A narrow view: The conceptualization of sexual problems in human sexuality textbooks

Abstract

This study examined the ways in which the meaning of ‘sexual problems’ is constructed and defined in undergraduate human sexuality textbooks. Drawing on feminist and critical discourse frameworks, the dominant as well as the absent/marginalized discourses were identified using critical discourse analysis. Sexual difficulties were largely framed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Thus, medical discourse was privileged. Alternative conceptualizations and frameworks, such as the New View of Women’s Sexual Problems, were included marginally and peripherally. We argue that current constructions of sexuality knowledge reinforce, rather than challenge, existing hegemonic discourses of sexuality.

Keywords

feminism sexual problems sexuality education

Introduction

The dominant approach to understanding knowledge purports that knowledge, more or less, reflects universally true concepts and processes (Crawford and Marecek, 1989; Gergen, 1992). Hence, knowledge is often presented and understood as objective and existing as an essential entity outside of those who experience it. In contrast to this objectivist approach, feminist and critical discourse scholars, among others, have contended that knowledge does not exist independently of the knower but rather it is negotiated within societies. Thus, history, culture, power relations and language are intertwined with production and propagation of particular forms of knowledge (Brickell, 2009; Foucault, 1990 [1978]; Gavey, 1989). In this article, we situate our research in feminist and critical discourse approaches to sexuality with a particular focus on how undergraduate sexuality textbooks produce and contribute to the conceptualizations of sexual problems.

Sexuality, power and language

In line with feminist and critical discourse perspectives, we understand sexualities as constructed rather than existing independently of social reality (Foucault, 1990 [1978]; Gavey, 1989; Lazar, 2007). Hence, a particular understanding of sexuality is regarded as constructed and produced via ongoing social interactions and negotiations. Power and language are considered to be of seminal influence on how sexualities are defined, described, experienced and regulated (Bartky, 1988; Foucault, 1990 [1978]; Hooks, 2000; McKinlay and McVittie, 2008; van Dijk, 2003). According to Foucault (1990 [1978]), one of the dominant modern forms of power is biopower, which represents ‘the subjugation of bodies and the control of populations’ (p. 140). In other words, the regulation and disciplining of bodies are fundamentally intertwined with the control of people. Various arrangements and technologies are employed to perpetuate and maintain the existing power structures with sexuality being one of the primary arrangements that constitute biopower (Bartky, 1988; Brickell, 2009; Foucault, 1990 [1978]). Hence, as Brickell (2009) suggested, power is deeply and intrinsically connected to how we constitute and regulate our bodies as well as our sexual subjectivities (e.g. perceptions, feelings, embodiment and behaviours).

It is important to note that within the feminist and critical discourse perspectives, language itself is not approached as a neutral mechanistic reflection of an essential reality. Rather, language is considered as actively incorporating, organizing and producing culturally and historically influenced understandings of sexualities where specific constellations of sexualities are legitimized, contested or marginalized (Bartky, 1988; Brickell, 2009; Gavey, 1989; Tiefer, 2004). In the words of Nicola Gavey et al. (1999), ‘sex is discursively constructed’ (p. 37) and subject to ongoing co-construction and contestation rather than intrinsically or biologically given (Marecek et al., 2004). In this vein, language contributes to discourses, which can be defined as meanings around a particular topic such as sexuality (Gough and McFadden, 2001). Availability and proliferation of particular discourses and marginalization and suppression of others will affect the dominant constellation of what sexuality is and means at any particular time and in any particular culture.

Reproductive sexuality, for example, constitutes one particularly dominant discourse of sexuality. Within this reproductive imperative, a strong emphasis is placed on heteronormativity¹ and the function of sexuality is understood as the primary means for creating and maintaining a family, materially (i.e. reproductively) as well as symbolically (e.g. Mills, 2013; Myerson et al., 2007). In addition, the notion of female sexuality as revolving around reproduction and motherhood is firmly embedded in this reproductive discourse (Scully and Bart, 2003 [1978]; Ussher, 2003). Unsurprisingly, and ostensibly logically, the biological and reproductive aspects of sexuality are hence positioned as natural and normative. The reproductive imperative and the associated discourses, such as heteronormativity, have been identified as prevalent in educational courses on sexuality (e.g. Jackson and Weatherall, 2010; Peel, 2010), wildlife documentaries (Mills, 2013) and gynaecology textbooks (Scully and Bart, 2003 [1978]; Ussher, 2003). In contrast, alternative discourses, especially those containing critical probes of heteronormativity and hegemonic masculinity and those which include dimensions of sexuality such as trans, queer and female desire, are marginalized or missing in the dominant constructions of sexualities (e.g. Beres and Farvid, 2010; Simmons and White, 2014).

The construction of sexuality knowledge in human sexuality textbooks

Within the discourse approach, we conceptualize sexuality knowledge as ‘what we know and how we know the various meanings around sexuality’. Sexuality knowledge is understood as socially constructed, as intertwined with power and language and as fashioning subjectivities (Stelzl and Stairs, 2014). Sexuality education, including sexuality textbooks, represents a form of sexuality knowledge. Sexuality education contains distinct themes, narratives and discourses around topics such as sexual functioning and sexual health and genders, among others (e.g. Loe, 2008; Myerson, 1986; Peel, 2010; Rind, 1998). The inclusion and linking of the topics and themes via specific arrangements of language and the reliance on some discourses but not others will result in a compilation of particular meanings around the topic of sexuality. Yet, the role of language, power, race, history and culture in the construction of sexuality is typically disregarded or is discussed only marginally in the majority of undergraduate survey-level university or college textbooks primarily published in the United States (Barker and Richards, 2013; Goettsch, 1987; Hartlaub and Dreznick, 2001; Myerson et al., 2007; Rind, 1998). For instance, in his examination of human sexuality textbooks, Goettsch (1987) found that physiological and male aspects of sexuality dominated explanations of topics such as sexual response and sexual dysfunctions. In contrast, gender power relations, sexual subjectivities and cultural factors were systematically under-represented. Similarly, Myerson et al. (2007) identified sexuality textbooks’ tendency to privilege dimorphic and biological discourses in explanations of gender and to favour the language of coital imperative in the description of male and female sexualities. Alternative, and possibly contradictory, explanations of gender and sexualities that included topics of power and criticisms of patriarchal structures were missing or scarcely noted in the majority of the reviewed textbooks. In this vein, Myerson et al. discussed the normative and regulatory implications of presenting various aspects of sexuality in a fairly narrow manner, without the inclusion of alternative possibilities and discourses, especially under the auspices of expanding horizons of knowledge.

In our own research, we found that biological determinism guided undergraduate sexuality textbooks’ overall topic organization as well as the explanations of the causes and treatments of sexual problems (Stelzl and Stairs, 2014). In the context of sexuality, biological determinism/essentialism reflects the tendency to position biology and its relevant aspects, such as hormones and genes, and drives as natural, unavoidable and determinant of genders, orientations and sexual functioning (DeLamater and Hyde, 1998; Tiefer, 2004). For example, the majority of the textbooks we analysed in our previous research situated the origin of one’s sexual difficulties within the individual, principally as physiologically or psychologically based. Fewer textbooks included information on inter-personal factors and even fewer mentioned culture and power factors, such as gender inequality, as possible causes of sexual difficulties (Stelzl and Stairs, 2014). Textbooks’ descriptions of treatments continued with this tendency and expanded on it by predominantly framing the alleviation of sexual problems in medical discourse.

The findings of our previous research raised the question of how sexual problems in and of themselves are conceptualized and defined.² Thus, in this study, we focused on analysing the construction of conceptualization(s) or meaning(s) of sexual problems in undergraduate human sexuality textbooks. In other words, we wanted to explore how textbooks represented the notion of ‘sexual problems’ itself. Given that undergraduate survey-level sexuality textbooks are aimed at students who tend to have fairly rudimentary knowledge of various aspects of sexuality, the ways sexual problems are discursively constructed can influence students’ interpretation and understanding of sexual difficulties, including their own sexual experiences. Speaking more broadly, and in relation to the sexuality–language–power nexus, we were interested in exploring how textbooks perpetuate and/or challenge dominant discourses and constellations of meanings around sexual health and sexual problems.

Analytical framework and method

Our analysis was guided by critical discourse analysis (CDA). The primary focus of CDA is on the ways in which language interacts with power and inequality (Gill, 2009; Wodak and Meyer, 2009), or as in Van Dijk’s (2003) words:

Critical discourse analysis (CDA) is a type of discourse analytical approach that primarily studies the way social power abuse, dominance, and inequality are enacted, reproduced, and resisted by text and talk in the social and political context. (p. 352)

Thus, we approached the process of conceptualizing and defining sexual difficulties as a site of power production, legitimization and contestation. In particular, we attended to textbooks’ terminology, chapters’ placement of definitions, concept explanations and the broader discourses used to describe and explain the meaning of sexual difficulties.

Our data corpus was drawn from 16 human sexuality textbooks.³ The textbooks were written at an undergraduate survey level and contained primarily American or Canadian content (e.g. statistics and citations). The intended audience of human sexuality textbooks includes undergraduate students from a variety of disciplines (e.g. psychology and sociology). Where both American and Canadian editions existed (typically with the same first author on both editions), we included the Canadian edition as we work in a Canadian university context. Furthermore, we wanted to avoid data duplication. The textbooks were published between 2011 and 2017. The most recent editions were used to identify current discourses of sexuality. Of the 16 textbooks, 12 contained a separate chapter on sexual problems and those were included in our analysis. The chapters were not titled uniformly and bore titles, such as ‘Sexual Difficulties’, ‘Sexual Dysfunctions’ and ‘Sexual Disorders’. The word ‘Treatments’ or ‘Therapy’ appeared in many of the titles.

In the first part of the analysis, the organization of each chapter was examined and we assessed whether the chapters contained distinct sections or segments dedicated to conceptualizing, defining and/or describing classification approaches to sexual difficulties. Such sections were either explicitly titled as conceptualization sections (e.g. ‘Labelling Sexual Dysfunctions’ – textbook D) or they were titled more broadly (e.g. ‘Sexual Dysfunction’ – textbook B), but still contained an explicit definition of sexual difficulty. If textbooks did not have a discrete conceptualization section, we searched for and included definitions and/or classification frameworks covered elsewhere in the chapter.

If a discrepancy in identifying various conceptualization sections/portions occurred, the first two authors discussed their differences until agreement was reached. The selected portions were then extracted and read multiple times in order to ascertain how the notion of ‘sexual problems’ was presented and defined. In addition, we also assessed what classification systems (if any) were drawn upon and where in the chapters they were positioned in relation to other topics covered and in relation to each other (if multiple frameworks were included).

Analysis

Presenting, defining and classifying sexual problems

First, we noted how sexual problems were presented in relation to the structure of the chapter content. Of the 12 textbooks, 6 had a discrete section(s) or segment(s) on conceptualizing sexual problems (textbooks B, C, D, E, F and P). Four of those textbooks (D, E, F and P) contained explicitly titled chapter sections referring to defining and classifying sexual difficulties. For example, textbook E contained a sub-section titled ‘Defining Function Difficulties: Different Perspectives’ and textbook P’s section was titled ‘What Is a Sexual Problem?’ The other two textbooks (B and C) had more broadly titled sections (‘Sexual Dysfunction’ in textbook B and ‘Sexual Disorders’ in textbook C), but both sections included a discrete definition of sexual dysfunction/disorder and, thus, were included in this section of analysis.

In the six textbooks, the individual sections and segments varied in length from one or two paragraphs to several pages. Typically, the conceptualization sections would precede chapter segments containing in-depth descriptions of specific male and female dysfunctions (usually in that order) and they also tended to precede segments on causes and treatments of those problems. Thus, the conceptualization sections were, in general, positioned as important, and possibly necessary, for the comprehension of other aspects regarding the topic of sexual problems, such as causes and treatments. With the exception of textbook B, five textbooks drew on the Diagnostic and Statistical Manual of Mental Disorders (DSM) model of classification in their conceptualization sections. The DSM is produced by the American Psychiatric Association (APA) (2013) and reflects a medical framework as it provides classification and diagnostic criteria regarding mental illnesses. For instance, textbook C started its section on ‘Sexual Disorders’ with ‘In this section we will consider seven categories of sexual disorders listed in the DSM-5’ (p. 493).⁴ The term ‘sexual disorders’ is then linked to a definition outside of the main text, ‘Sexual disorders: Problems with sexual response that cause a person mental distress’ (p. 493). Thus, in the majority of cases, the DSM served as the foundational framework for providing and situating meanings of sexual problems. As stated above, textbook B did not include a DSM-based approach to conceptualizing sexual difficulties. However, the following definition was provided in the introductory part of the chapter: ‘sexual dysfunction is a chronic inability to respond sexually in a way that one finds satisfying’ (p. 689). In this definition, a sexual problem is labelled as ‘dysfunction’ and described as ‘a chronic inability’. Both terms, dysfunction and chronic, reflect medical, and more specifically pathologizing, terminology.

The additional six textbooks (G, I, J, K, M and N) did not contain a discrete section dedicated to conceptualization of sexual problems (e.g. explicitly titled). However, sexual difficulties were still defined or explained within the chapter. In those textbooks, medical language tended to be used to introduce and frame the topic of sexual problems. For example, textbook G opened its chapter with ‘Sexual dysfunction is a persistent or recurring lack of sexual desire or difficulty becoming sexually aroused or reaching orgasm’ (p. 326). Thus, sexual problems are immediately constructed as pathological (i.e. dysfunction). Furthermore, there is an implicit yet unambiguous connection to a pre-DSM-5 categorization via the linkage of sexual disorders to difficulties with sexual desire, arousal and orgasm which used to be the main diagnostic categories of the DSM (in addition to pain). In textbook M, the fourth sentence of the introductory paragraph stated, ‘All diagnoses listed in the DSM – including ones related to sexual expressions and behaviours – are considered as psychopathology (i.e. mental illness)’ (p. 388). In this instance, explicit connection is made between ‘sexual expressions and behaviours’ and ‘psychopathology’, with psychopathology clarified as being a ‘mental illness’. Hence, the topic of sexual problems is foundationally framed as a form of mental pathology.

Aside from using the DSM classification to define and conceptualize sexual problems, six textbooks included a definition or expanded description of alternative frameworks (i.e. non-DSM) of sexual difficulties. Of those, three textbooks (B, E and F) included alternative classification approaches within the same portion of the chapter where the DSM classification was presented. Additional three textbooks (C, I and P) covered alternative classifications elsewhere in the chapter than the DSM. In the next two sections, we elaborate on the inclusion and coverage of the DSM and non-DSM classification frameworks.

The use of the DSM classification to conceptualize sexual problems

As outlined above, the textbooks’ construction of the meaning of sexual problems appeared to be primarily driven by the medical discourse of the DSM. The following excerpts further illustrate the prominence and authority given to the medical framework of the DSM:

Scientific communication demands a terminology, and each sexual difficulty has been given a general label. The most commonly accepted source of diagnostic categories is the Diagnostic and Statistical Manual of Mental Disorders. (Textbook D: 468)

The most widely used system of classification of sexual dysfunctions is based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (the DSM). (Textbook G: 328)

In these two textbooks, the DSM is acknowledged to be the most widely used framework for classifying sexual problems. This is certainly the case in the United States and Canada (Lafrance and McKenzie-Mohr, 2014; Tiefer, 2004; Wood et al., 2006), but additional classification systems exist, such as the World Health Organization’s (WHO) International Classification of Diseases (WHO, 2010) and the New View of Women’s Sexual Problems (Kaschak and Tiefer, 2001). Yet, neither of these textbooks contained an alternative framework within the same section of the text nor elsewhere in the chapter.

In the next two excerpts, the authority given to the DSM regarding a particular interpretation of sexual experiences is also evident:

Defining a sexual problem can be difficult … To help to clarify definitions, some sex therapists in Canada and the United States use the Diagnostic and Statistical Manual of Mental Disorders (DSM), which provides diagnostic criteria for the most common sexual problems. (Textbook J: 390)

People can experience a wide array of sexual difficulties. Some of these difficulties are formally recognized in the ‘Bible’ of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders (DSM). (Textbook M: 388)

In textbook J, the trickiness of defining sexual problems in a precise manner was acknowledged and two limitations regarding the DSM (i.e. the DSM’s reliance on physiology and the failure to directly incorporate other factors, such as culture, gender issues and relationships) were stated within the same paragraph as the excerpt above. Textbook M did not contain a separate section on the conceptualization of sexual problems and the excerpt above represents the first two sentences of the entire chapter. Hence, the DSM is established immediately as the classification framework. Furthermore, the DSM is presented as ‘the Bible’ of psychiatric diagnoses. Thus, not only is the DSM positioned as a formal source of classifying sexual problems but it is also given a formidable, religious-like, measure of authority. Furthermore, the DSM, like the Bible, is largely based on a Western perspective, allotting it a certain amount of privilege over non-Westernized models of health, illness and normalcy in North America (Kriegler and Bester, 2014). By connecting the DSM to the Bible, the textbook strengthens the ‘inherent’ power of the medical approach and, in turn, marginalizes more holistic approaches to health and illness that exist in many non-Western cultures. In addition, when DSM limitations were (briefly) discussed, as per textbook J, the opportunity to introduce alternative frameworks to address such limitations was missed.

In chapters where the DSM was integrated in the conceptualization and description of sexual problems, the updated and revised DSM-5 edition replaced the previous Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) edition. To assess the textbooks’ adaptation and responsiveness to DSM-related shifts in relation to constructing the meanings of sexual problems, we also examined the incorporation and coverage of the DSM-5 changes. The DSM-5 contains several overall major revisions with respect to sexual dysfunctions (i.e. across diagnoses), such as the inclusion of severity and duration criteria, the modification of the distress criterion (i.e. focus on personal or individual distress and removal of inter-personal difficulty criterion), the cessation of mapping disorders onto the human sexual response model, the separation of male and female dysfunctions rather than categorizing them as analogous and the addition of associate factors (e.g. partner and relationship factors; APA, 2013; Graham, 2016; Sungur and Gündüz, 2014).⁵ Of the listed changes above, textbooks were most likely to note the individual distress criterion as well as the inclusion of severity (difficulty occurring in 75%–100% of sexual encounters) and duration (at least 6 months) criteria. However, in contrast to the DSM-5’s move away from categorizing female and male disorders as analogous to each other across the human sexual response cycle (HSRC), many textbooks still relied on mapping sexual disorders onto the HSRC. In the previous DSM-IV-TR edition, the understanding of sexual dysfunctions was based on Masters and Johnson’s and Kaplan’s models of human sexual response, and hence, the sexual disorders were organized according to the response cycle’s components of desire, arousal and orgasm with the additional category of pain (Graham, 2016; Tiefer, 2004). All the textbooks, that noted the HSRC, linked the cycle to the DSM-5 categorization of sexual dysfunctions. As the following two excerpts illustrate, the tendency to situate the DSM’s classification of sexual dysfunctions in the HSRC was unambiguous:

The fifth edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013) labels sexual function difficulties as disorders and characterizes them according to the four phases of Masters and Johnson’s sexual response cycle. (Textbook E: 432)

Notice also that sexual problems are classified, in large part, according to the sexual response cycle as first described by Masters and Johnson (1966, 1970) and Helen Kaplan (1979). The four major categories are desire disorders, arousal (excitement phase) disorders, orgasmic disorders, and sexual pain disorders. (Textbook F: 342)

The DSM-5’s disengagement from the HSRC reflects ongoing concerns and debates regarding whether the model accurately captures sexual response (e.g. Basson, 2014; Graham, 2016). Yet, the textbooks continue, inaccurately, to explicitly map the classification of sexual disorders onto the model. Given that three components of the model are predominantly physiologically oriented (e.g. Basson, 2000; Mitchell and Graham, 2008), this coupling of human sexual response to the classification of sexual disorders perpetuates the tendency to reduce sexual expression, including sexual difficulties, to the level of biology and physiology.

Alternative classifications of sexual problems

In comparison to the significant reliance on medical discourse and the DSM in defining and conceptualizing sexual problems, alternative (i.e. non-DSM) approaches were largely absent from the textbooks we analysed. As stated above, six textbooks included a non-DSM approach. From those, only three textbooks (B, E and F) included definitions or explanations within the main section(s) of the chapter devoted to this sub-topic. For example, textbook F included both, the WHO’s and the APA’s, definitions of sexual difficulties in the section on classification of sexual disorders:

The World Health Organization’s International Classification of Diseases–10 (ICD-10) defines sexual problems as ‘the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish’ (WHO, 2010). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines sexual disorders as ‘a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure’. (p. 341)

Beyond this inclusion of WHO’s and APA’s definitions of sexual difficulties, the DSM was applied exclusively to the description of various specific male sexual difficulties, such as erectile dysfunction. However, under the section of ‘Female Sexual Problems; Classification of Sexual Disorders’, the International Consensus Conference (Basson, 2000) was used as an alternative framework for the overview and description of female difficulties, such as female orgasmic disorder. Thus, notably, textbook F incorporated several frameworks in its sections on defining sexual problems and describing the classification approaches.

Textbooks B and E included the New View of Women’s Sexual Problems (Kaschak and Tiefer, 2001) in their sections on defining sexual difficulties. The New View reflects a collaborative effort by a number of feminist scholars, activists and clinicians who formed The Working Group on A New View of Women’s Sexual Problems in 2000 (Kaschak and Nicholls, 2008; Tiefer, 2001, 2010). Leonore Tiefer and other feminist scholars criticized the dominant medically oriented models of female sexuality as not representing the contextual factors of women’s lives and as therefore not reflecting women’s sexual experiences (e.g. Cacchioni, 2007; Tiefer, 2001). Ergo, the New View proposed an alternative model which conceptualizes and categorizes sexual problems across a number of dimensions, such as socio-cultural, political or economic conditions; partner and relationship aspects; psychological conditions; and finally, medical factors (Tiefer, 2002). With respect to the two textbooks, textbook B closed its conceptualization section with a paragraph describing Tiefer’s and her colleagues’ efforts to reframe how female sexual problems are constructed. Textbook E provided significant coverage of the diverse ways in which sexual difficulties can be conceptualized and categorized. The authors of the textbook briefly outlined and then, across several pages of text, described two frameworks: the DSM (APA, 2013) and A New View of Women’s Sexual Problems (Kaschak and Tiefer, 2001). Both frameworks were accorded similar amount of space. Notably, the role of language was also considered:

An alternative term to ‘sexual dysfunction’ is sexual function dissatisfaction. Sexual dissatisfaction is a common outcome of a difficulty in sexual functioning. In contrast to the broad medical focus of the DSM term, this term reflects an individual perception … An advantage of the term ‘sexual function dissatisfaction’ is that it acknowledges sexual scripts as individual and avoids overarching definition of what is ‘normal’ versus what is dysfunctional (i.e., pathological). Adopting this subjective and personal view might help people be more comfortable with their own sexuality and less likely to feel ‘sexually flawed’. (Textbook E: 432)

The discussion of different terminologies as well as the inclusion of alternative ways of framing sexual problems challenges the DSM as the knowledge source and, at the same time, legitimize the possibility that sexual problems can be constructed and understood in distinct and multiple ways.

Additional three textbooks (C, I and P) incorporated alternative frameworks elsewhere in their chapters on sexual problems within another distinct sub-section. In all three textbooks, the particular framework described was the New View. Its coverage was located outside the actual section(s) regarding the conceptualization of sexual problems and, in two textbooks, those sections were situated towards the end of the particular chapter. Textbook C incorporated a section titled ‘A New View of Women’s Sexual Problems and Their Causes’ (p. 506) at the end of its major section on the causes of sexual disorders and prior to a section on therapies. This textbook also applied the New View to a case study regarding low sexual desire within an inset.⁶ Textbooks I and P also provided distinct sections on the New View with the placement of these sections at the end of the chapters on sexual difficulties. For example, in textbook I, the section on New View was titled ‘New Views on Women’s Response Cycles May Influence Treatment Options’ (p. 455). This sub-section was placed under major section called ‘Lack of Desire for Sex Is Not Necessarily a Problem’ (p. 452) and it followed two other sub-sections incorporated in this segment, ‘Estrogen or androgen treatment may improve sexual desire in women’ (p. 452) and ‘Sex therapy may be helpful for low sexual desire on women’ (p. 454). Aside of the New View, no other alternative frameworks, such as the WHO’s International Classification of Diseases, were covered in any significant detail in any textbooks with the exception of textbook F.

It is worth noting that textbooks K and N opened the chapter with the WHO’s definition of sexual health as ‘a state of physical, emotional, mental and sexual well-being related to sexuality’ (Textbook K: 431). The placement of the definition at the start of the chapter served as a lead-in for the more detailed explanation of the sexual problems that followed. Aside from this opening definition, however, both textbooks utilized the DSM framework exclusively in their depiction of specific sexual difficulties.

Discussion

The privileging of medical discourse and the DSM in the conceptualization of sexual problems

Overall, we found that the textbooks’ relatively unscrutinized preference for medical discourse, particularly via the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013), in the conceptualization of sexual problems together with the relative dearth of significant coverage afforded to alternative models resulted in the predominant constructions of sexual experiences and difficulties as medically based dysfunctions. In other words, the medical discourse in the construction and conceptualization of sexual problems was legitimized and largely uncontested across the data corpus we examined. In the majority of the textbooks, sexual difficulties quickly and implicitly became sexual disorders by being singularly and unequivocally derived from the DSM classification.

The essentialist and medicalized construction of sexual problems as sexual disorders is further compounded by the textbooks’ systematic reliance on Masters and Johnson’s and Kaplan’s models of human sexual response in relation to the DSM classification of sexual dysfunctions (which is no longer an accurate reflection of the current edition of the DSM). The textbooks’ tendency (in the form of a curious oversight with respect to this DSM-5 change) continues to reduce the categorization of sexual disorders to physiologically situated pathologies. Hence, when textbooks do utilize the DSM in defining and constructing the meaning of sexual problems, it is important that they do so accurately by incorporating the DSM-5 changes, including the departure from the application of the HSRC to the classification of sexual problems. To synthesize our findings specifically in relation to sexuality knowledge, we next discuss the parallel tendencies of privileging medicalized, that is, DSM-based, conceptualizations of sexual problems and the penurious framing of alternative approaches.

Sexuality textbooks: the DSM versus alternative frameworks

The DSM was used in the majority of the textbooks as the standard of classifying and thus conceptualizing sexual difficulties. The medical and individualizing basis of this approach was explicitly acknowledged in some textbooks but not in others. Given the general lack of alternative frameworks on par with the DSM, the textbooks reproduce and legitimize the DSM as the source of knowledge for sexual problems, granting the medical discourse an inherent and absolute position of authority. In turn, this privileging of essentialist medical discourse conveniently leads to biomedical treatments as the logical solution to the treatment of sexual problems (Stelzl and Stairs, 2014). Aside of the notable exception of three textbooks, which included alternative frameworks in the same sections as the DSM, the placement of alternative frameworks, such as the New View, was peripheral in relation to the DSM. Hence, alternatives were constructed as being of secondary significance or as an afterthought rather than considered a foundational component of knowledge on this topic. This further legitimizes the DSM as the authority regarding conceptualization of sexual distress and sexual problems.

Similar to our findings, other research on sexuality textbooks has demonstrated that alternative frameworks and forms of understanding are largely absent or are incorporated to a fairly trivial extent in comparison to the mainstream constructions of sexuality (Barker and Richards, 2013; Goettsch, 1987; Myerson et al., 2007; Stelzl and Stairs, 2014). For example, Barker and Richards (2013) reviewed John Bancroft’s then-current edition of Human sexuality and Its Problems. This text is described as ‘compiling the full sweep of theory and research on human sexuality’ (Barker and Richards, 2013: 244) and is used in clinical as well as university settings to inform clinical professionals and to teach undergraduate students. Barker and Richards (2013) found that even though the book claimed to embrace an interdisciplinary and inclusive approach, neurophysiological aspects of sexuality predominated psychological and socio-cultural ones (p. 247). In our analysis, we also detected that attempts were made in some textbooks to incorporate a broader language as well as alternative frameworks, yet, those attempts remained largely at the initial stages.

Conclusion

In the examined textbooks, the privileged, reproduced, legitimized and largely unchallenged conceptualizations of sexual problems were intertwined with and boosted by medical language and, in particular, the DSM. When alternative frameworks were discussed, they were systematically undermined by being presented as less significant than the DSM. Given current human sexuality textbooks’ reliance on the DSM in their construction of the meanings of sexual problems, we ask who benefits from such a narrow understanding of human sexual experiences, including sexual problems. For example, it has been argued that the medical framing of some sexual experiences as sexual disorders is significantly impacted by a profit-driven agenda and one of the major criticisms of the DSM-5 has focused on ties of panel members to the pharmaceutical industry (e.g. Cosgrove and Wheeler, 2013; Marecek and Gavey, 2013). Yet, textbooks rarely acknowledge these influences and thus, rather than providing a complete survey of the various ways sexual problems can be understood, they reinforce the existing hegemonic discourses of sexual experiences and difficulties. The largely uncritical adoption of the dominant construction of sexuality within textbooks enables the existing power structures to prevail unchallenged.

The implications of textbooks’ systematic reliance on medical discourse are equally problematic for students’ understanding and interpretation of their own experiences. Those who read and learn from survey-level textbooks may not have had the opportunity to be exposed to the understanding that sexual experiences exist on a continuum and are subject to different forms of conceptualizations and understandings. This can be especially troubling if students are led to believe that sexuality knowledge presented in textbooks is objective rather than shaped by culture, power and language. As a result, students may label their subjective experiences as solely individually based, as dichotomized, pathological and self-defining. While we acknowledge that a medical understanding of sexual problems, together with non-medical approaches, may be useful in certain professional settings, we argue that the multidisciplinary, survey-level nature of human sexuality textbooks presents an opportunity for inclusive and comprehensive explorations of the meanings of sexual problems. Accordingly, textbooks need to move away from a primarily medical understanding of sexual problems to holistic and contextualized conceptualizations, including explicit troubling and contesting of the dominant discourses. Thus, we close this article with a call for a substantial and meaningful transformation of the discursive constructions of sexual problems. First, we urge the authors of human sexuality textbooks to critically reflect on their understandings and representations of the meaning of sexual problems, where these understandings come from, whom do they benefit and whom do they harm. Second, rather than positioning alternatives as ‘other’ or not equal to the medical discourses, we advocate for substantial incorporation of alternative discourses. Discourses of diverse bodies and diverse sexual possibilities as well as discourses of health and pleasure need to be given the same attention as discourses of pathology and medicine in human sexuality textbooks.

Footnotes

Appendix 1 Acknowledgements

We thank the two anonymous reviewers for their insightful and constructive comments on this article.

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 the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by a St. Thomas University Research Grant (GRG 6-2013).

Notes

ORCID iD

Monika Stelzl

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