illegitimate. More nuanced approaches critique the overmedicalization of human variation but recognize the value of medical approaches in some instances. Consider, for example, the case of “low sexual desire,” which the DSM defines as “Hypoactive Sexual Desire Disorder,” or HSDD. This diagnostic category medicalizes asexual people, even those do not perceive their low sexual desire as a disorder. Some asexual activists have asserted the possibility of happy asexuality while also leaving room for psychological and medical approaches to sexual disinterest.
The most salient criticism of the HSDD diagnosis is that it pathologizes people who identify as asexual (see CJ DeLuzio Chasin, Eunjung Kim, and Lori Brotto and Morag Yule). Theoretically, the DSM’s stipulation that a lack of sexual desire must cause “marked distress or interpersonal difficulty’’ in order to meet the criteria for an HSDD diagnosis would prevent self-identified happy asexuals from being labeled mentally ill. But what if distress about the absence of sexual desire is due to social stigma? And what if “interpersonal” difficulties simply reflect benign differences in partners’ levels of interest in sex? If the construction of HSDD as a disease category promotes the idea that asexuals are mentally disordered—and if this idea in turn produces distress—then will the DSM have created the disorder it claims merely to describe?
Feminist scholars have also critiqued HSDD, arguing that it pathologizes benign variations in women’s levels of sexual interest, increases pressure on heterosexual and bisexual women to live up to male partners’ sexual expectations, and inappropriately locates the cause of sexual dissatisfaction in the individual instead of society (see Leonore Tiefer, Janice Irvine, and Annemarie Jutel). Feminist activists have largely rejected medical treatments for HSDD – for example, groups such as the New View Campaign have testified against FDA approval of drug treatments for female HSDD.
Asexual activists, however, have been more moderate than feminists in their response to HSDD. The Asexuality Visibility and Education Network, or AVEN, the largest online community of people who identify as asexual, submitted a report on HSDD to the chair of the DSM5 Sexual Dysfunctions Subworkgroup in 2009. The report acknowledges that there may be individuals for whom low sexual desire is distressing, and that these individuals might benefit from medical and psychiatric treatment. The report recommends: including “attraction to neither males nor females” as a sexual orientation category in the DSM; requiring that an absence of sexual desire cause individual distress (not merely “interpersonal difficulties”) in order for a diagnosis of HSDD to be made; and specifying that the diagnosis of HSDD does not apply to people who consider themselves asexual.
If implemented, these proposals might reduce the pathologization of people who identify as asexual, which would certainly be a good thing. However, AVEN’s report is limited by some ableist conceptual moves. Rather than challenging stigma against both mental illness and asexuality, it seeks instead to rid asexuality of the stigma of mental illness. Such normalizing tactics may come at the cost of intersectional analyses and coalitional possibilities. Responding to some to asexual men’s practice of emphasizing that their “plumbing works fine,” Eunjung Kim worries that the statement “we are not sick” may serve as a “distancing strategy that erases other asexual people who have mental or physical illnesses, disabilities, and neurological differences” (160). So, too, with racial and ethnic difference. Ianna Hawkins Owen has observed that when black asexuals post to AVEN in search of other black asexuals, they often receive “unhelpful, colorblind, dismissive, and racist forum comments like ‘I didn’t know race mattered, lol’ and ‘everyone is a minority here!’”
No doubt, AVEN’s approach to difference is often limited by unexamined ableist and racist assumptions. But in contrast to its normalizing rhetoric in some contexts, its report on HSDD can be read as moving away from normalization. In the report, low sexual desire is not assumed always to be either a disease in need of a cure or invariably “normal and healthy.” Instead, asexuality is accepted as a potentially fulfilling way of being in the world, while people who do not consider themselves asexual, and who are distressed by their lack of sexual desire, are free to receive medical recognition and treatment. In 2011 and 2012, I conducted a series of in-depth interviews with thirty self-identified asexual people, recruited from AVEN. Like the authors of the AVEN report on HSDD, my interviewees shared a commitment to reducing the stigma associated with asexuality, while at the same time supporting the potential value of medical labels and treatments in some cases. As one interviewee put it, “I’m totally happy with myself the way I am now, but I could see if someone was upset about it and wished that they had more of a drive, then I would say let them take the medication if they want to.”
Most interviewees were comfortable with others seeking treatment for HSDD, and some left open the possibility that they might want to set aside their asexual identity and seek treatment in the future. A few went even further: they were willing to allow people to claim both labels—asexuality and HSDD—simultaneously. For these interviewees, there was no necessary conflict between a positive asexual identity and the use of medical treatments to increase sexual interest. As one interviewee stated, “It’s kind of like where if you identify as a lesbian but if you date a guy, then it’s like, ‘Oh, you’re not a real lesbian.’ Well, that’s bullshit because I’m still me—behaviors and identity are not ever congruent—they’re not ever 100% congruent.”
The approach of many AVEN activists, and of most of my interviewees, respects that for some people a lack of interest in sex may be experienced as a detriment to flourishing, while for others asexuality is perfectly consonant with happiness.