The problem of sexual imbalance and techniques of the self in the Diagnostic and Statistical Manual of Mental Disorders

Introduction

In May 2013, the American Psychiatric Association (APA) published the fifth volume of the Diagnostic and Statistical Manual of Mental Disorders (DSM), ¹ the first major revision of the psychiatric handbook since the DSM-IV in 1994. The DSM-5 introduces a number of changes to the categorization of psychiatric disorders and, like most of its predecessors, its release was met with controversy. ² Despite criticism levelled against previous editions, ³ many categories of sexual dysfunction originally introduced in the DSM-III (1980) have been maintained in the DSM-5, albeit with changes to nomenclature and interpretation. In fact, the sexual disorders found in the DSM-5 still owe much to the intellectual climate that pervaded the disciplines of psychiatry and sexology in the late twentieth century. The DSM-III emphasized the question of sexual amounts, and classified low sexual desire and inhibited sexual excitement as paradigms of ‘psychosexual dysfunctions’. The DSM-5 intensifies this turn to the problematization ⁴ of sexual imbalance and is accompanied by modified techniques of diagnosis.

In this article, I argue that the historical development of the DSM reveals an important refiguring in medical knowledge from the pathologization of sexual object choice to the problematization of amounts, degrees and appetites of sexual relations. ⁵ In particular, I demonstrate how reductions in levels of sexual appetite and a lack of interest in sex have increasingly become conspicuous foci of the DSM. While the concern with balance in sexuality is neither new nor unprecedented in medicine, the focus of the historiography of sexuality has by and large been the question of object choice. ⁶ In the following pages, I turn instead to the question of amounts of sexual appetite, and argue that medical interest in sexual imbalance and disequilibrium has intensified in the emergence of subsequent editions of the DSM in the early twenty-first century. It examines how the intensification of the medical gaze towards amounts, degrees and appetites in the DSM harnesses a range of techniques which, in addition to pathologizing the patient, invite him/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.

As a rubric, the DSM is not necessarily reflective of a consensus on the meanings and conceptualizations of sexuality and sexual appetite. However, my analysis of the DSM is informed by its status as a prominent and widely used index. As Rachel Cooper notes, the DSM can be considered a ‘contact language’, meaning that the Manual provides a common vocabulary for health professionals (Cooper, 2007: 94–5). In a constellation of varied symptoms, the Manual allows for different physicians to communicate on diagnosis and treatment, despite ‘bracketing off points of theoretical disagreements’ (p. 95). Given its widespread use and cultural history, the DSM can be viewed as a repository of knowledge on sexuality and, as a catalogue, the compendium reveals broader cultural concerns around sexuality, amounts and balance.

The first section of this article contextualizes the emergence of discourses of sexual appetite in the DSM in the late twentieth century. The DSM-III transformed the nosology of psychosexual disorders, by associating them primarily with the problem of sexual imbalance. Contemporary psychiatric discourses of sexuality now manifest a prominent concern with the quantities of desire, frequency of sexual activities and the imperative of maintaining balance between excessive and exiguous sexual appetite. The necessity to maintain sexual equilibrium operates both in the psychiatric compendia and in clinical research that applies the categories of disorders of the DSM.

The second section approaches the contemporary architecture of sexual disorders in the DSM as an apparatus for the management of sexual appetites. In particular, I focus on the problematization of sexual lack through the most recent addition to the DSM-5: Female Sexual Interest/Arousal Disorder (FSI/AD). I examine through the case study of FSI/AD how diagnostic manuals and sexuality-related measurement devices exceed professional uses. The classification of this disorder in the DSM-5, as well as the content and use of questionnaires to ascertain the amounts, degrees and fluctuations of sexual interest and arousal, function as tools for self-diagnosis. I thus explore how women have become tasked – through the implementation of techniques of classification and examination – with sharing responsibility for their pathology and managing their sexual imbalance. This study then has two related aims: to historicize the intensification of the medical gaze towards amounts and frequency in sexuality in the last two decades of twentieth-century North American psychiatry, and, in doing so, to approach the development of the DSM as a technical object for both professional diagnosis and for the care of the self.

The emergence of sexual appetite in the DSM-III

Released in 1980, the DSM-III effected a substantial break with the psychoanalytic tradition that had, since the DSM-I (1952), characterized North American psychiatry. Earlier versions of the DSM, as well as their predecessor, the military manual Medical 203, ⁷ conceptualized psychiatric symptoms as signs of a disturbed subconscious. The DSM-III was published with the intention of effacing psychoanalytic theory from the Manual, firmly ensconcing biological knowledge of the human mind, and producing classifications based on ‘shared clinical features’ (Spitzer and Williams, 1983: 808). Repudiating the subconscious, the DSM-III emphasized categories of illness and represented a completely new system of classification. ⁸ For supporters of the paradigm shift from an ‘old psychiatry [derived] from theory [to] the new psychiatry from fact’ (Maxmen, 1985: 31), the DSM-III embodied ‘science in the service of healing’ (Klerman et al., 1984: 541). With 83 more diagnoses and 360 more pages than the DSM-II, the third volume of the psychiatric handbook inaugurated the modern DSMs by transforming it from a ‘psychoanalytic-personality-development model to a more amorphous descriptive model with biological undertones’ (Houts, 2000: 947). Melvin Sabshin, medical director of the APA from 1974 to 1997, noted that the DSM-III and DSM-III-R (1987), while broad in scope, ‘attempt[ed] to provide objective criteria for diagnosing each disorder’ and represented the ‘predominance of science over ideology’ (Sabshin, 1990: 1272).

The approach to mental illness developed by the DSM-III advocated a consideration of multiple aspects of the person’s life, in addition to the specific concern of the individual. Following this methodology and applying it to sexuality, the DSM-III mobilized sexological principles and, in addition to disorders of sexuality based on biological functionality and inhibitions, the Manual included the ‘complete sexual response cycle’, a system that delineated the physiological processes involved in a predominantly heterosexual encounter. In the DSM-III, the four stages of the cycle consisted of ‘appetitive, excitement, orgasm and resolution’ (APA, 1980: 276). The psychosexual dysfunctions found in the DSM-III could occur at any stage of the sexual response cycle. The Manual explicitly classified changes, in particular a reduction in levels of sexual excitement, as a problem. These fluctuations of intensity, which were depicted as signs of pathological sexual imbalance, would go on to characterize the later DSMs’ approach to the sexual dysfunctions.

The sexual appetites had already made their appearance in psychiatric nomenclature since 1952. In the DSM-I, frigidity and impotence were listed in Appendix C as supplementary terms of the urogenital system, while nymphomania, also listed in the same appendix, was depicted as a supplementary term that affected the psyche and the body, yet did not affect ‘a particular system exclusively’ (APA, 1952: 120). The DSM-II, on the other hand, only listed impotence as an example of a ‘psychophysiologic’ disturbance in which ‘emotional factors play a causative role’ (APA, 1968: 47). Hence, while the DSM-III certainly introduced more disorders and revised existing typologies, the intellectual and medical terrain covered by the third edition of the Manual was generally similar to that of its predecessors (Mayes and Horwitz, 2005: 251). The presence of frigidity, impotence and nymphomania in appendices of the DSM-I and DSM-II highlight how the concentration of the medical gaze on problems of quantity and intensity took place gradually over the second half of the twentieth century and subsequent revisions of the Manual.

While the concern with the quantity and intensity of sexual activity was included in the DSM-I and the DSM-II, the incorporation of a description of the mechanisms of sexual activity was a new addition to the DSM-III. The sexologists William Masters and Virginia Johnson originally formulated the human sexual response cycle in the 1960s. In Human Sexual Response (1967), and several other works, they pioneered the principles of twentieth-century American sex therapy. They expounded ideas of natural human function and asserted that their plan for sex therapy ‘consist[ed] of putting sex back into its natural context’ (Masters and Johnson, 1970: 9). Focusing strongly on patterns of behaviour and inhibitions, these authors affirmed that individuals all possess the potential, the capacity, for a satisfying sex life and they can help to excavate this natural spring of satisfying desire, performance and pleasure.

Masters and Johnson especially influenced Helen Singer Kaplan, an American physician and sex therapist whose work in the late 1970s would greatly influence the design of the DSM-III. ⁹ Kaplan (1979: 9–23) redeveloped Masters and Johnson’s four-part sexual response cycle into a triphasic model of human sexuality: desire, excitement and orgasm (pp. 9–23). Kaplan introduced the concept of inhibited sexual desire (ISD) into psychiatric discourse, which became part of the DSM-III. As Segal (1994: 101) notes, Kaplan used ‘desire’ to ‘bring in individual psychopathology to help explain the rapidly growing “disorders of desire”’. In other words, despite her commitment to ‘pure’ biology, Kaplan restored the importance of the psyche through the introduction of the word ‘desire’ into the pathological condition and emphasized that the psyche was inhibiting the body’s sexual potential.

Thus, difficulties during the ‘appetitive’ phase of the sexual response cycle were covered in Inhibited Sexual Desire (ISD), a disorder defined as ‘[p]ersistent and pervasive inhibition of sexual desire’ (APA, 1980: 278). The diagnostic criteria of ISD states that the clinician must take into account the ‘intensity and frequency of sexual desire’. In addition, the DSM-III specified, ‘this diagnosis will rarely be made unless the lack of desire is a source of distress to either the individual or his or her partner’ (p. 278). The introduction of ISD enhanced and formalized the psychiatric concern with amounts and intensity in sexual life. Dismissing psychoanalysis and the language of ‘neurosis’, the DSM instead incorporated research from sexology and turned to the question of distress. With this conceptual gesture, the patient is invited to participate in the production of the narrative of disease and the formulation of diagnosis. The inclusion of desire also silenced gender differences. The definition of desire itself, under the ‘appetitive’ phase of the complete sexual response cycle, was simply ‘fantasies about sexual activity and a desire to have a sexual activity’ (p. 276). Desire was approached as a kind of attraction or appeal in the psyche. One begins to fantasize about a possible mate and experiences a kind of eroticized need. In the DSM-III, this need bears no gender distinction.

However, the remarkable break in the DSM-III was the inclusion of the diagnostic category of Inhibited Sexual Excitement (ISE), and its separation from ISD. The DSM-III introduced ISE with the note: ‘This has also been termed frigidity or impotence’ (APA, 1980: 279). ISE was defined as ‘[r]ecurrent and persistent inhibition of sexual excitement during sexual activity’, with the specifications:

In males, partial or complete failure to attain or maintain erection until completion of the sexual act, or

In females, partial or complete failure to attain or maintain lubrication-swelling response of sexual excitement until completion of the sexual act. (p. 279, original italics)

The difference in the experience of ISE between men and women was classified in exclusively biological terms. It was to be identified by examining lasting physiological changes, or their absence – vasocongestion and muscular tension. The re-classification of frigidity and impotence as ISE in the DSM-III reveals an intensification in medical circles towards examining amounts in sexual activity, but specifically locating the ebb and flow of desire in biological processes, while the relevance of the psyche was located in ISD. The diagnostic criteria specify that the physician needs to judge whether ‘the individual engages in sexual activity that is adequate in focus, intensity and duration’ (APA, 1980: 279, italics added). The physician now had to enquire into how hard or how wet patients get, and in turn, the patients needed to possess an awareness of their bodies in order to provide an account of their body’s receptivity and reactions.

The changes to the nomenclature of sexual dysfunctions in the DSM-III, which were made possible by the introduction of ISE and ISD, have not been as widely examined by historians of sexuality as the removal of sexual object choice in 1973. ¹⁰ However, it is important to note that medical interest in the association between object choice and sexual equilibrium was maintained by the DSM-III. For instance, while homosexuality was removed from the DSM in 1973, in 1980 the DSM-III retained the category ‘ego-dystonic homosexuality’, which was dedicated to individuals whose homosexuality was a persistent source of distress. The description specified that ‘[i]ndividuals with this disorder may have either no or very weak heterosexual arousal’ (APA, 1980: 281, italics added). The Manual also remarks, ‘Individuals with Inhibited Sexual Desire may sometimes attribute the lack of sexual arousal to “latent homosexuality”’ (p. 282). In 1980 then, the degree or amount of arousal was still attached to object choice, as homosexual individuals could experience an imbalance of sexual arousal (i.e. too weak) in a heterosexual context. With subsequent editions of the DSM, low sexual desire became further distanced from object choice.

Through the inclusion of ISE and ISD as well as the association of sexual object choice and sexual arousal, the DSM-III enhanced and intensified its attentions to questions of intensity and frequency. We witness then the progressive emergence of discourses of sexual appetite and the appearance of the idea of balance in sexuality. The final removal of ego-dystonic homosexuality from the DSM-III-R (APA, 1987) severed the connection between object choice and amounts in the Manual and expanded the problematization of sexual appetite. Contemporary psychiatric discourses, as exemplified by the DSM-III and its successors, now manifest a heightened concern with the problematization of quantity: an individual who desires too little suffers from a pathological imbalance. The transformations in the architecture of psychiatric taxonomy from the DSM-I and DSM-II to DSM-III formalized and institutionalized a broader cultural concern on sexual amounts and balance.

Sexual dietetics

From 1980 to 2013, the Diagnostic Manual further modified the structure and content of the classification of sexual dysfunctions. Low sexual desire, previously Inhibited Sexual Desire, was modified to Hypoactive Sexual Desire Disorder (HSDD) in the DSM-III-R (APA, 1987). It remained as such, with no distinction between men and women in the Manual until 2013, when it was changed to Female Sexual Interest/Arousal Disorder (FSI/AD) and Male Hypoactive Sexual Desire Disorder (Male HSDD). Inhibited Sexual Excitement became Female Sexual Arousal Disorder and Male Erectile Disorder in 1987, before the former was incorporated into FSI/AD and the latter was defined as Erectile Disorder in 2013. The creation of Female Sexual Interest/Arousal Disorder and Male Hypoactive Sexual Desire Disorder in the DSM-5 introduces striking gender differences in the Manual to the extent that women can express ‘sexual interest’ or ‘arousal’, while men can exhibit ‘desire’. The DSM-5 thus marks a significant shift in the language of sexual dysfunctions, particularly insofar as it constructs gendered accounts of the quality and quantity of sexual activity.

This change in nomenclature, however, reveals how each subsequent volume of the DSM has further encouraged patients to conduct themselves as ethical sexual subjects. In the DSM-5, the dissemination of the language of sexual balance in conjunction with the application of measuring devices such as questionnaires and inventories has intensified the role of the patient in sharing responsibility for diagnosing their own pathology. That is to say, the development of the DSM as a diagnostic manual for psychologists and psychiatrists in the twenty-first century has also produced techniques for patients to assume responsibility for managing a balanced diet of sex.

The use of the word ‘diet’ with reference to sexuality is found in the writings of the French scholar Michel Foucault, especially in The Use of Pleasure (1985), the second volume of The History of Sexuality. In a broad study of Ancient Greek medical and philosophical approaches to the body, sexuality and pleasures, Foucault (1985: 115) notes:

dietetics problematized sexual practices not as a set of acts to be differentiated according to their forms and according to the value of each of them, but as an ‘activity’ the whole of which should be given free rein or curtailed depending on chronological considerations.

In Foucault’s reading of Ancient Greek scholarship, sexual relations were submitted to an administration, a regimen. Subjects assumed responsibility for managing their pleasures (aphrodisia). ¹¹ This mode of governance was concerned not so much with objects of desire, rather the regimen of aphrodisia focused on the prudent management of the quality and quantity of bodily actions, relations and rhythms. Excess and passivity ‘were the two main forms of immorality in the practice of the aphrodisia’ (Foucault, 1985: 47). In fact, self-governance for the Greeks cannot be limited to what is understood in the twenty-first century by sexuality or even sexual relations for that matter, for the use of pleasures (chrēsis aphrodisiōn) was conceived of by the Greeks as ‘a whole art of living’ (p. 101). Foucault asserts that the use of pleasures of (free male) individuals at the time was marked by an attention to the stylization of an ethics of the self. In other words, it ‘did not seek to justify interdictions’, but to cultivate an aesthetics, an art of existence (p. 97). The development of an ethics of the use of pleasure was a way, then, to develop a relationship to one’s freedom. Ancient Greek writings on the development of an ethics or a regimen of eroticism focused on questions of dietetics, moderation and balance. They expressed a concern with how one could use and regulate their pleasures and take care of their relations. Instead of being a moral issue, the management of urgings was undertaken with the aim to optimize or maximize the experiences of pleasure and desire. Far from being confined to individuals and bodies in isolation, recommendations on sexual dietetics were relational.

Foucault expands these ideas of the ethical consumption of sexual pleasure in The Care of the Self (1986), in which he examines Ancient Graeco-Roman texts on the hermeneutics of the subject. ¹² For Foucault, ‘[s]exual ethics requires, still and always, that the individual conform to a certain art of living which defines the aesthetic and ethics criteria of existence’ (Foucault, 1986: 67). He contends that ‘the art of living’ in existence during this epoch required intense self-inspection. In The Care of the Self, Foucault examines the first two centuries of the modern era and identifies an intensification of discourses of self-inspection in the works of Roman thinkers. Individuals needed to conduct self-examination and account for their interests, beliefs and thoughts, in order to be able to take care of their pleasures and desires. Moreover, the care of the self constitutes ‘an intensification of social relations’ (p. 53) as it also implies the care of/for the other. According to Foucault, Graeco-Roman perspectives on eroticism and the use of pleasures were strongly aware of the ‘limits’ of the body, that is to say, the limits of their relations to others, as mediated by the body. Individuals were counselled that they should not get carried away by pleasure, because it may not only detrimentally affect their own body, but also the body of another. Pleasure ‘is a matter of the soul’s correcting itself in order to be able to guide the body according to a law which is that of the body itself’ (p. 134). What we have then is the confluence of a tripartite discourse that forms the ‘techniques of the living’ (Foucault, 1997a: 89): pleasures must be recognized, practised and managed, their management must aim towards achieving moderation and balance, neither too much nor too little, and finally, in order to manage pleasures properly, the individual must develop tools to lead an ethical life.

The development of the practice of the care of the self in Ancient Greece and Rome constituted a lifelong work and required self-awareness of the modalities of bodily actions, relations and rhythms. The individual was encouraged to perform an assessment of themselves, of their thoughts, practices and affects, to develop a regimen of moderation and a strategy for regulating their conduct in relation to others. This continuous process of the self is often categorized by Foucault as technologies of the self. The fundamental technique that Foucault identifies in Ancient schools of thoughts, that of Askesis, generates a set of tools that involve the training of the mind, the body and the soul. As Foucault (1988: 35) explains, Askesis ‘include[d] exercises in which the subject puts himself in a situation in which he can verify whether he can confront events and use the discourses with which he is armed’. The practice of taking care of the self, then, involves a procedure of testing the self. Testing the self refers here to a mode of self-evaluation and reflection. It is a course of actions that the individual undertakes, performs and repeats in the formation of ethical subjectivity.

Managing sexual appetites in the twenty-first century: the case of FSI/AD

The adaptation of Foucault’s reading of Ancient Graeco-Roman texts to contemporary contexts must be approached with caution. Certainly, the subjectivity of Ancient Greeks and Romans differs sharply from our modern Western era. However, as Paras (2006: 131) notes: ‘To the extent that ethical questions were ones in which what was at stake was the way in which free individuals related to one another … the ancient arts of living – while not directly imitable – had the potential to speak to our situation.’ Indeed, in the introduction to The Use of Pleasure, Foucault (1985) remarks on the continuity between now and then. He argues that one develops ethical subjectivity through certain techniques of subjectification that involve the testing, managing and improving of the self. Foucault’s elaboration of Ancient Graeco-Roman techniques for the management of the use of pleasures and the fashioning of ethical subjectivity are highly relevant to my discussion in this article. I am suggesting that although the content and techniques of ethical subjectivity have been transformed, what is continuous, despite recurrent focus on the history of sexual object choice, is how the concern with sexual appetites, and the techniques for their management and regulation, has endured in various forms. Sexual appetite, whether too little or too much, remains subject to intense introspection. Hence, by using the case study of Female Sexual Interest/Arousal Disorder (FSI/AD), I will argue in the remainder of the text that through the development of a diagnostic manual and the psychiatric therapeutic encounter, the individual adopts different techniques and develops strategies for inspecting and managing the self. The objective of self-analysis – and what has never disappeared from sexual medicine – is an intense examination of the dietetics of pleasure and desire.

Rose (1989: 248) observes that texts of psychotherapy operate as ‘a kind of instruction manual in the techniques of the self’. He extends Foucault’s work by drawing links between the ancient practice of the care of the self and modern therapeutic processes. The DSM, whose aim is to classify mental disorders and provide strategies to identify disease, also manifests this link. The DSM-5 supplies the clinician with a set of guidelines and procedures that must be followed for the diagnosis of sexual dysfunctions. Yet in the deployment of these criteria during the therapeutic encounter, patients are not only expected to reveal their sexual life, they are required to actively participate in the process of making diagnosis by examining the frequency, duration and intensity of their sexual practices. Since at least 1980 the DSM has emphasized that in the examination of a patient’s sexuality, all aspects of their interpersonal relationships have to be taken into account. In the process of confessing to the clinician their pleasures, desires, relations and actions, the patient needs to recognize herself as the subject of scientific inquiry. The late twentieth and early twenty-first century psychiatric approach to sexuality in the DSM requires the patient to become more active in the development of their diagnosis. Indeed, the Manual emerges as a technique for managing sexual balance. Disorders of sexual appetite are brought into being not only through clinical practices, but also through critical practices carried out by the patient. By coming into contact with techniques of classification in the DSM, the patient partakes in enacting the reality of sexual dysfunctions and achieves an awareness of the condition of ‘being sick’. This reality is also reproduced in the work the patients perform on themselves, through the practice of self-monitoring and self-management. The self-aware subject is enacted and produced, repetitively, by using clinical techniques, such as those of classification and examination, which are harnessed to garner information about the sexual life of the patient.

In the architectonics of the DSM-5, FSI/AD is found in Section II: Diagnostic Criteria and Codes under ‘Sexual Dysfunctions’. The technique of classification relies on different diagnostic criteria in the making of pathology and the Manual specifies conditions that have to be met for a patient to be diagnosed with FSI/AD. The classification produces an idea, a picture of the patient with FSI/AD. The system of criteria delineates steps and procedures that must be followed by the physician in the performance of her/his role. At the same time, the criteria set forth objects, activities and circumstances on which the patient will need to comment. A classification system, write Bowker and Star (1999: 10), ‘is a set of boxes (metaphorical or literal) into which things can be put to then do some kind of work – bureaucratic or knowledge production’. In the assemblage of one’s personal biography, the subject engages with the classification of the DSM and its instruments, questionnaires and technical equipment.

Criterion A of the FSI/AD requires patients to account for their patterns of sexual activity:

A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:

For all these indicators, the patient will need to provide certain specifications; whether the ‘condition’ is life-long or acquired, whether she is experiencing disturbances that are generalized or situational and, with the help of the patient’s narrative, the clinician will specify the level of distress: mild, moderate or severe. Criterion A covers different concepts of sexual activity: interest, fantasies, initiation, pleasure, receptivity and genital functionality. The patient needs to be able to provide a narrative responding to all those different indicators. The different paradigms incorporate subjective, affective sensations as well as an evaluation of physiological responses. Criteria A1 and A2 ask the patient about her interest in sexual activity as well as her sexual or erotic thoughts and fantasies. To account for these two aspects, the patient must comment on whether there has been a reduction in her interest in sexual activity and whether she fantasizes about having sex. She is required here to comment on the quantity and quality of interest and thoughts. The patient needs to provide an account of her affective inclinations; does she imagine erotic and sexual scenarios, is she interested in sexual relations, does she exercise her mind erotically, and if there has been a reduction in carnal appeal, when did this begin.

Criterion A3 focuses on the question of initiation and receptivity. This introduces the examination of the patient’s relations, that is, how she is managing sexual activity with one, or more, partner(s). As the DSM-5 states, Criterion A3 is ‘behaviorally focused … A couple’s beliefs and preferences for sexual initiation patterns are highly relevant to the assessment of this criterion’ (APA, 2013: 434). In the application of this criterion then, the patient will not only need to account for her own behaviour, but will also need to discuss how her partner reacts to her lack of initiation or her lack of responsivity. By taking into account her behavioural patterns and those of her partner, an ‘ideal’ outcome is produced - that is to say, how she would like to act or respond when faced with a sexually charged situation. In doing this, the patient actively fashions her own sexual subjectivity, and she produces a picture of what sexuality could become. For instance, she might desire to initiate sexual activity more, which could lead her to confess to her distress about her inability to initiate. Conversely, she may be distressed because she does not experience excitement when faced with sexual initiation. The next criterion, Criterion A4, delves into the experience of excitement and pleasure. Here the patient needs to give information about the situations and contexts where excitement and pleasure are decreased or absent. She needs to think about the past six months and consider whether the reduction or absence amounts to the majority of all her sexual relations during that time.

The diagnostic criteria require that the patient scrutinizes and monitors her bodily rhythms, relations and actions in order to recognize whether she fits at least three of the six criteria. I want to suggest here that, through the technique of the Manual and through providing information on the different criteria, the patient participates in a project of shaping her subjectivity. Patients are tasked with engaging in a kind of self-entrepreneurialism where they have to educate themselves in developing the ability to recognize interest and to erotic thoughts, identify receptivity and realize whether they initiate sex enough. In other words, the patient will develop an awareness of her body and passions, and regulate any imbalances by conducting self-monitoring and engaging in social intercourse armed with this knowledge. An analysis of FSI/AD reveals that the clinical examination demands that the patient is active, cooperative and contributing to the diagnosis. The clinical encounter is central to the deployment of sexuality; as the patient takes a seat in the therapeutic office, she is immersed in the ‘institutional incitement’ (Foucault, 1978: 18) to speak about sex. There is no doubt that during this process, through the procedures delineated by the Manual, the individual will provide an account of her feelings, interests and desires. However, in her interaction with the diagnostic criteria the patient is far from a passive recipient of psychiatric expertise; in fact the patient is already undertaking work upon herself in the form of self-analysis.

Criterion A5 asks the patient to give an account of her responses to ‘sexual/erotic cues’ (APA, 2013: 433). She is asked here to comment on how erotic stimuli affect her interests and her arousals. The patient will need to be able to distinguish between her physical and subjective affective reactions, as well as to provide commentary on her ability to make this distinction. She will also answer questions as to what form of stimuli was most or least effective on her senses. For example, the patient will reveal here her consumption of erotic material, if any. Hence Criterion A demands an extensive awareness of one’s body and one’s mind; the patient needs to be able to comment along both paradigms. While the system of classification requires a patient to comment on her subjective feelings and physiological responses, the Manual is quite clear that it relies on the patient’s perception of vaginal wetness:

[Criterion A6] may include reduced vaginal lubrication/vasocongestion, but because physiological measures of genital sexual response do not differentiate women who report sexual arousal concerns from those who do not, the self-report of reduced or absent genital or nongenital sensations is sufficient. (APA, 2013: 434)

The patient must make an assessment of her genital responses, and how conscious she is of lubrication and sensations in her genitalia. The patient has the responsibility to estimate her viscous imbalance. In other words, she needs to be able to comment on whether her subjective awareness of desire, that is her interest, matches, and is balanced with, her physiological changes.

Since 1987, the DSM has noted that symptoms must cause ‘clinically significant distress in the individual’, in accordance with criterion C ¹³ (APA, 2013: 433). The DSM-5 also states that distress ‘may be experienced as a result of the lack of sexual interest/arousal or as a result of significant interference in a woman’s life and well-being’ (APA, 2013: 434). The patient needs to account for her relations and comment on whether the ‘condition’ impacts on her ability to maintain intimate relationships. She needs to comment on how her lack of sexual interest and arousal affects her personal and relational well-being. Distress, then, is a performative category. The patient will express her degree of anxiety and anguish, and simultaneously will consolidate an account of sexual appetite as distressingly lacking. The psychiatrist will use these answers to specify what the ‘current severity’ of the patient’s condition is: mild, moderate or severe. In giving an account of one’s sexual history and one’s distress, the patient is always already immersed in the vocabulary of self-evaluation. In this process, the patient turns to her sexual past and present in order to locate and diagnose a problem, and invests hope for change, for balance in her future self.

Under criterion B, FSI/AD specifies that symptoms in criterion A must have persisted ‘for a minimum duration of approximately 6 months’ (APA, 2013: 433). These requirements are important in order to rule out temporary or momentary sexual shortcomings and establish that there is a psychiatric condition. In the description of disease, and the naming and production of diagnosis, the DSM relies on behaviours, functions, signs, symptoms and data on the progression of disease over a period of time. ¹⁴ Thus, criterion B of FSI/AD stipulates that the symptoms must have persisted for about half a year. This indicator requires the individual to keep time. Patients need to monitor their imbalances in sexual appetite. They need to be attentive to the changes in amounts of desire, when and where they desired less, and whether the situation went on for a minimum of six months. Patients need in a sense to ‘write down’ their desires and keep a diary of them, to project their imbalances upon an organization of duration and location. Patients are particularly required to take note of their desire(s), map their arousals and ‘chart’ these in terms of duration and location.

The change in language from desire to interest draws attention to the problem of self-awareness in the therapeutic encounter. For example, it highlights the difficulties in distinguishing between desires and interests. In light of the removal of ‘desire’ from female sexual dysfunctions, I suggest that women in particular need to be aware of the differences between their interests – that is, the affective aspects of their experience of sexuality – as well as their arousals. This means that any sexual activity will have to be assessed and evaluated in terms of bodily responses. The patient will make an assessment of her genital sensations during the sexual relations that she engages in over the course of six months and she will compare the different occasions. The key feature here is that the reduction in the number of times one thinks about sex, responds to initiation, or initiates sex becomes a problem only when it occurs frequently and it causes distress. In addition, the DSM is interested in the circumstances of reductions in desire. Patients need a certain awareness or alertness to their rhythms of desire. This is an imbalance which, should it cause clinically significant distress, requires clinical intervention. Thus, there is a dual action of management and regulation while the onus remains on individuals to monitor their rhythms in order to comprehend their disorder.

During the passage through the clinical process, the patient discovers and uncovers patterns of behaviour, emotional and physical truisms and fashions, with the help of psychiatric language and tools, an ‘improved’ self. The patient also develops techniques that assist in the continued management of the self. The classification technique is pedagogical and emancipatory. The patient will come out of the clinical process having learnt about certain events, patterns and behaviours. Thus, in the Manual, caring for the self is a process of developing and enacting subjectivity; it entails the awareness of what kind of subject one is and what kind of subject one aspires to be. This process does not tend towards finality, as the subject needs constant monitoring and improvement, and hence invokes a ‘becoming’ of the subject rather than a ‘being’.

The DSM’s classification of FSI/AD deploys different criteria and requires the psychiatrist to be skilled in the interpretation of such paradigms in order to detect pathology. At the end of the twentieth century, the psychiatric gaze is not only marked by a sustained attention to biology and its dysfunctions, but it is also interested in the capacity of the body to lend itself to measurement and the capacity to re-establish balance. These functions need to be excavated and studied in order to attain the source of the disorder. This, however, is compounded with notions of individual responsibility, as individuals not only need to provide an account of their desires and their intensity, but they also need to take care of their bodies, moderate the use of pleasures and assume responsibility for their relations.

Clinical techniques and self-awareness

In the diagnosis of Female Sexual Interest/Arousal Disorder, the medical subject needs to confess desires, however perverse or immoral, to outline a personalized, individual sexual historiography. The confession requires a patient to have insight into her relations, rhythms and actions. To help the patient think about symptoms of her sexual imbalances, psychiatrists routinely make use of questionnaires to contribute to the process of diagnosis. The guidelines of the DSM are supported by questionnaires that delve into the intensity of the patient’s sexual appetite and her levels of distress. In addition, the use of scales, questionnaires and sexual inventories form an integral part of the clinical examination. These questionnaires ‘encourage physicians to discuss sexuality as part of the routine patient encounter’ (Clayton et al., 2010: 2191). I suggest, however, that the questionnaires not only support the work of the clinician, but also incite the patient to speak about sex, to reveal her desires and their intensities, and they work to achieve what can be referred to as instances of recognition in the patient. The questionnaires encourage patients to evaluate, ‘take stock’ of their own histories of sexuality, and to promote self-realizations. In other words, they promote the development of ethical sexual subjects, as patients need to think about sexual balance, amounts and frequencies in order to be able to respond to the questions. Through this exercise on the self, the patient accesses the techniques of self-diagnosis. In developing an awareness of the differences between being aroused and being interested, the woman can govern her emotions, performances, moods and affects. This is achieved through the apparatus of classification as well as surveys that can be structured interviews administered by the physician, or self-report questionnaires led by the patients.

In what follows, I focus on a questionnaire dedicated to female sexual dysfunctions, in order to shed light on how the application of techniques of self-awareness is now required by the patient in the process of answering the questionnaires. ¹⁵ One of the more recent questionnaires developed to ascertain dysfunctions of desire in women is the Sexual Interest and Desire Inventory-Female (SIDI-F). In 2005 a team of researchers developed the SIDI-F, which was the first instrument specifically designed for assessing the severity of what was then called Hypoactive Sexual Desire Disorder in women (Jutel, 2010: 1087). The questions delve into the patient’s relationships, her ability to respond to initiation and her ability to initiate sex, the frequency of sexual desire and affective desires, her satisfaction about her desires, her perceived level of distress, the positive thoughts she has about sex, her consumption of erotic material, the ease of arousal, as well as her orgasmic abilities, her experience of pain during sex, overall moods, and energy levels. This broad range of questions provides the physician with an in-depth picture of the patient’s sexual and emotional situation for the past month. Some examples of SIDI-F questions include:

The answers to Item 4 offer as possibilities: ‘did not encourage/initiate’, ‘subtle indirect initiation or encouragement’ and ‘actively (overtly) initiated’, with frequency ‘1–2 times/month’, ‘3–4 times/month’ and ‘more than once a week’. Item 5 presents two axes covering both the frequency of desire and the corresponding intensity experienced. This type of question offers grades from one to two times a month and more than once a week as possible answers. Similarly, affection and positive thoughts are graded according to strength and rate of occurrence. Arousal in Item 12 and Item 13 is assessed in terms of frequency and intensity (ease and continuation of arousal). Questions such as ‘How easy was it for you to get aroused in the past month?’ and ‘Once this happened, did you desire further stimulation and how strong was this desire?’ provide an exceptional inducement for the patient to engage in self-examination and develop self-awareness. The woman needs to be conscious of her bodily reactions and the viscosity in her vaginal cavities. These questions institute a constant, repetitive process of self-monitoring. The awareness of arousal and interest emerge as a form of labour, an action to be cultivated, managed and refined in order to achieve balance.

Reflecting and learning to recognize certain patterns of behaviour arm the patient with techniques that help her to manage future sexual encounters. The questionnaires, in other words, have a pedagogical aim as well as an emancipatory promise. It is no longer about sexuality ‘by itself’. Examining her life through such questions and through the therapeutic process, the patient becomes:

the target of a reflexive objectifying gaze, committed not only to its own technical perfection but also to the belief that ‘success’ and ‘failure’ should be construed in the vocabulary of happiness, wealth, style, and fulfilment and interpreted as consequent upon the self-managing capacities of the self. (Rose, 1989: 239)

Repetitively conducting self-examination will lead patients to recognize that they experience certain emotions frequently; they feel recurrent fatigue, sadness or discomfort. Patients are encouraged to remember and recognize when these events occur. The patients’ ideas about themselves are constructed, fashioned and enacted around certain patterns. Or perhaps it is not so much that identity is constructed, but rather that the patient comes to understand herself through the knowledge of recurrent life patterns.

In order to answer the questionnaires as accurately as possible, the patient needs to be attentive to her sexuality, to the emotional aspects of her life and the responses of her body. The key concept here is awareness and understanding of the affective, intimate and imaginative dimensions of one’s life. As Foucault (1997c: 285) writes, ‘[t]aking care of oneself requires knowing oneself. … To take care of the self is to equip oneself with these truths: this is where ethics is linked to the game of truth’. First, the patient is required to be attuned to her body and to recognize what she is feeling and, second, she needs to be able to translate these affects into numbers, into measurable data. This is a central aspect of the medicalization and the management of sexual appetite. Tools such as the SIDI-F supplement the confession to the physician and encourage the subject to become more aware of her disorder. Asking individuals to quantify the intensities of arousal and interest instructs them to account for their desire, body and life. In this manner, ‘the individual is summoned to recognize [herself] as an ethical subject of sexual conduct’ (Foucault, 1985: 32). The patient is an active participant in the production of meaning, knowledge and disease. To the extent that the DSM relies on the individual to make an assessment of her distress, notwithstanding that expert judgement still needs to be made as to whether it is ‘clinically significant distress’, it is a tool that promotes regimen and self-reliance.

Developing attunement or awareness is always completed in relation to others. The relationships of the patients have to be analysed, diagnosed and realigned or repaired in order to foster a self-possessed, harmonious self. The instrument, then, has a pedagogic function, as patients need to learn what behaviours are detrimental to their well-being. When answering the questions listed in the SIDI-F, patients conduct introspection; they scrutinize their relations, their affects, needs and emotions. Patients undertake a journey towards moments of recognition that will point to what is beneficial and detrimental about their private lives. In Rose’s terms, such encouragements towards self-discovery imply a ‘neuroticization of social intercourse’ whereby relationships with friends, colleagues, family members and lovers ‘are discovered as key functional elements in both our personal happiness and our social efficacy’ (Rose, 1989: 245). Such careful scanning of one’s life, through the SIDI-F, also implicates the intensity of these relations. For instance, Item 6, ‘Affection’, asks the patient how often she experiences inclinations for non-sexual physical affection and also requires her to state if it is mildly intense, moderately intense or extremely intense (Sills et al., 2005: 814). This can be interpreted as non-sexual physical affection with friends or family, not only lovers and partners.

Conclusion

In Ancient Greek medical treatises, disease was approached as a state of imbalance between the humours. Good health and harmony existed when the humours – black bile, yellow bile, blood and phlegm – were balanced; too little or too much of any component resulted in illness. Curing a disease involved rebalancing the unevenness to re-establish a harmonious self, and treatment ‘had to take into account both external and internal factors, including the patient’s lifestyle and his or her temperament’ (Arikha, 2007: 8). Furthermore, disease in classical medical treatises was defined not solely by disequilibrium, since it was ‘an effort on the part of nature to effect a new equilibrium’ in individuals (Canguilhem, 1991: 40). That is, the state of disease was designed to generate a cure, a new state of being and a new state of balance. This new and improved balance was achieved by examining the whole life of the individual. In other words, the humours were not confined to the interiority of the body; it was not solely a question of viscosity, fluids and blood. Rather, it was important to consider the lifestyle practices of the patients, for example their nourishment, how they sleep, where and for how long they work, their amorous activities and so forth. Centuries of technological advancements in examination, diagnosis and treatment separate contemporary Western medicine from Ancient Greek and Roman medical knowledge. However, in contemporary psychiatric engagements with sexual appetite, the question of imbalance becomes refigured and revivified, while techniques and instruments continue to be developed to make patients aware of their imbalances and guide them towards the restoration and maintenance of sexual balance.

This study has examined the development of the DSM and selected tools of diagnosis in the twentieth and twenty-first centuries. It has explored how ideas of balance and self-care circulate through the dissemination of the Diagnostic Manual and techniques of classification and examination. The accentuation of discourses of sexual appetite and balance occurred with the publication of the DSM-III in 1980. In this edition of the Manual, the concern with object choice began to recede from view and psychiatry became increasingly preoccupied with sexual imbalances, too little or too much sexual appetite. The focus of this article has been lack or reduction of sexual appetite as embodied in FSI/AD.

I have argued that the emergence of discourses of sexual appetite occurred alongside the elaboration of pedagogical and emancipatory ideas of the care of the self. If the DSM maintains that sexual response ‘has a requisite biological underpinning, yet it is usually experienced in an intrapersonal, interpersonal and cultural context’ (APA, 2013: 423), then techniques such as classification, interviews, questionnaires and surveys work towards making the patient more aware of these contexts and variations. The Diagnostic Manual provides the tools of self-diagnosis and emerges as an apparatus to take care of the self, to fashion the self as a medical subject, to manage sexual imbalances. The ethical, responsible sexual subject materializes from the therapeutic encounter and carries on the labour on the self. The DSM is now laden with the language of ethics. Indeed, the language of taking responsibility for one’s own disorders increasingly emerges in each rendition of the DSM. Concurrently, the DSM requires that the physician oversee the instrument of classification. The application of the technique of classification manifests a tension between self-diagnosis and self-management, and the duty of the expert for the naming of disease and the administering of care.