What Is the Problem With Sexual Intimacy Following Intimate Partner Violence in the DSM -5?

Abstract

Drawing on a data subset from a larger Australian-focused project, this article reports on the ways that women’s voices have been silenced and misrecognized in the representation of the impact on sexual intimacy following experiences of intimate partner violence. Bacchi’s “What Is the Problem Represented to Be?” approach was used to identify, explore and unpack the “problem” representations of the impacts on sexual intimacy following women’s experiences of intimate partner violence within the Diagnostic and Statistical Manual of Mental Disorders.

Keywords

sex feminism intimate relationships

Introduction

Historically, women’s sexual experiences have been framed as less important than those of men (Cacchioni, 2007; Grose, 2016; Tiefer, 2001a) and impacts on women’s sexual responses following intimate partner violence (IPV) have been viewed as “dysfunctional” (Deacon, 2013). Women have also been demonized for not satiating men’s sexual desires (Grose, 2016). When women are unable to measure up to a mythical norm of their sexual responses, their problems have often been medicalized (Cacchioni, 2007; Tiefer, 2001a). The mythical norm is a “stereotype that is perpetuated by society, against which everyone else is measured” (Lorde, 1999, p. 362). These ideas have been critiqued by feminist researchers (Marecek & Gavey, 2013; Tiefer, 2001a).

Feminist research has identified the limitations of focusing on the medical model of female sexual dysfunction (FSD) and gendered stereotypes without looking at the broader picture of women’s lives (Tiefer, 2001a). It is because there are physical, emotional, and social impacts of IPV (Centers for Disease Control and Prevention [CDC], 2019; World Health Organization [WHO], 2019a) that shape women’s experiences of intimacy.

A feminist lens critiquing medicalized representations of the impact on sexual intimacy following women’s experiences of IPV has been used by several studies. These include Tiefer’s (2001a, 2004) New View Campaign, which critiqued the medical model of women’s sexual lives, and Cacchioni’s (2007) study into how women strive to improve their sexual lives. However, despite the link between IPV, post-trauma symptoms, and the impact on intimacy (Dolan, 2015; Yehuda et al., 2015), there is a gap in research that focuses on the impact on sexual intimacy following women’s experiences of IPV.

This article, using a feminist lens, reports on a study that explored where women’s voices have been silenced in the representation of the impact on sexual intimacy following experiences of IPV. This was undertaken by exploring “problem” representations in a key document, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). The research focus is on interpersonal violence, including sexual abuse, physical abuse, and emotional abuse, within intimate relationships.

Locating Interpersonal Violence and a Review of the Literature Surrounding the Impact on Sexual Intimacy

The following discusses the definition and prevalence of IPV and the impacts on a victim/survivor’s life. A brief review of the literature explores the history of FSD to understand how gendered norms impact understandings of, and responses to, sexual intimacy (Widom, 1984). In addition, feminist arguments for considering impacts on sexual intimacy beyond the medical model are discussed (Tiefer, 2001a). The medical views of masculinity and femininity and how they influence and are influenced by society are also explored (Bancroft, 2002).

Definition and Statistics of IPV

According to the WHO (2019a), IPV is one of the most common forms of violence against women. IPV is defined as acts of physical and sexual violence and sexual coercion as well as emotional abuse, threats of harm, controlling behaviors and restricting access to financial resources, education, and medical care.

The WHO (2019b) states that IPV violates women’s human rights and is a significant public health issue. In Australia, one in six women experiences physical or sexual abuse, and one in four Australian women experiences emotional abuse from an intimate partner (ANROWS, 2014; Our Watch, 2019). Gender equality and family violence organization, Our Watch (2019), argues that while men experience IPV, statistics show that Australian women are three times more likely to experience IPV.

Impacts of IPV

Victim/survivors of IPV experience a significantly higher risk of experiencing negative impacts on intimacy (Bagwell-Gray, 2021). In addition, it is important to recognize both the short- and long-term impacts of IPV and that the longer IPV continues, the more significant the impact (Black et al., 2011).

Physical

Physical impacts of IPV are the leading health risk for victims/survivors (Australian Institute of Health and Welfare, 2018). Physical impacts can be far-reaching, disruptive in both the short- and long-term, and can cause painful sex or a fear of intimacy (CDC, 2019; Kearney-Cooke & Ackard, 2000). Physical impacts include FSD, pelvic inflammatory disease, and sexually transmitted infections (CDC, 2019; WHO, 2019b).

Emotional/psychological

The emotional and psychological repercussions of IPV are numerous and can be short- or long-term (Pico-Alfonso et al., 2006). These impacts may remind the victim/survivor of her experiences and influence self-esteem (Kearney-Cooke & Ackard, 2000). Historically, the impacts on a woman’s sexual life have been medically diagnosed as mental health issues including, for example, anxiety, depression, suicidal ideation (Pico-Alfonso et al., 2006), and post-traumatic stress disorder (PTSD) (ANROWS, 2016; Black et al., 2011; CDC, 2019; Pico-Alfonso et al., 2006; WHO, 2019b). The CDC (2019) suggests that “inability to trust others, especially in intimate relationships, fear of intimacy, emotional detachment, sleep disturbances, flashbacks, replaying assault in the mind” (para. 10) can also be consequences of IPV and impact sexual intimacy (Kearney-Cooke & Ackard, 2000). This loss of safety compounds the impacts of IPV on sexual intimacy and creates trust barriers in future relationships (Bagwell-Gray, 2021). It has also been shown that poor emotional intimacy and lack of communication can increase the risk and severity of IPV (Gerlock & Tinney, 2017).

Social

A significant social impact of IPV is stigma (Kennedy & Prock, 2016; Overstreet & Quinn, 2013). The IPV Stigmatization model suggests that cultural stigma leads to internalized feelings of shame and failure. Cultural stigma is a result of societal beliefs that de-legitimize victims/survivors through victim blaming. Internalized stigma relates to how victims/survivors blame themselves. In addition, anticipated stigma relates to the fear of how other people will react. While identification as a victim can potentially absolve the individual of blame, it can simultaneously construct them as weak and contribute to victim blaming (Kennedy & Prock, 2016).

DSM-5 Definition and History of FSD

The definition and the history of FSD are complex (Basson, 2005; Swerdloff & Wang, 2016; Tiefer, 2001a). The definition has changed over time due to incremental accounting of external factors including relationships, trauma, and other mitigating circumstances (Tiefer, 2001a). The DSM-5 (5th ed.; DSM-5; APA, 2013) aimed to move toward a more specific, female-function-focused diagnosis (IsHak & Tobia, 2013) influenced by the human sexual response model (HSRM). The HSRM assumed a normative linear progression from sexual desire to arousal, to orgasm and resolution (Masters & Johnson, 1966).

The history of FSD contributes to the difficulties of diagnosis, leading to restricted service provision and accessibility (Swerdloff & Wang, 2016). To understand how the impacts on sexual intimacy are reflected in the medical model, it is important to understand how women are viewed by society, and therefore may understand themselves through this viewpoint (Grose, 2016).

The definition of FSD is influenced by the history of the construction of women’s sexual issues, and medical definitions cannot encapsulate the entirety of the issue (Basson, 2005; Taylor, 2015; Tiefer, 2001a). Sexual dysfunction (including FSD) is currently defined in the DSM-5 (5th ed.; DSM-5; APA, 2013) under the “Sexual Dysfunction” section as:

. . . a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure. (p. 423)

Further research into women’s sexual responses has brought the current definition and models including the HSRM into question (Basson, 2005). For example, according to the HSRM, if the linear process was not “naturally” followed, the woman could be diagnosed with FSD (Basson, 2005; Masters & Johnson, 1966).

According to Angel (2011), 43% of women experience what could be diagnosed as FSD. However, FSD is underreported, underdiagnosed, and undertreated (Swerdloff & Wang, 2016). In addition, impacts on sexual intimacy can cause strain in emotional relationships (Kearney-Cooke & Ackard, 2000). It remains difficult to determine whether an “abnormal” sexual response is a “dysfunction” or a natural response to trauma or other circumstances–for example, relationship problems, cultural contexts, or religious beliefs (Basson, 2005).

The medical history of FSD has grown in stages, as reflected in the development of the DSM editions themselves. To start with, in 1952, the DSM-I listed 60 categories of abnormal behaviors (IsHak & Tobia, 2013). The 60 categories have now been narrowed to the current three diagnoses of FSD in the DSM-5 (5th ed.; DSM-5; APA, 2013).

The discussion about FSD has also evolved in medical, psychological, and public discourse (Angel, 2010) to the point where research has analyzed FSD from a variety of angles, including the efficacy of pharmaceutical interventions (Angel, 2010; Tiefer, 2001b). As a result, medical professionals and pharmaceutical companies have focused on developing medical treatments for FSD (Hartley, 2006), further medicalizing women’s responses to IPV.

The DSM and the HSRM have been criticized for silencing women’s voices and ignoring the social and emotional aspects of women’s sexual experiences (Tiefer, 2001a). This marginalization of women’s experiences reflects and perpetuates a power imbalance whereby women are oppressed by the male-dominated field of psychiatry featured in the diagnoses and classifications in the DSM and HSRM (Marecek & Gavey, 2013).

The field of psychiatry, diagnoses, and clinical practices activate a positivist model, which upholds the belief in a universal “truth” (Marecek & Gavey, 2013). Dodd (2015, p. 313) emphasizes that:

Feminists cited evidence that women were over diagnosed and overmedicated and suggested that male psychiatrists’ propensity for diagnosing women with disorders like depression was little different from earlier ideas of women as hysterical.

Tiefer (2001a) and Bancroft (2002) argue that the medical model compartmentalizes the mind and the body into generalizations about women’s sexual responses. Despite concerns from feminists about the medicalization and standardization of women’s sexual lives and their experiences of IPV, the DSM-5 (5th ed.; DSM-5; APA, 2013) was published with seemingly limited revision (Dodd, 2015; Marecek & Gavey, 2013).

A gendered medical history

The social construction of gender influences attitudes, roles, expectations, and ideologies about sexual intimacy (Bancroft, 2002). This results in a gender imbalance produced and maintained by patriarchal ideology. Patriarchal ideology in this context constructs and perpetuates systems and structures that act to oppress women in a variety of realms, including sexual intimacy (Walby, 1990).

The DSM-5 (5th ed.; DSM-5; APA, 2013) (influenced by the HSRM model) includes three FSD diagnoses (APA, 2013; IsHak & Tobia, 2013): female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, and female orgasmic disorder. However, these conditions must be approached with caution as there are other factors to consider, such as differences in female and male sexual responses (Bancroft, 2002; Tiefer, 2001a).

Westernized societies have long problematized women’s sexual experiences, and women’s bodies continue to be a site of struggle and control (Teghtsoonian & Moss, 2008). Teghtsoonian and Moss (2008) also argue that men and women are historically understood to sexually respond in similar ways even though feminists challenge the medical model of FSD and the assumption of similarities between genders (Tiefer, 2001a). For example, physiologically, an erect penis is assumed to be the same as a lubricated vagina. Thus, when a vagina does not lubricate, it is often diagnosed as FSD, without taking other factors into account (Basson, 2005).

In addition, female orgasms were presented to operate the same way as a male orgasm in the HSRM. Angel (2010) explained that:

the failure of vaginal orgasm became the conceptual lynchpin of “frigidity.” . . . Moreover, the woman desiring clitoral stimulation, as opposed to vaginal intercourse, became representative of women who behaved like men . . . behavior that led to neurosis, isolation, and social disintegration. (para. 7)

The concept of frigidity (Angel, 2010) led to the medical model of FSD defining “normal” and “abnormal” sexual responses, and the assumption that FSD is primarily physiological and able to be treated medically (Teghtsoonian & Moss, 2008).

The Impact of Gendered Norms and Expectations on Female Sexuality

Gendered norms and the resulting expectations about female sexuality come from societal ideas about gender power relationships (WHO, 2019). This includes beliefs about “men’s rights” to dominate and physically discipline women for incorrect behavior, which are supported by the notion that men are socially superior (WHO, 2019). Furthermore, sexual intercourse (including rape) is often promoted as normative masculine practice, particularly within marriage. According to the WHO (2019), common beliefs exist that even if a woman is unwilling, she should tolerate violence for the greater good of her family.

Research suggests that men have more power in sexual relationships than women do (Lefkowitz et al., 2014). It has been argued that these expectations stem from the perpetuation of a cisgendered, normative idea that sexual responses are biologically gendered (Tiefer, 2001a).

Moving Forward

Despite an ongoing investigation into the management of FSD, IPV, and how they affect sexual intimacy, the link between the three presents a gap in current research. The Centers for Disease Control have discussed FSD, risky sexual behaviors, and fear of intimacy, and Kearney-Cooke and Ackard (2000) examine self-esteem, difficulties in relationships, and issues with trust. However, there is no link shown in the research between how these compound and impact a victim/survivor (Kearney-Cooke & Ackard, 2000; Tiefer, 2001b).

Clinical researchers appear to hide behind standardized questionnaires focused on a vocabulary of sexual acts possibly due to discomfort about the psychology of sex (Tiefer, 2001b). Tiefer (2001b), therefore, suggests that “researchers talk instead about sexual desire, arousal, and activity as if these were natural and universal, spontaneous and standardizable, comparable in people and rats” (p. 626). The implication is that perhaps researchers are embarrassed and avoiding research into how sex can be connected to deep longing for affirmation, inner doubt, need for power, and sense of identity (Tiefer, 2001b). This gap in research could further silence women’s experiences of sexual intimacy and prevent them from accessing the help they need.

Method

What Is the Problem Represented to Be?

This study uses Bacchi’s (2009) feminist “What Is the Problem Represented to Be?” (WPR) approach to explore the DSM-5 (5th ed.; DSM-5; APA, 2013) for gendered ideologies, how the ideologies influence DSM-5 content and, in turn, how this influences society (Leavy, 2011). WPR is widely acknowledged as being effective in analyzing documents to recognize “problem” representations and influential discourses within them (Bletsas, 2012). WPR is typically used to explore “problem” representations in policies (Bacchi, 2009). However, it can also be used for critical analysis of other authoritative texts (Bletsas, 2012; Coveney & Putland, 2012), such as medical manuals (Coveney & Putland, 2012).

The aim of WPR is to look within the text to develop an awareness and understanding of how the “problem” is represented, as well as the effects created by the representations (Coveney & Putland, 2012). WPR facilitates interrogation into issues, such as public health, and how the “problem” representations can be influential in policy and practice through a six-question process (Bletsas, 2012; Coveney & Putland, 2012). This process unpacks “problem” representations, as well as the presuppositions and assumptions, and history of the representations. The method also analyzes for groups of people whose voices are silenced within the representations, the effects of the representations, the publication and defense of the representations, and how these representations might be challenged and replaced (Bacchi, 2009).

Applying WPR to the DSM-5

Bacchi’s (2009) WPR approach has been used to learn how women’s experiences with sexual intimacy following IPV are “problematized” by medical and psychiatric fields via the DSM-5 (5th ed.; DSM-5; APA, 2013). The DSM-5 (5th ed.; DSM-5; APA, 2013) is important to understand because it is a standardized document utilized worldwide (Frances, 2013) and is often embedded in government and agency health documents or policies.

What Is the Problem of Sexual Intimacy Following IPV Represented to Be in the DSM-5?

The first question posed in this analysis seeks to investigate what the DSM-5 (5th ed.; DSM-5; APA, 2013) considers the “problem” to be, and then what is considered necessary to address the “problem” to “fix” it. The DSM-5 (5th ed.; DSM-5; APA, 2013) represents the impact on sexual intimacy following IPV as “sexual dysfunction,” described as:

Sexual dysfunctions include . . . female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder. (p. 423)

Genito-pelvic/pain/penetration disorder is a recent DSM-5 (5th ed.; DSM-5; APA, 2013) update on the original diagnostic term “vaginismus” due to research indicating that vaginal spasm was not the only, or even the dominant, cause for painful penetration (Perez & Binik, 2016). The shift from vaginismus (Diagnostic and Statistical Manual of Mental Disorders; 4th ed.; DSM-IV; APA, 1994) was considered important to better incorporate research data, such as the tensing of the pelvic floor and fear of penetration (Perez & Binik, 2016).

The writing most relevant to sexual intimacy following IPV can be found in the “Sexual Dysfunctions” and “Trauma and Stressor-Related Disorders” sections of the DSM-5 (5th ed.; DSM-5; APA, 2013) where “FSD” is defined as:

Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in the person’s ability to respond sexually or to experience sexual pleasure. (p. 423)

This means that when women experience a disinterest in sex, unresponsiveness to stimulation, lack of orgasm, or painful sexual experiences, it is then defined, named, and consequently diagnosed as “female sexual dysfunction” [FSD] (APA, 2013, p. 423).

The DSM-5 (5th ed.; DSM-5; APA, 2013) does not split the “Sexual Dysfunctions” section according to gender identity and only discusses unitary male and female dysfunction without expanding to other genders. In addition, this description of “sexual dysfunction” (APA, 2013, p. 423) pathologizes sexual intimacy as purely physiological (Fontes, 2001; Tiefer, 2001a, 2004). Further to this, in the DSM-5 (5th ed.; DSM-5; APA, 2013), sex is referred to as “sexual intercourse” or “penile-vaginal intercourse” (APA, 2013, p. 430). The focus on “penile-vaginal intercourse” assumes a heterosexual sexual relationship in which a woman is engaging in penetrative sex with a male partner.

Problem Representations

Three problem representations (Bacchi, 2009) are revealed through analysis of the DSM-5 (5th ed.; DSM-5; APA, 2013) based on the frequency of the terms used.

Women’s sexual responses are physiological rather than emotional

This problem representation can be found in multiple diagnostic descriptors in the DSM-5 (5th ed.; DSM-5; APA, 2013), for example:

Marked delay in, marked infrequency of, or absence of orgasm . . . Markedly reduced intensity of orgasmic sensations (p. 430); lack of, or significantly reduced, sexual interest/arousal (p. 433); absent/reduced genital or nongenital sensations. (p. 433)

These diagnostic criteria describe physiological, not emotional, aspects of women’s sexual responses. This exposes an underlying assumption that there are certain known ways that female arousal should look or feel. This is emphasized through the following diagnostic criteria:

Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g. written, verbal, visual). (APA, 2013, p. 433)

The assumption is that to not have sexual arousal, or to have reduced sexual arousal, is not normal (APA, 2013; Masters & Johnson, 1966; Tiefer, 2004). This focuses on physiological sexual responses, which is akin to the conceptualization of male sexual dysfunction.

This “problem” representation not only treats the impact on sexual intimacy following IPV as dysfunctional and physiological but also normalizes and creates a discourse where sexual intimacy is medicalized. As a result, even in recent times, medical and psychiatric professions have responded to “FSD” by treating it as a purely medical physical condition (Marecek & Gavey, 2013; Tiefer, 2001b). From a feminist perspective, this is a patriarchal framing of psychiatry that underpins the DSM-5 (5th ed.; DSM-5; APA, 2013) (Marecek & Gavey, 2013; Tiefer, 2001b). Such a focus on the pathology of the survivor of IPV displaces attention away from the abuse of power that is a function of violence (Humphreys & Ravi Thiara, 2003).

The DSM-5’s (5th ed.; DSM-5; APA, 2013) emphasis on physiological responses ignores the fact that women’s sexual responses can be precipitated by emotional, social, and relational factors (Marecek & Gavey, 2013; Tiefer, 2001a). This also disregards how women’s fulfillment of multiple roles in life and relationships may thus deplete energy for sexual engagement (Ellison, 2001). Emotions can significantly influence the development of female relationships and sexual expression (Schrock & Knop, 2014), as, stereotypically, women are socialized to be emotional, while men are not (Shields, 2002). Due to socialization, positive emotions within a relationship may be a significant factor in helping women to build trusting sexual relationships, while negative emotions may cause fear or distrust (Schrock & Knop, 2014).

Women are “dysfunctional” if they do not follow the “mythical norm”

The DSM-5 (5th ed.; DSM-5; APA, 2013) circulates the idea that the existence of an impact on sexual intimacy, following women’s experiences of trauma such as IPV, is “dysfunctional.” Also disregarded is the consideration of the waning, phasing of sexual interest as a natural part of sexual experience for women (Tiefer, 2001a) in the diagnostic criteria. For example:

. . . absent/reduced interest in sexual activity . . . absent/reduced sexual/erotic thoughts or fantasies . . . absent/reduced sexual excitement/pleasure. (APA, 2013, p. 433)

The DSM-5 (5th ed.; DSM-5; APA, 2013) suggests that if these criteria are experienced “approximately ‘75%–100%’ of the time” (p. 431), it is then a “clinically significant disturbance” (p. 466). This activates the assumption of a “mythical norm” about women’s interest in sexual activity, including sexual/erotic thoughts, fantasies, and sexual excitement/pleasure. The benchmark of what is “normal” should not be universal or homogeneous. However, the DSM-5 (5th ed.; DSM-5; APA, 2013) measures the frequency or infrequency of women’s sexual desires and responses against an unstated goalpost, which has been suggested as the norm of a standardized level of male interest in sexual activity, desire, and enjoyment (APA, 2013; Tiefer, 2004). These norms pressure women to adhere to the standardized performative criteria discussed above. When women do not meet these criteria, they are conceptualized as faulty or difficult (Tolman, 2001), regardless of the cause. This is problematic because there is no interrogation of unstated norms of standardized, heterosexual, or phallocentric measures. In addition to imposing a rigid standardization, this ignores the diversity of the human nature of sexual relationships and how a person’s social location and sexual history may shape what they experience in the future (Fontes, 2001).

Women’s sexual experiences are measured against their sexual partner/s

Standardized, heterosexual, and phallocentric goalposts reveal the way the DSM-5 (5th ed.; DSM-5; APA, 2013) propagates the idea that women’s sexual experiences are shaped by their male sexual partner/s. For example, the term “penile-vaginal intercourse” (APA, 2013, p. 430) focuses on heterosexual relationships. In addition, “genito-pelvic pain/penetration disorder” (APA, 2013, p. 437) is described as “marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts” (APA, 2013, p. 437). This criterion further promotes the established sexual conventions against which women are measured. This is the case even when meeting the expectation causes women pain and contributes to “. . . fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration” (APA, 2013, p. 437).

The construction of women’s reluctance to have penetrative sexual activity as “fear” solely of penetration is consistent with patriarchal views of sex, which prioritize male desire and assert this desire is for penetrative sex alone (Tiefer, 2001a). This makes it difficult to wholly understand women’s fear other than in relation to the act of penetration. At the same time, if fear is in fact the reason some women do not desire penetrative sexual activity, this is a rational explanation for why many women might be less inclined to want penetrative sex with their male partner (Cacchioni, 2007).

As discussed above, “disordered” arousal or interest also focuses on the sexual partner. In the “Sexual Dysfunction” section in the DSM, “Female Sexual Interest/Arousal Disorder” (APA, 2013, p. 433) is described as “No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempt to initiate” (APA, 2013, p. 433). This diagnosis and “problem” representation often centers on women’s “ability” to respond to sexual advances from their sexual partner without questioning why women may choose to not engage or say no.

The DSM-5 (5th ed.; DSM-5; APA, 2013) states that a diagnosis of FSD requires “. . . ruling out problems that are better explained by a nonsexual mental disorder . . . by severe relationship distress, partner violence, or other stressors” (p. 423). Following this, the criteria for relationship distress, partner violence, and other stressors are explained as “relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse)” (p. 423).

This would suggest that a history of abuse or IPV should rule out a diagnosis of FSD. However, this could then place blame on women who experience impacts on sexual intimacy following IPV (Tiefer, 2001).

What Are the Presuppositions and Assumptions of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV?

Assumption that women’s sexual responses follow the same cycle as those of men

A key assumption underlying the “problem” representation is that women’s sexual responses follow the same cycle as those of men. The idea that women follow the same cycle as men is evident in the medicalization of women’s sexual experiences of “FSD” (APA, 2013). This is evidence of the continued influence of the HSRM that insinuates everyone’s sexual responses follow a similar pattern of excitement to plateau to orgasm to resolution (Masters & Johnson, 1966). Furthermore, this assumption is reinforced by medical languages and treatment, such as the female Viagra drugs, Addyi, and Vyleesi (Tiefer, 2001b).

Assumption of partnered sex

The “problem” representation and diagnosis of FSD also assume that sex is always partnered (Ellison, 2001), ignoring forms of sexual expression such as masturbation. In addition, the medical model overlooks women’s sexual dissatisfaction by placing the emphasis on her partner for gratification (Allina, 2001). This further contributes to the oppression of women who have experienced IPV by displacing women’s needs and desires (Dolan, 2015; Yehuda et al., 2015).

Assumption that all women respond the same way sexually

The third assumption underlying the “problem” representation is that all women respond the same way sexually. This is an assumption that the DSM-5 (5th ed.; DSM-5; APA, 2013) upholds and perpetuates through descriptions of “sexual dysfunction” (p. 423). The mirroring of the HSRM’s linear progression of arousal and the measurement of women’s sexual responses around normative and phallocentric standards have been heavily criticized by feminist researchers (Marecek & Gavey, 2013; Tiefer, 2001a, 2004).

Assumption that heterosexuality is the norm

The fourth assumption underlying the “problem” representation is that heterosexuality is the norm. The DSM-5 (5th ed.; DSM-5; APA, 2013) focus on “penile-vaginal intercourse” (p. 430) and fosters heterosexual penetrative sex as both normative and primary. In turn, this invites feelings of shame and guilt when cisgender women experience impacts on sexual intimacy following IPV when penetrative sex is limited. This poses issues as many women have argued that sexual intimacy is important to their identities (Cacchioni, 2007). This assumption stems from an era when heterosexuality was considered normal and expected, and any other sexuality was considered deviant (Garnets & Peplau, 2001). This heteronormative standard is also grounded in phallocentric constructs around sex as penetrative and necessary for men to experience pleasure.

How Has This Representation of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV Come About?

The following discussion explores historical factors that have supported the development of the “problem” representations. Several theories have been influential in the development of the current “problem” representations. For example, Freud’s theories of women’s sexuality, including frigidity, described as sexual inhibitions (Angel, 2011), and Kinsey’s theories of women’s sexuality regarding what is normal and in the range of women’s sexual experiences (Kinsey et al., 1998).

For Freud, “there was an innate biological sequence of human development and . . . this pattern was universal for men and women alike” (Goodstein & Sargent, 1977, p. 169). Freud centered the phallus as the starting point for the development of masculinity and femininity, and the female body, because it is without a penis, is considered a “site of lack” (Mansfield, 2000, p. 32). Freud (1931) also defined women’s sexual experiences in relation to men, including vaginal sexual responses, and their feelings of “threatened masculinity” (p. 3). Freud (1931) stated:

. . . she clings in obstinate self-assertion to her threatened masculinity; the hope of getting a penis sometime is cherished to an incredibly late age and becomes the aim of her life. (p. 3)

This idea, termed as penis-envy, suggested that women were men without penises, and their sexual responses are passive and mirrored those of men (Yadav, 2018). Freud was also influential in the dismissal, or omission, of clitoral pleasure (Angel, 2011; Tiefer, 2004).

Kinsey’s study of what is “normal” for women’s sexual behaviors developed into the text Sexual Behavior in the Human Female (Kinsey et al., 1998). There were several components of the study, including “Types of sexual activity among females” (Kinsey et al., 1998, p. xii). This included topics such as:

Pre-Adolescent Sexual Development . . . Masturbation . . . Nocturnal Sex Dreams . . . Pre-Martial Petting . . . Pre-Marital Coitus . . . Marital Coitus . . . Extra-Marital Coitus . . . Homosexual Responses and Contacts . . . Animal Contacts . . . Total Sexual Outlet. (Kinsey et al., 1998, pp. xiii-xvi)

In addition, Kinsey et al. (1998, p. xvii) also began to study comparisons between males and females including topics such as:

Anatomy of Sexual Response and Orgasm . . . Physiology of Sexual Response and Orgasm . . . Physiologic Factors in Sexual Response . . . Neural Mechanisms of Sexual Responses . . . Hormonal Factors in Sexual Response. (Kinsey et al., 1998, pp. xvii-xviii)

In this way, Kinsey et al. (1998) established the framework from which modern studies on sexuality developed. This was influential in defining both what is “normal” and the supposed extent of the range of behaviors and expressions women experience or engage in (Kinsey et al., 1998). This links to the assumption that women follow the same sexual response cycle as men.

Masters and Johnson (1966) developed the HSRM and conceptualized sexual response as “. . . (1) the excitement phase; (2) the plateau phase; (3) the orgasmic phase, and (4) the resolution phase” (Masters & Johnson, 1966, p. 4). These phases created the foundation from which the understanding of female sexual response has traditionally been built (Masters & Johnson, 1966; Tiefer, 2001a). At the time, Masters and Johnson (1966) argued that the research was ground-breaking and controversial as no one had conducted a study like it before. The HSRM defined the lack of female orgasm as atypical and detrimental to the woman and her sexual relationships (Wakefield, 1988). The HSRM was also the first study on sexual responses to emphasize clitoral pleasure, and the differences between clitoral and vaginal orgasms (Masters & Johnson, 1966). In 1974, Kaplan collapsed the HSRM into a three-stage model—desire, arousal, and orgasm (Angel, 2010; Tiefer, 2001a). These models were the foundation for the “sexual dysfunction” diagnosis in the DSM from the third edition onward (Angel, 2010; Tiefer, 2001a).

The diagnoses of vaginismus, dyspareunia, and orgasmic dysfunction in the DSM were directly taken from the HSRM (APA, 2013; Masters & Johnson, 1966; Tiefer, 2001a). This is problematic because the research conducted into these models contained subject bias, as the study only included people who had experienced orgasms and penetrative sexual intercourse (Masters & Johnson, 1966; Tiefer, 2001a). The research also focused on the response to “effective sexual stimulation” (Tiefer, 2001a, p. 81). This contributed to ideas that women respond the same way as men, that all women respond the same way, and that heterosexuality is the norm (Taylor, 2015). These models are limited and oppressive in the way they conceptualize women and their sexual experiences (Basson, 2005; Tiefer, 2001a).

Gender socialization is also key to understanding the “problem” representations. Expectations about sexual experiences begin with how masculinities and femininities are conceptualized and perceived, such as dominance and subservience, respectively (Iasenza, 2001; Lefkowitz et al., 2014). Feminists challenge ideas of femininity as less than, as empty and as other, and as sitting outside meaningful subjectivity. Simone De Beauvoir (1949) sums this up as “He is the subject, he is the Aboslute–she is the Other” (p. xvi), arguing that an understanding of femininity is depicted only as she exists in relation to masculinity. This also makes women accountable to men because “he” represents the Absolute and the universal. Men, however, are not held accountable to women other than by negation. For De Beauvoir (1949), women’s subjectivity is sexual and her purpose is sexual in nature.

These ideas are relevant because of the formation of roles and duties within sexually intimate relationships (Iasenza, 2001; Lefkowitz et al., 2014). This includes ideas about sexual subjects (the focus) and sexual objects (where women are there to fill the need of the subject) (Iasenza, 2001; Tiefer, 2004). Feminist researchers argue that gendered norms and assumptions set a precedent for a gender power imbalance and ignore the needs and desires of all genders. This, in turn, creates unconscious pressure to perform within the gendered norm, leading women to focus on meeting the desires of men (Iasenza, 2001; Lefkowitz et al., 2014; Tiefer, 2004). This links to the assumption that women’s sexual responses are shaped by their sexual partners.

What Is Left Unproblematic in the Representation of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV? Where Are the Silences? Can It Be Thought About Differently?

These questions explore the impact on sexual intimacy following women’s experiences of IPV and consider the impact as a natural response to trauma, possibly caused by fear of vulnerability. These questions also explore the reality that heterosexuality is not the only sexual orientation. Furthermore, these questions illustrate the idea that nonpenetrative sexual experiences are equally valid. These questions enable the consideration that the impact on sexual intimacy, following the experience of IPV, is a natural response to trauma. Considering the silences provides opportunity to consider survivors’ fear of being vulnerable during sex. These questions also open up the critique of heteronormativity within the DSM-5 (5th ed.; DSM-5; APA, 2013) and, in turn, the importance of taking nonpenetrative sex into account.

How trauma and fear of vulnerability can affect sexual intimacy

Earlier questions identified the “problem” representations as: Women’s sexual responses are physiological rather than emotional; women are dysfunctional if they do not follow the mythical norm; and women’s sexual responses are measured against those of their sexual partner/s. These representations silence feelings caused by IPV including fear, worry, and anger. These feelings should not be ignored in sexual relationships (Dolan, 2015; Tiefer, 2004; Yehuda et al., 2015) and are very relevant when considering trauma following IPV.

The Trauma- and Stressor-Related Disorders section within the DSM-5 (5th ed.; DSM-5; APA, 2013) contains the diagnosis of PTSD (APA, 2013, p. 271) and includes symptoms, such hermore, the feelings of fear, anger, and shame may contribute t as “. . . persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)”. (p. 271). Furthermore, the feelings of fear, anger, and shame may contribute to “. . . feelings of detachment or estrangement from others” (p. 272) and “. . . persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)” (p. 272).

This indicates that the DSM-5 (5th ed.; DSM-5; APA, 2013) recognizes that emotions such as fear, shame, and detachment from others can result from IPV and can affect intimacy (Yehuda et al., 2015). Women who have experienced IPV may continue to be afraid and feel shame around the ideas of sexual and emotional intimacy and may detach from current or future partners (Dolan, 2015; Yehuda et al., 2015). Despite this, however, the DSM-5 (5th ed.; DSM-5; APA, 2013) does not show a strong link between FSD and PTSD. Sexual relationships at the best of times require consistent work around communication, trust, and emotional connection (Cacchioni, 2007). This connection may be difficult for women who have experienced a breach of trust in the past (Dolan, 2015; Yehuda et al., 2015).

The silencing of natural responses to trauma

The “problem” representations silence the way that fear and vulnerability, as a result of experiencing IPV, can lead to physiological responses, such as reflex action (Kantor, 1922). The reflex action in this context is related to vaginal or pelvic floor contractions (Ellison, 2001). These spasms or contractions are represented in the DSM-5 (5th ed.; DSM-5; APA, 2013) as “genito-pelvic pain/penetration disorder” (p. 437). Women can experience this for various reasons, including as a result of trauma (Ellison, 2001; Tiefer, 2004). Sexual abuse of any form (violent and coercive) and emotional abuse can cause this reflex (Karakurt & Silver, 2013). Therefore, it is important to recognize significant natural, and understandable, impacts on sexual intimacy following women’s experiences of IPV (Kearney-Cooke & Ackard, 2000; Tiefer, 2004).

Different sexual orientations are not considered

The “problem” representations are heteronormative and do not consider other sexualities as evidenced by the focus on “penile-vaginal intercourse” (APA, 2013, p. 430; Kleinplatz, 2001). The “problem” representations come from both a phallocentric and reproductive perspective, which focuses on what “happens between a woman’s legs in bed,” with penetrative vaginal sex as the goal (Kleinplatz, 2001, p. 124). The assumption of heterosexuality is embedded in a patriarchy where women and their sexual experiences are only considered in relation to men (Garnets & Peplau, 2001; Tiefer, 2004). Some feminist researchers argue that sexual experiences are the primary form of control that men exert over women (Garnets & Peplau, 2001; Tiefer, 2004). This ignores women’s identification with diverse sexualities and ignores the reality that women’s sexuality can be fluid (Garnets & Peplau, 2001).

Marginalizing the validity of nonpenetrative sexual activities

The “problem” representations focus on penetrative sexual experiences that involve genitals (APA, 2013). These representations silence the validity of other sexual experiences such as foreplay. However, the term foreplay is also problematic as it devalues sexual experiences that do not solely exist before “penile-vaginal intercourse” (APA, 2013, p. 230) such as connection and nonpenetrative sexual pleasure (Tiefer, 2004). For example, foreplay is often suggested to couples that are healing from the impacts of IPV on sexual intimacy, which can be facilitated via nonsexual touching, including hugs and kisses (Iasenza, 2001).

What Effects Are Produced by This Representation of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV?

This question explores the effects of the “problem” representations. According to Bacchi, (2009), there are three categories of effects caused by “problem” representations: discursive, subjectification, and lived effects (Bacchi, 2009). Discursive effects have an impact in terms of what is and is not accounted for or constructed and shape the way that the experiences of women may not be acknowledged (Bacchi, 2009). Subjectification effects are the ways in which subjects are positioned within discourse (Bacchi, 2009). Lived effects are material effects that affect everyday life (Bacchi, 2009). This list of effects is not exhaustive and does not assume that all women experience the same effects.

One of the discursive effects of the identified “problem” representations is stigma. Stigma is associated with a disgraceful quality, person, or circumstance (Lexico, 2019). The stigma of FSD can be connected in large part to Freud’s ideas of women’s sexuality, including frigidity (Angel, 2010; Freud, 1931) and the idea that females are defective males (Cohler & Galatzer-Levy, 2009). In addition, the classification of FSD as a “mental disorder” in the DSM-5 (5th ed.; DSM-5; APA, 2013, p. xli) conjures another form of stigma related to mental illness (Corrigan & Bink, 2016).

Another discursive effect of the identified “problem” representations is the reductive binary. Within the current representation of FSD, women are classified as only either functional or dysfunctional (APA, 2013). Binary opposites suggest that one is more preferred to the other or that one is more correct (Fook, 2007). In this case, it denotes that women who experience impacts on sexual intimacy following experiences of IPV are faulty or abnormal, further stigmatizing them (Tiefer, 2004).

Gender norms create further binary opposites where men are superior because they are active and powerful and women are inferior because they are passive (Fook, 2007; Iasenza, 2001). To extrapolate, women are seen as submissive receptacles (Iasenza, 2001) because “FSD” is measured against a woman’s ability to have “penile-vaginal intercourse” (APA, 2013, p. 430). This shapes understanding of the nature of sexual experience (Loofbourow, 2018).

Victim blaming is a significant factor in the aftermath of IPV (Hayes et al., 2013). Women who have experienced IPV are often held responsible in some way for the abuse that occurred. This includes the outcome or consequences (Hayes et al., 2013) such as difficulties with sexual intimacy. The male-centric focus of sexual experiences can prioritize men, and when their desires are not met, this can create conflict (Angel, 2010). This forces the responsibility onto women, magnifying guilt, which may make the impact of IPV worse (Hayes et al., 2013).

The “problem” representations also create material lived effects that affect how, where, or when women can receive help. The APA (2013) suggests that difficulties with intimacy can be difficult to diagnose and treat. This is because women’s sexual experiences are more complex than the diagnostic categories in the DSM-5 (5th ed.; DSM-5; APA, 2013) allow. The predominant treatment for FSD is based on physiology, such as pelvic floor physiotherapy (Jean Hailes Magazine, 2017) or muscle relaxants. This may treat the physical symptoms but ignores the emotional, social, and political contexts.

How Is the Representation of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV Produced, Disseminated, and Defended?

The impact on sexual intimacy following women’s experiences of IPV as represented in the DSM-5 (5th ed.; DSM-5; APA, 2013) is produced, defended, and disseminated through use in practice (APA, 2013; Cacchioni, 2007; Tiefer, 2001a, 2004). For example, the DSM-5 (5th ed.; DSM-5; APA, 2013) is the most commonly used text for diagnosis in medical, psychiatric, and psychological practice (APA, 2019). It is interesting to note that the editors-in-chief of the three previous editions (Robert Spitzer and Allen Frances) have condemned the revision by the current editors (Marecek & Gavey, 2013).

Frances wrote a contribution to the Psychiatric Times titled, “Why Doesn’t the DSM-5 (5th ed.; DSM-5; APA, 2013) Defend Itself? Perhaps Because No Defence Is Possible” (Frances & Frances, 2011, para 1). As Tiefer (2001a, 2004) explains, there is a problem with diagnosing people who are not actually ill, particularly when this can cause further disadvantage and discrimination.

The DSM has created a standardization of practice in diagnosis and treatment of the impact on sexual intimacy following women’s experiences of IPV, represented as FSD. Standardization is claimed to be effective as it simplifies billing and coding and guides therapy and research (Fritscher, 2019). However, it oversimplifies human behavior and promotes stigmatizing labels (Fritscher, 2019; Tiefer, 2001a, 2004).

How Could the Representation of the Impacts on Sexual Intimacy Following Women’s Experiences of IPV Be Questioned, Disrupted, and Replaced?

It is possible to question the current “problem” representations by suggesting that women can take active roles in their own pleasure. Women should be able to experience pleasure in safe, healthy, and consenting ways. This is promoted by organizations such as For Goodness Sake, with their program OMGYes, and VictimFocus. These organizations advocate that it is time to bring women’s sexual pleasure out of the shadows, to focus on their experience of pleasure and to privilege both female orgasm and women’s general sensual pleasure (For Goodness Sake LLC, 2019; Victim Focus, 2019).

It is also possible to challenge the dominant “problem” representations by speaking about women’s ability to build self-worth outside of relationships. Women’s identities and sexual experiences are often shaped by their relationships with others (Cacchioni, 2007; Tiefer, 2004). However, it is crucial for women to have self-worth that is not defined by external sources (Szymanski et al., 2011). Self-worth helps build healthy relationships and can empower some women to leave unhealthy relationships (Wisconsin Relationship Education, 2010). Self-worth can also help some women to balance the scales of power within their lives and their relationships (Szymanski et al., 2011). Furthermore, self-worth can prevent some women who have experienced IPV from blaming themselves and help them to form positive relationships (Tiefer, 2001a). Comprehensive sexual education can also play a part in creating healthy intimate relationships and shift attitudes around violence (Makleff et al., 2020).

Conclusion

Through engaging with Bacchi’s (2009) “WPR” approach, it is apparent that the DSM-5 (5th ed.; DSM-5; APA, 2013) is underpinned by a medical model that pays attention to physiological responses to penetrative sex at the expense of other diverse aspects of women’s sexual responses and desires. When women are unable to engage in penetrative sex, this is pathologized and the factors making penetrative sex not possible, such as fear, vulnerability, and difficulty with trust are not considered. Instead, FSD, a diagnosis that positions the woman as defective in some way is determined. This constrains the understanding of how women are dealing with the impact of interpersonal violence, disregards acknowledgment of PTSD in the DSM-5 (5th ed.; DSM-5; APA, 2013), and holds women accountable to a mythical and standardized norm that homogenizes relationships and homogenizes the men and women who engage in sexual relationships. Consequently, the machinations of power that were present in a woman’s initial experience of IPV are likely to be at worst reproduced and at best disregarded. Instead, she is at risk of being positioned as problematic and misrecognized as defective. Feminist research and analysis can highlight the ways that positivist, medicalized, and phallocentric discourse embedded within the DSM-5 (5th ed.; DSM-5; APA, 2013) does not serve women well following human rights violations such as IPV.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Alannah Buller

Author Biographies

Alannah Buller, BSW(Hons), is a family relationships practitioner with the social services organization Child, Adolescent and Family Services (CAFS). Her research interests are feminist critical social work and feminist critical teaching pedagogies, the representations of gender and sexuality in literature, feminist psychosexual therapies, and feminist sex education.

Sarah Epstein, PhD, is a lecturer in Social Work at Deakin University. Her research and teaching interests are in the area of feminist critical social work education, the intersection between feminism and masculinity, and human rights-based social work practice.

Norah Hosken, PhD, is a senior lecturer in Social Work at Deakin University. Her research and teaching interests are in the areas of feminist critical social work education, institutional ethnography, poverty, class, and shame.

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