What's ‘normal’ sex? Shrinks seek definition

Most of these suggestions are inherently political, as much as the APA and most psychiatrists would wish to avoid politics. Sex exists as part of the culture, and it cannot be separated from it.

The DSM has reflected cultural shifts through its revisions and new editions. The most famous example is homosexuality. When the first DSM was created in 1952, homosexuality was declared a mental illness. By 1973, and after much heated debate and over objections from religious conservatives, the DSM-II excluded homosexuality as a disorder with the exception of one variant, and that was soon dropped in an interim revision.

Once deviant, now desirable
“Definitely a change in culture affects diagnoses,” Leiblum says. “We used to think oral-genital sex was deviant and we have embraced that. Masturbation was evidence of out-of-control behavior, now we see it as not only normative but to be encouraged.”

So if enough people start to do it, or are more public about doing it, does that mean it is no longer a disorder? “I think it probably affects the degree to which people are willing to look at scientific evidence,” Regier says.

This fuzziness is why, starting in the 1980s, the field moved toward adding the notion of “distress” to the DSM.

“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” explains Regier. “I would say also if there is no victim involved … this behavior is not imposing a person’s will on another person, that is a critical component when one looks at conditions in this area.”

If you aren’t distressed, and everyone is a consenting grown-up, then there probably isn’t a disorder. But things won’t be that simple for the creators of the new DSM.

“How do you make a criteria that does not pathologize low desire?” Leiblum asks rhetorically. You add the need to be distressed about it. “But then whose distress should be looked at?” she asks, referring to a sexual partner. “You can have hypertension and not feel any distress because there is objective criteria for what is high blood pressure. But there is none of that for sexual diagnoses, even premature ejaculation. What constitutes premature?”

(At a press conference Monday, the International Society of Sexual Medicine made a stab at a definition, saying premature ejaculation is "a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration; and, inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.”)

This problematic lack of clarity, Leiblum argues, is especially acute for the paraphilias. Does the criteria amount to “If it’s mine it’s OK, but if it’s yours it’s kinky? These issues need to be grappled with.”

Brian Alexander is the author of the new book “America Unzipped: In Search of Sex and Satisfaction."

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