Hi, everyone! Welcome to the new year! I hope it’s off to a great start for you and yours. Today, I’m introducing a new feature (ish). Or at least an attempt at one: weekly, short personal essays about, well, whatever people would like me to talk about or a random topic I came up with on my own. Comments currently remain disabled on the blog, yes, but you can hop on over to Patreon for now.
These weekly posts are immediately available to everyone and hover somewhere below 2,500 words. I try to keep them under 2,000 words, but sometimes you end up with more anyway. This one is 2,100 words! The next one will have a shiny new standardised intro and such loveliness.
This week’s rambly essay is called “Asexuality vs Diagnostic Criteria”. Also known as “But what the heck do the DSM and ICD actually say about asexuality?” Because the answer to that is slightly complicated and the question comes up… more often than you’d think.
Asexuality vs Diagnostic Criteria
Once upon a time, I did a Twitter thread. Because it’s a topic that comes up… far more often than a lot of people think, I thought it would be useful if I also wrote up the information in a blog post. They’re more accessible, allow more space and nuance and are a bit more durable than Twitter threads, after all.
The topic? Whether asexuality is or is not considered a medical or mental health condition in need of treatment. You’ll find anti-ace people simultaneously claim that yes it is and no it’s not, depending on the turn the argument is taking.
So what is actually going on?
Well. I’m glad you asked because we can actually look most of this up online. And the only thing we need is basic reading comprehension! So, disclaimer time: I am not a health provider.
And just to head this off at the start: I have been denied proper health care specifically because I identified as asexual. That was the explicit reason given. This will undoubtedly come up again later, but I just want to note here that yes asexuality is pathologized and yes it leads to asexual individuals getting denied health care they specifically requested and no mine is not an isolated incident.
Anyway! Let’s start with some very basic facts.
First of all, actual research into asexuality indicates two things: 1) that asexuality has been medicalised, 2) that asexuality shouldn’t be medicalised. A good summary of the research available can be found in Asexuality and Sexual Normativity: An Anthology and you should be able to find academic research backing up my statement in the Amazon sample because it’s part of the introduction as well as the first essay it publishes.
Secondly, when we talk about health – and especially mental health – there are two books that get mentioned a lot because they’re, um, kind of a big deal in health care of any kind.
They’re the Diagnostic and Statistical Manual of Mental Disorders (DSM) and and the International Statistical Classification of Diseases and Related Health Problems (ICD). The DSM is published by the American Psychiatric Association (APA). This is, as I understand it, the most widely used book of diagnostic criteria for mental health issues. It’s currently in its fifth iteration, the DSM-5, published in 2013.
The ICD, on the other hand, is maintained by the World Health Organisation and covers ALL health issues, not just mental ones. Australia uses a modified version of the ICD that it licenses to a whole bunch of other countries[1]. The ICD is in its eleventh iteration, published in 2018. Theoretically, the ICD is most commonly used in Europe, but you’ll find at least some psychiatrists, for whatever reason, leaning towards the DSM.
Other non-Western countries may use entirely different diagnostic manuals. I don’t really know because I’m approaching this from a Western (and specifically a European) perspective.
Anyway, as I said, the DSM was last updated in 2013. In its full and unabridged reference version, the DSM-5 explicitly includes a way for self-identified asexuals to opt-out of getting diagnosed with either Female Sexual Interest/Arousal Disorder or Male Hypoactive Sexual Desire Disorder. (More details.)
So… You’d think that’s the question answered, right? Researchers say asexuality is not a disorder. The full DSM-5 explicitly allows asexuals to say “I exist” based on that research, so we’re not pathologising asexuals, right? Wrong.
You see, many health providers don’t use this version of the DSM-5. It’s easy to see why; the thing’s almost 1,000 pages and Amazon tells me it weighs 1.4 kilograms (or 3 pounds). What they use is the Desk Reference (that’s this one), which is half the length and, like, five times lighter at 0.25 kg/9 ounces. That version, the one that health providers actually use? That one doesn’t include the “People who self-identify as asexual do not have these disorders”.
I won’t go into the issues with the DSM-5’s treatment of asexuality because the link I gave you explains it in enough depth. I just want to talk about the part where part of the diagnostic criteria for these disorders is “clinically significant stress” because that’s where we really run into trouble. But let’s take a look at the ICD-11 first because you’ll find that these two manuals, for all their differences, actually have much of the same problems when it comes to asexuality.
To my knowledge the DSM-5 isn’t available online, so that blog post’s screenshots will have to do when it comes to proof backing up what I’m saying. Luckily for us, the ICD-11 is available online! In full! You can find it right here.
Now, as I mentioned, the ICD was last updated in 2018, five years after the DSM-5 was completed and released. In fact, the version of the ICD I just linked, ICD-11, was released on 18 June 2018. That is less than half a year ago. Just… sit with those numbers for a bit because if you thought the DSM-5 was bad at including asexuality five years ago. Well. Prepare yourself for the grand step forward the ICD-11 has made.
Are you prepared?
Yes? Great because I’m going to need you to go to the online version of the ICD-11 and do a couple of quick searches for me. If you’d rather not, don’t worry. I’ve got screenshots too. I just think it’ll be more effective if you run the search yourself.
Have you got the page open in another tab? Try running a search for ‘asexual’ and ‘asexuality’.
Surprise! The ICD-11 doesn’t make any mention of ‘asexuality’ or ‘asexual’. Look, here’s the searches I ran on December 29th, 2018:
You see? Both results come up empty. Because asexuality isn’t in the ICD-11 at all. We can tell, from this, that the ICD-11 does not explicitly acknowledge the existence of asexuality because it doesn’t mention it. (The unabridged DSM-5 mentions it at least twice.)
So, okay. The DSM-5 technically says asexuality isn’t a mental disorder and the ICD-11 doesn’t mention it exists at all. Surely that’s all proof that asexuality isn’t pathologized and us aces are all just making stuff up because we want to be oppressed, right?
Well, not quite. (We’ll just ignore that the DSM-3’s presentation of homosexuality followed a similar “If you tell your health provider you’re gay, you totally do not have a mental disorder! Promise! Unless we think being gay is having an adverse effect on your life. Then it absolutely is even if you think it’s not” pattern. Coincidentally, one of the reasons anti-ace arguments will say asexuality isn’t pathologized the way homosexuality is, is because until 1987 homosexuality was mentioned in the DSM by that name[2]. Asexuality has never been mentioned in these manuals by name before the DSM-5 in 2013. Mostly because the term wasn’t around and “Hypoactive sexual desire disorder” sounds much more sciency and serious. Anyway!)
What the ICD-11 does have are descriptions and definitions that are similar to those used by asexuals to describe themselves and their experiences.
You’ll find it under 17 Conditions related to sexual health – Sexual dysfunctions – HA00 Hypoactive sexual desire dysfunction, but for ease of reference you can just read the quote.
Hypoactive Sexual Desire Dysfunction is characterized by absence or marked reduction in desire or motivation to engage in sexual activity as manifested by any of the following: 1) reduced or absent spontaneous desire (sexual thoughts or fantasies); 2) reduced or absent responsive desire to erotic cues and stimulation; or 3) inability to sustain desire or interest in sexual activity once initiated. The pattern of diminished or absent spontaneous or responsive desire or inability to sustain desire or interest in sexual activity has occurred episodically or persistently over a period at least several months, and is associated with clinically significant distress. (ICD-11)
You’ll notice that this disorder describes asexuals (and others on the asexual spectrum) pretty well on the whole. That said, asexuality is a spectrum and you absolutely can find asexuals who don’t fit part or all of this description, especially the second criterium because our, ah, plumbing is usually fine. But, on the whole, this is a pretty decent place to start exploring asexuality.
Notice, though, that like the DSM-5, this definition includes the wriggly words “associated with clinically significant distress”. (Fine, the DSM-5 said ‘stress’.) Okay! So that settles then, right? If you’re asexual and your asexuality isn’t causing you any kind of stress or distress, you don’t have this disorder and both the DSM-5 and the ICD-11 clearly and emphatically do not pathologise asexuality, right? Right?
Well…
Not quite.
Remember when I said that these words “clinically significant (di)stress” are where we really run into trouble? This is the time we run into it because neither the DSM-5 or the ICD-11 offer us any kind of guidelines on what constitutes “clinically significant (di)stress” and that’s left, not to the asexual person to decide, but the health provider.
And, it’s a sad but true fact, that simply telling medical professionals that your asexuality is not causing you any distress or any kind at all, is not considered proof that not experiencing sexual attraction/desire (or just less of it than said medical professional thinks is normal) is not causing that person “clinically significant distress”.
The fact that you went to someone for help, with just about anything whether it’s visibly related to asexuality or not, though, is taken as proof that this is causing people “clinically significant distress” because… well, otherwise you’d not be seeking help for a start. And in a lot of cases the more you try to assert yourself and ask for help with something entirely unrelated, the more convinced the health practitioner will become that you’re in denial and this whole “no sexual attraction” thing is what’s causing you so much stress you need professional help dealing with it. And not, say, the stress of going to someone who is supposed to help you and then decides that the best way to do that is to ignore everything you’re telling them!
And this is all ignoring the part where it’s just as (if not even more) likely that if someone is experiencing clinically significant distress” because of their (a)sexuality, it’s far more likely to be because social pressure is trying to mould them into something they’re not. And doesn’t that sound awfully familiar? Because it should. I’m sure you can work it out, though. (If not, here’s a hint: read a copy of the DSM-2 and DSM-3.)
So, back to the ICD-11. Read that description carefully. There is absolutely no acknowledged in the ICD-11 or the DSM-5 that asexuals may experience “clinically significant distress” for reasons other than their sexuality. I’ve had depression and anxiety since I was, like, six due to severe bullying because I was a girl (and, worse, a smart girl with an interest in ‘boy things’ and ‘weird things’). This is both well-attested and well-documented. The moment I mentioned asexuality, though, that history vanished. Didn’t matter anymore. My depression? Caused by asexuality. My anxiety? Caused by asexuality.
It was ridiculous. But I bring this up to illustrate the way asexuality is pathologized with a personal and more immediate example. It’s easy to read the DSM-5 (in full) and the ICD-11 and argue that asexuality isn’t pathologized because the disorder isn’t named ‘asexuality’ and because both the DSM5 and the ICD-11 theoretically allow an opt-out clause. But doing so ignores the way health professionals engage with these manuals. It ignores the way these manuals are used. It ignores the parallels between the treatment of asexuality and homosexuality as valid expressions of human sexuality in their own right.
And let me remind you all that the DSM-5 was published in 2013 years ago when we were just starting to explore asexuality as an academic topic. It made an effort similar to the way the DSM-3 made an effort. The ICD-11, which I remind you all was published last year… does not even try to differentiate between asexuality and a sexual disorder.
So… Is asexuality pathologized? The answer is: basically, yes. While it’s complicated by the general invisibility and lack of understanding regarding what asexuality is, asexuality’s emergence in the wake of the activism of older generations, and the ongoing fight for recognition and acceptance faced by all queer individuals today, both the DSM and the ICD still fail to meaningfully acknowledge that asexuality is an orientation in its own right and a normal part of the spectrum of sexuality rather than a subset of HSDD, which is where the manuals health providers actually use currently lump it.
Wait, you want to know about aromanticism and these manuals too? Well, aromanticism just plain doesn’t exist and if you thought telling a health professional that you’re asexual was bad, try telling them you’re aromantic. They will never stop convincing you that your romantic orientation means you’re broken just because they can’t conceive you ever leading a happy and fulfilling life. Unless you’re really lucky which I genuinely hope you are because you are not broken and you deserve to get help for the thing you went to get help for, not the thing you’ve mentioned isn’t a problem and may even be a source of pride, identity and accomplishment for you.
End Notes
[1] Courtesy of Twitter user Mm C: https://twitter.com/mmastertheone/status/1056130887836790784
[2] Rather, it was known as ‘ego-dystonic homosexuality’ in the DSM-3. The DSM removed it in 1987. In the ICD-10 we can find a similar definition under ‘ego-dystonic sexual orientation’, although the ICD-10 includes a note that a sexual orientation on its own is not a disorder. There is no mention of ‘ego-dystonic sexual orientation’ in the ICD-11. It also appears to have removed the note that sexual orientations are not disorder.
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