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To provide an overview of conceptualizations of female sexual problems, and ‘Female Sexual Dysfunction’ in particular, throughout the 20th century, especially in relation to psychiatry and mental illness.
In the past 15 years, there has been an increase in both medical and public discourse about ‘Female Sexual Dysfunction’. I discuss a variety of literature sources dealing with female sexual problems, where these are understood variously as problems of developmental psychopathology, as technical phenomena to be resolved through education, or as medical problems to be addressed pharmaceutically.
The stigma of mental illness shapes much recent discussion of female sexual problems, as does the legacy of the postwar critique of psychodynamic psychiatry.
In the current debate about ‘Female Sexual Dysfunction’ (FSD), it is sometimes claimed that female sexual problems have not been scrutinized by the medical profession [1•,2]. This is far from the case, although much discussion in the 20th century has taken place in locations that some feel unsure about designating as ‘medical’. In what follows I shall provide an overview of some key aspects of the conceptualization of female sexual problems during the course of the century, particularly in relation to psychiatry. My focus here is primarily the Anglo-American context.
Female sexual problems have been discussed in sexological, gynecological, psychiatric, and psychoanalytic literature, as well as marital advice material. The salience of psychiatry in discussions of female sexual problems has its roots in the mutually entangled development of psychiatry, sexology, and criminology in the last quarter of the 19th century. A forensically minded sexology classified sexual behaviors, identities, and relationships, with nomenclature (homosexuality, sadism, masochism, nymphomania, fetishism, and so on) flourishing from the late 19th century well into the 20th [3–5,6••,7].
In the early 20th century, American psychiatry became increasingly professionalized and medicalized; from the 1930s, it also became significantly psychoanalytic. Psychoanalysis – not Freud’s own writings as much as their elaboration by others – dominated discussions of female sexuality and its problems, frigidity in particular. Too much – or too little – desire figured in this period as indices of developmental psychopathology, where that psychopathology involved the failure to adhere to norms of gender and femininity [8–10]. Freud’s account of the development of femininity and female sexuality [11••,12–14] posited a transfer of erotic zones in the young girl’s life from the clitoris to the vagina; this process was interpreted by many analysts and commentators as a crucial part of a biological imperative to reproduction, as well as to heterosexuality. In work going beyond Freud’s own pronouncements, the failure of vaginal orgasm became the conceptual lynchpin of ‘frigidity’; Hitschmann and Bergler [15•] defined the condition as the inability of a woman to have a vaginal orgasm (cf [16,17]). Moreover, the woman desiring clitoral stimulation, as opposed to vaginal intercourse, became representative of women who behaved like men and denied their maternal obligations – behavior that led to neurosis, isolation, and social disintegration. In addition, social and psychological ills such as feminism and lesbianism were also linked to a clitoral sexuality [10,18–21]. Here, the elucidation of norms for female sexuality was also a way of enjoining norms of femininity and heterosexuality.
Marital advice literature, which burgeoned in the United States and the UK from the early 20th century [22••,23–25], emphasized the importance of sexual pleasure in marriage. Women’s sexual problems were cast as technical problems to be understood in terms of social phenomena and resolved through education regarding the profound physical, emotional, and spiritual differences between men and women. Sexual fulfillment was vital for a happy marriage – and by extension also for a healthy society. Numerous obstacles lay in the way of sexual compatibility, however. As Helena Wright put it  (p. 50): A ‘man’s sex feelings are easily and quickly aroused, and quickly satisfied, and the actual sensations are limited to the relatively small area of the skin of the penis. A woman’s desires, on the contrary, are neither quickly aroused nor quickly satisfied’. A traumatic wedding night, in which a bride discovers both the brutality of men and what sex is, could stunt forever her potential for sexual happiness . In fact, the frequency of ‘sexual anesthesia’ or ‘frigidity’ in women was due to their not having been ‘taught to love’ . A wife has the ‘potentiality of a keen sexual appetite’, which it is the husband’s ‘privilege to arouse and maintain’ with patient tenderness  (p. 383) . Frigidity (defined variously as failure to reach vaginal orgasm, failure to reach orgasm, or absence of desire) [15•,16,17] had myriad possible causes: lack of adequate friction, childbirth injuries, male premature ejaculation, coitus interruptus, and fear of pregnancy. Many of these could be addressed medically or educationally. Men, wrote Huhner  (p. 400), will often have experienced sexual intercourse with prostitutes before marriage; this could make them either unaware of how to elicit female pleasure, as prostitutes ‘from long experience’ know ‘how to simulate passion’, or indifferent to it, mistakenly believing ‘women do not have pronounced sexual feelings as they, men, do’  (p. 394). Women’s lack of education in their own sexual capacity meant that many ‘not knowing any better, suffer in silence’; never experiencing sexual pleasure, some ‘never know the cause of their irritability or hysteria, as it is often diagnosed’  (p. 394). Inadequate knowledge could, then, lead to chronic nervous and mental illness.
While these texts underlined female sexual pleasure, they also sought to contain it by emphasizing the role of husbands in eliciting and managing it within social norms of gender, heterosexuality, and motherhood. Female sexuality is to be elicited from women’s asexual innocence, but, if too assiduously awakened, threatens to tip into voracious nymphomania [17,24] – a condition with often tragic consequences such as incarceration in insane asylums. For the woman unable to reach coital orgasm, sitting astride the man ‘is certainly better than titillation of the clitoris’  (p. 407). Where nothing else can be done, such ‘titillation’ is admissible, for the alternatives are serious: ‘unhappiness in the marriage relationship, possibility of divorce, and even the temptation of the wife to try her luck elsewhere’  (p. 407). Women who cannot reach coital orgasm but nonetheless have normal or even intense desire are put under a tremendous nervous strain, with resulting neurasthenic symptoms of pain and exhaustion  (p. 394), through the chronic irritation of organs. Insanity is the consequence, then, not only of too much desire, but also of too little pleasure.
In the postwar period, the connotations of female sexual problems as mental disorders continued in part due to the important role played by the American Psychiatric Association’s Diagnostic and Statistical Manual. (There is of course an important history of sexual problems in relation to psychosexual counseling, psychotherapy, psychoanalysis, and clinical and general practice as opposed to psychiatric nomenclature, for which I do not have space here; see [28–33]).
The Diagnostic and Statistical Manual of Mental Disorders’ (DSM’s) first edition in 1952  (pp. 38–39) contained, under the rubric of Personality Disorders, the category of Sexual Deviation (including homosexuality, transvestism, pedophilia, fetishism, and sexual sadism). Problems such as impotence and frigidity belonged to a separate category of ‘Psychophysiological autonomic and visceral disorders’ (under a larger group of ‘Disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain’), of which a ‘psychophysiological genitourinary reaction’ was an instance. These disorders represented the visceral expression of affect that is often ‘prevented from being conscious’. Symptoms are due to a ‘chronic and exaggerated state of the normal physiological expression of emotion, with the feeling, or subjective part, repressed. Such long continued visceral states may eventually lead to structural change’  (p. 29).
The manual reflected both the psychoanalytic cast of American psychiatry at this time and the influence of Adolf Meyer’s psychobiological framework, which stressed concepts of adaptation and maladjustment to environmental influences and posited a continuum between the healthy and the sick [35,36]. The ‘psychophysiological disorders’ also reflected the influence of Franz Alexander, a key figure in the history of American psychosomatic medicine [37–39], who described a set of ‘visceral neuroses’. Unlike conversion reactions (in which unconscious psychological content is converted into a somatic representation of psychic conflict), these are conditions in which symptoms do not have a primary symbolic meaning, but are the somatic equivalent of an emotion.
The DSM simply tells us that psychophysiological genitourinary disorders include ‘some types of menstrual disturbance, dysuria, and so forth, in which emotional factors play a causative role’  (p. 30). The DSM-II of 1968 is similar, though it adds ‘dyspareunia and impotence’ to the examples listed  (p. 47). Little detail is given, then, and the kinds of disorders enumerated are not meant to be comprehensive. An etiological process is posited, and it is the process – rather than its specific manifestations – that is salient.
This changes significantly with the DSM-III of 1980, which is widely seen as having marked a categorical shift from a psychoanalytic to a biological psychiatry. In the years from the 1960s, psychoanalytic psychiatry was subject to a wide scientific and cultural critique [41••,42–45, 46••,47••,48]. Psychiatric critics underscored a widespread confusion over diagnostic criteria that they saw as leading to a corrosive unreliability. Infused by the conviction that there is a clear boundary between the normal and the sick and that there are discrete mental illnesses, the manual introduced explicit diagnostic criteria, chipped away at the psychoanalytic concept of neurosis, and claimed to be neutral with respect to theories of etiology. It saw itself as eliminating ‘the disarray that has characterized psychiatric diagnosis’  (p. 187), ensuring reliability and the evaporation of problematic subjective judgments. The DSM has received much criticism, however, on the grounds that it brutally evicted psychodynamism, is deeply intertwined with the interests of the pharmaceutical industry, and has fostered an American hegemony in world psychiatry [50–54].
In DSM-III, instead of separate categories for Sexual Deviations and Psychophysiological Genitourinary Disorders, there is an overarching chapter on ‘Psychosexual Disorders’ [55••]. This is broken down into gender identity disorders (transsexualism and gender identity disorders), paraphilias (fetishism, transvestism, pedophilia, voyeurism, and so on), and psychosexual dysfunctions. The latter include (for women) the following:
The DSM-III-R of 1987  changed ‘Psychosexual Dysfunctions’ to ‘Sexual Dysfunctions’, listing the following:
In DSM-IV, this remains the same, except that Inhibited Orgasm becomes Orgasmic Disorder. It also adds Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction .
DSM-III marks an increasing detailing and differentiation of sexual problems within American psychiatry, reflecting not only the influence of thinkers on gender such as John Money, Robert Stoller, and Richard Green, but also the impact of the work of William Masters and Virginia Johnson [58••,59]. Masters and Johnson were not the first to approach sexual problems with a form of behavioral conditioning [60,61] or to emphasize the clitoris in female sexual pleasure [62•], but their detailed physiological studies heralded the professionalization of a behavioristically inflected sex therapy. They outlined a four-stage Human Sexual Response Cycle (excitement, plateau, orgasm, and resolution) and three female sexual disorders: dyspareunia, vaginismus, and orgasmic dysfunction (primary and secondary). They were not directly involved in the DSM-III; Helen Singer Kaplan [63•,64], a sex therapist and psychoanalyst who sought to combine behaviorist and psychoanalytic models in her work, was; she modified their system into a three-stage model of desire, excitement, and orgasm, which was incorporated into the document.
‘FSD’ is a generic, descriptive – rather than diagnostic – term. And yet it has come to be treated, rhetorically, as if it were in itself a condition, despite the different diagnostic categories constituting it [65•,66]. Literature throughout the century has privileged problems of desire and orgasm; ‘arousal’ became more important through Masters and Johnson. Marital advice dealt with pain, often as a mechanical problem to be medically, surgically, or educationally addressed; in the recent debate, however, the literature on pain [67–71] gets somewhat short shrift.
The fact that Viagra, licensed for Erectile Dysfunction in 1998, seemed to work so well was repeatedly invoked as proof that Erectile Dysfunction was not a psychological problem, but merely a mechanical problem [72,73]. Medical, pharmaceutical, and public discussions of FSD increased in its wake, with much of the scientific and indeed popular discourse about female sexual problems emphasizing their medical nature – where medical is understood to exclude the psychiatric.
For example, an influential 2001 Consensus Report on FSD, written by prominent figures in the debate [1•], queries the location of sexual problems within the DSM, which it describes as ‘limited to consideration of psychiatric disorders’ and ‘not intended to be used for classification of organic causes of Female Sexual Dysfunctions’. The ‘definitions of sexual dysfunction in DSM-IV’, it writes, ‘tend to be more useful to mental health practitioners than medical practitioners, as disorders are viewed in the DSM as psychosomatic in etiology’. The Consensus Report, in contrast, aims to cover ‘psychogenic and organically based disorders’, ‘regardless of etiology’, developing a diagnostic system ‘applicable in medical and mental health settings’ [1•] (pp. 84 and 92, my italics).
These claims are curious, because an organic and medical classification, and an etiological neutrality, are precisely what the DSM, since the third edition of 1980, has seen itself as enabling. It ‘attempted to be neutral with respect to theories of etiology’ and to provide ‘a medical nomenclature for clinicians and researchers’  (pp. xvii–xviii). The Consensus Report’s insistence that FSD be understood anew as a medical condition reveals that, for its authors, merely being in the DSM is unacceptable. By virtue of its inclusion within the DSM, FSD is too much associated with psychiatry: a troubling fringe discipline with a problematic past and a problematic ontology. When Ray Moynihan [65•] published a British Medical Journal (BMJ) article on FSD entitled ‘The making of a disease’, arguing that Big Pharma were significant in shaping the category, outraged responses flew in, accusing him of accusing women of lying or inventing their distress. Prominent practitioners have written that they are ‘shocked’ to hear how many doctors tell their patients that their sexual problems are ‘emotional, relational, or due to fatigue from child rearing or their busy jobs.... We hope that this book will serve as an antidote to what women have heard for decades. The problem is not just in your head. You are not crazy.... We are beginning to recognize Female Sexual Dysfunction as a medical problem’ [74•] (pp. x–xi). Claims about what influences diagnostic categories and etiological narratives are repeatedly interpreted as claims about the reality of symptoms, with the fraught status of mental illness creating a divisive public discourse.
Many critics have argued that the inclusion of FSD in the manual is inappropriate because the DSM is in the business of pharmaceutical medicalization of sexuality. Prevalent medical FSD discourse, they suggest, understands sexual problems as reductionistically biological, ignoring the contextual (social, cultural, personal) factors shaping sexuality and its difficulties [52,75••,76]. These critiques are echoed in much media coverage (e.g. Ref. ). The feminist heritage of this critique is the strand of second-wave feminism, in the 1960s and 1970s, that embodied a distinct antipathy toward the psychological discourses of sexuality associated with Freud [46••,48,77–80].
Throughout the 20th century, and in diverse locations, female sexual problems have been associated – through psychoanalysis, theories of nervous irritation, or DSM psychiatry – with nervous and mental illness. Different literatures emphasize the social aspects of sexuality and the educational potential for resolving problems in various ways. The shift away from a primarily psychoanalytic psychiatry in DSM-III involved a striking differentiation of sexual ‘dysfunctions’. What has since emerged is a fraught debate in which numerous protagonists seek to distance the possibility that ‘FSD’ be understood as a mental illness – because of a fear that this is equivalent to blaming or disbelieving sufferers. The contested status, within second-wave feminism, of both psychogenic etiology and of psychiatric expertise operates in the current critique of FSD. The legacy of both the scientific and cultural critique of psychodynamic psychiatry in the postwar period, as well as that of the feminist critique of psychotherapy and psychiatry, have, thus, converged to create a heated contemporary debate about sexuality, pleasure, psychiatry, and technology.
K.A. is funded by a Wellcome Trust Postdoctoral Fellowship in the History of Medicine.
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 608–609).