(Katherine Stiefel ’20 wrote this as a final paper for WRI 190 Madness and Culture.)
In the fields of psychology and psychiatry, there is a book known as the Diagnostic and Statistical Manual of Mental Disorders (DSM)  published by the American Psychiatric Association (APA) that lists and describes every currently recognized mental disorder. The DSM is the defining text of mental health in America. On some level, any discussion of mental or behavioral issues in America cannot be had without at least some recognition of the DSM. Professionals in multiple fields rely on the information disclosed in the manual including healthcare providers and scientists alike (American Psychiatric Association 2013).
In the fourth edition text revision (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000), a diagnosis known as Hyposexual Desire Disorder (HSDD) was published under the sexual dysfunctions category. It also appeared in the DSM-III based on a paper published in 1977 which characterized the symptoms (Kaplan, H.S., 1977). There were only three listed diagnostic criteria for HSDD in the DSM-IV which are readily condensed: the individual must experience “distress” or “interpersonal difficulty” because of “deficient” or “absent” “sexual fantasies and desire” (APA, 2000, p. 541). In 2013 with the release of the fifth edition (5th ed.; DSM-5; APA, 2013), the previous diagnosis of HSDD was split by gender. For men, the disease was re-named Male Hyposexual Desire Disorder (MHSDD) and remained largely unchanged (American Psychiatric Association, 2013, p. 440). For women, the diagnosis was combined with another sexual dysfunction disorder called Female Arousal Dysfunction (FAD) and re-labelled as Female Sexual Interest/Arousal Disorder (FSIAD) (APA, 2013, p. 433). The disorder is understood by two mechanisms. The first is that the brain is “insensitive” to “sexual cues”, leading the patient to understand intellectually the need or basis of sexual desire but not respond with actual desire (Belkin, Z.R., Krapf, J.M., & Goldstein, A.T., 2014, p. 163). The second is that the patient has “over-reactive” inhibitions, which can be understood as anxiety, that prevent them from responding to sexual cues (Belkinet al., 2014, p. 163).
The symptoms that describe these three related disorders – most clearly a lack of sexual desire or a distressingly lower level compared with a sexual partner – are of particular interest because they can also describe a sexual orientation known as “asexuality”. Though people who cannot be described by the homo/heterosexuality axis have been recognized since the 1940s with sex-researcher Alfred Kinsley’s group “X”, “asexuality” as an orientation term did not begin to crystalize until the early 2000s with David Jay’s founding of the Asexuality Visibility and Education Network (AVEN) in 2001 (http://www.asexuality.org/). This website created the first community-space for those identifying on the scale of “asexuality” to first interact. Not every individual on the website identifies as “asexual”, as this term is a sexual orientation while “asexuality” is an orientation scale. “Asexual” is, after all, a label people chose to embrace to describe themselves and not an exactly defined word.
Now that those who identify on the asexual spectrum are rapidly building a formal social-political group, conflicting views with researchers studying FSIAD/MHSDD and, previously, HSDD are becoming increasingly salient. Essentially, the community and sympathetic researchers interested in exploring the phenomenon are beginning to resist the pathologizing of something they view as natural. It would further the conversation between the two sides to use the historical precedence set by the removal of homosexuality to examine the conversation. Doing so will reveal some critical characteristics that can be examined to deconstruct both sides of the debate, specifically the research supporting the diagnosis. Researchers examining HSDD and its subsequent forms have taken a perspective on asexuality that is too narrow, focused on medicalizing the issue and ignoring contrary evidence that ultimately prevents them from reconciling with asexuality researcher. I will argue that, based on the precedent set by the removal of homosexuality from the DSM and research on the disorder and asexuality, MHSDD and the aspects of FSIAD pertaining to HSDD should be revised in the DSM-6 to reflect the acceptance of “lifelong” HSDD as asexuality and other variants of HSDD as a different classification of disorder.
Sexual Dysfunctions and Sexuality in the DSM: Homosexuality
The relationship between HSDD and asexuality, between overlapping psychiatric disorder and sexuality, is not unique; homosexuality at one point was also heavily pathologized but is no longer considered a disorder. By examining the conversation surrounding its transition from disorder to sexuality, the history of homosexuality illuminates the conversation surrounding asexuality. One of the first diagnostic labels applied to the orientation of homosexuality was in “Psychopathia Sexualis”. Kraft-Ebbing, the author of the scientific text, called it “antipathic sexuality”, literally classifying it as an aversion (“antipathy”) to “[hetero]sexuality” (1901, p. 269). Though this example is old, it is a clear example of the perspective that those pathologizing homosexuality upheld: heterosexuality is the only “natural” state, therefore making homosexuality some kind of disorder.
Jack Drescher clarified this philosophical framework in his historical examination of the pathologizing of homosexuality in the DSM. Descher argues that the perspectives on homosexuality that influenced its pathology can be summed into three groupings. The oldest is the pathological view of homosexuality as some sign of defect from a detectable cause (which is also purported by Kraft-Ebbing). The second is a Freudian psychological theory of immaturity (i.e. homosexuals are heterosexuals with stunted mental growth). The third is an assertion that homosexuality is “normal variation” by equating natural with normal – essentially, that people are born as homosexuals and should be accepted because it is their natural state (Drescher, 2015). Both theories that support the placement of homosexuality in the DSM involved implicit thoughts of homosexuality as an unnatural phenomenon worthy of research in order to “fix” it. Only by considering the phenomenon through the last perspective, equating its appearance as a naturally occurring, innate difference between people with normality, could the scientific community move past medicalizing the sexuality (Drescher, 2015).
The catalyst for the DSM in particular as opposed to the general acceptance of homosexuality by medical and research communities had two other facets. First, activism by people in the homosexual community urged for recognition of the resulting “anti-homosexual social stigma” caused by medicalizing the orientation (Drescher, 2015). Second, the Nomenclature Subcommittee of APA produced a definition of a disorder worthy of treatment that homosexuality as a disorder could not fulfil: “[the disorders] all regularly caused subjective distress or were associated with generalized impairment in social effectiveness of functioning” (cited in Drescher, 2015). By applying this definition to the APA’s works, such as the DSM-IV and DSM-5, we can determine whether of any given “disorder” meets these chosen standards.
Even acknowledging the issues of pathologizing homosexuality, the dissociation of homosexuality with mental disorders was not immediate. In the DSM-III, for example, there was a listed disorder (now-recognized by the APA as failing to meet the basic requirements of disorders) known as “Ego Dystonic Homosexuality” that allowed the for treatment of people distressed by their sexual orientation (Drescher, 2015). While the disorder technically meets the APA’s standards because it stresses the individual’s distress over something (per the Nomenclature Subcommittee’s definition), it is no longer utilized because the idea of treating someone distressed about the changing of their unchangeable identity aspects is currently recognized as illegitimate; instead, researchers focus on understanding the traits underlying the identity (cited in Drescher, 2015).
The historical review of homosexuality in the DSM has therefore given us a precedent for analyzing the validity of any given possible “sexuality” as a mental disorder. First, the alleged-sexuality must be considered some natural variation. If it has passed that test, the current disorder must then fail to meet the APA’s definition of a disorder by either: 1) not causing distress or social impairment; or 2) causing either aforementioned symptom in relation to the in-born, unchangeable nature of the sexuality. I assert an examination of asexuality under this lens will prove that the sexual orientation is valid and that the related diagnoses of HSDD, MHSDD, and the aspects of FSIAD arising from HSDD need revision.
The Roots of “HSDD”: “Asexuality” as an Alternative
The approach of researchers towards the naturality of asexuality varies discipline to discipline, presenting a dichotomy between those who emphasize the sexuality and those who emphasize the disorder. HSDD was originally added to the DSM based off a paper written in 1977 titled “Hypoactive sexual desire”, which framed the basis for the disorder (Kaplan, 1977). This diagnosis was created before the asexual community was even called such, let alone organized into a coherent advocacy group. Consequently, all current research on the disorder relates back to the premises established by Kaplan in her proposal of HSDD made before the emergence of the concept of asexuality. I argue the non-natural viewpoint supporting the diagnosis is only so because of a narrow perspective taken up by those working within the framework of the diagnosis either explicitly or implicitly unaware of the asexual community like Kaplan. Looking at the points of the original paper that delineated HSDD (and thus MSDD and the aspects of FSIAD arising from HSDD by association), we can evaluate the agreement of modern research with the heart of the disorder. In examining papers attempting to classify the diagnosis HSDD and critically examining the authors’ assumptions on the naturality of low sexual desire, I will show that “asexuality” is a fair alternative to Kaplan’s diagnosis.
In her paper, Kaplan admits she began to examine variations in sexual desire because it was resistant to then-current methods of sex-therapy (1977, pp. 3-4). This raises an immediate intellectual question: does the resistance derive from a natural, in-born state – making the disorder likely not one at all according to the APA’s own metrics (cited in Drescher, 2015)? Most probably unaware of asexuality, the same question would not have bothered Kaplan. The only confounding factor acknowledged in the piece is that physicians should be aware of potential cases where patients report desire issues as some other (hypothetically less-embarrassing) sexual performance problem (Kaplan, 1977).
Approximately twenty years after the acceptance of HSDD as a disorder in the DSM, however, researchers noted in a guide to the treatment of sexual dysfunctions that the disorder was still “highly resistant to treatment” and that “long-term success rates [were] low” (cited in Dziegielewski, S.F., Resnick, C., Nelson-Gardell, D., & Harrison, D.F., 1998). In 2014, a study on the results of clinical drug trials evaluating the efficacy of the medications in response to treating FSIAD according to the previous categorizations of FAD and HSDD was published. Despite directly addressing the issue of changing sexual desire, the proposed medications actually focused on making sexual arousal easier or increasing sensitivity to sexual cues which then, they extend, should correlate with more sexual desire (Belkin et al., 2014). This subtle distinction, influencing biologically based systems that correlate instead of cause the desired results, suggests that the researchers believe that “desire” is, yet again, not easily treated and possibly not completely neurobiologically-based.
While the original paper on hypoactive sexual desire noted that the biology sexual desire had not yet been “delineated precisely”, it made claims that the origins would be an interaction of testosterone in the limbic system or “psychic forces”(Kaplan, 1977, p. 4). As mentioned in the introduction, however, the contrasting understandings of the disorder as either a distinct neurological etymology or anxiety-linked disorder are continually growing further apart (Belkin et al., 2014). If a unique biological basis can be found, it would prove beyond doubt that the disorder is a valid construct. If the anxiety perspective proves to be a better framework, then it is likely that the symptoms aggregating under HSDD are neither strictly sexual dysfunction nor completely sexuality but instead a distinct presentation of some anxiety disorder that has sexual manifestations. Given that the anxiety interpretation would lead to the revising of MHSDD and the editing of FSIAD for uncontestable reasons, I will focus on the possibility of a biological base for the disorder for this section.
Kaplan herself suggested the use of animal research to construct an understanding of the disorder in terms of natural drives (1977, p. 4). In 2013, a group of researchers outlined the current understanding of the neurobiology of sexual desire in animals to shed light on the development of treatments for HSDD (Kim et al.). This is in accordance with Kaplan’s original intentions and suggests the results should be relevant in the discussion of HSDD. The paper does separately locate the majority of motivational processes, including sexual/sensual motivation, in the limbic system of the brain and discusses the correlation between testosterone and sexual motivation in accordance with Kaplan’s guesses (1977, p. 4; Kim, et al., 2013). In addition, the paper examines seven different “neuroscientific” explanations for sexual desire but admits, like all other sources focused on the diagnosis, “we still do not have effective agents to treat male or female [HSDD]” (Kim et al., 2013). Though it effectively reviews the neuroscience behind the “drives” associated with sexual behavior, the paper sticks to the realm of scientific fact and refuses to acknowledge any divergent behaviors (Kim et al., 2013). For example, their explanation in the subsection “Neural basis of sexual desire” begins with the neural reaction to a facial nerve stimulation, which some may consider to trigger sensual desire but not sexual desire, without noting this possibility (Kim et al., 2013). The paper also does not mention any variations of the word “asexual” or “ace” despite its relevancy, suggesting ignorance of the phenomenon in animals or purposeful dismissal (Kim et al., 2013).
Perhaps more revealing is a study conducted in 2000 on the influence of castration and androgen hormone therapy on the mating behaviors of rams ignored by the researchers behind the 2013 review. The 2000 group designated their sample into three orientations: female-orientated, male-orientated, and asexual (Pinckard, K.L., Stellflug, J., & Stormshak, F., 2000). It is interesting to note the lack of lifelong-permanency in the operational definition. Instead of classifying the rams based off of their entire “mating” or “sexual history” (to borrow a term from human interactions), the researchers were only examining the ram’s preferences across a few mating interactions events (Pinckard et al., 2000). The study concluded that, for both male-oriented and asexual rams, neither method had a statistically significant influence on the animals’ behavior; regardless of the possible effects of testosterone derivatives on sexual cue sensitivity, there was not enough to change the rams’ preferences (Pinckard et al., 2000). Again, these studies that Kaplan claimed would further an understanding of HSDD instead suggest a natural aspect of the lack of sexual desire resistant to attempts to return to a “normal” sexual state analogous to the resistance of homosexuality to return to a “normal” heterosexual state.
Researchers working to understand low levels of sexual desire outside of the framework proposed by Kaplan can trace their basis back to Alfred Kinsey’s revolutionary works “Sexual Behaviors in the Human Male” and “Sexual Behaviors in the Human Female”, published in the mid-20th century. While trying to place homosexuality and heterosexuality on a scale with each other as opposed to distinctly separate categorizations, Kinsey discovered a group “X”, who he described as having “no socio-sexual contacts or reactions”, which could not be fit on one axis (Kinsey, A.C., Pomeroy, W.B., & Martin, C.E., 1948, p. 638 and p. 647; Kinsey, A.C. & Institute for Sex Research, 1953, p. 472). Despite the likely smaller proportion represented than the asexual community at large due to the use of sexual history as a parameter, the acknowledgement of group “X” is one of the earliest official studies of people who would likely identify on the asexuality spectrum today. Even after Kaplan and the introduction of HSDD into the DSM, researchers in other disciplines continued to explore groups of what would now be considered asexuals. Strikingly in 1980, Michael Storms reimagined the single axis metric proposed by Kinsey into two dimensions based on “erotic orientation”. In the low-low quadrant of this graphic, Storms labelled the area “asexuals” (the sexual orientation) – portraying the orientation as a natural extension of the existence of homo- and hetero-sexuality (Storms, 1980).
Kinsey’s observational research predates Kaplan’s proposal by nearly two decades. In other words, the lack of “socio-sexual…reaction” as a naturally-observed phenomenon predates the diagnosis that frames this difference as a disorder. Before the normality of lacking sexual desire became an issue, researchers had begun noticing its natural occurrence. This means that the disorder can be understood as an interpretation of the noted phenomenon (“asexuality”) as opposed to the phenomenon arising from resistance to the labelling of the disorder even in the absence of people who called themselves “asexual”. The distinction seems slight, but instead of philosopher Ian Hacking’s antagonistic “downwards” expert and “upwards” social labelling vectors, the labels of “asexual” and “HSDD” are apparently in competition with each other while “group X” is the original “downward” expert proposal on those currently identified as aces (Hacking, 1999, pp. 104-5). Most importantly, Kaplan’s original caveat to her thesis was that not only do we not have a standard “normal sexual desire”, but we also must admit that these things are “ultimately subjective” (1977, p. 4). One reasonable answer to this subjectivity explaining the gaps in Kaplan’s understanding of individuals with low levels of sexual desire is the label of “asexuality” proposed by themselves via AVEN.
Acknowledging asexuality as an orientation opens many more interesting conversations limited by HSDD. Unlike homosexual or heterosexuals who supposedly experience desire the same way (another assumption of those researching sexual desire), not all aces experience asexuality the same way. While some do not feel sexual attraction whatsoever (sometimes referring to themselves as “non-sexual”) and others experience neither sexual nor romantic attraction (calling themselves “aromantic asexual(s)” or “aro ace(s)”), still other experience a disconnected form of sexuality labeled by a researcher as “autochrissexual”, or “identity-less sexuality” to describe an erotic orientation that is not necessarily low-low (according to the Storms model) but does not involve the individual in the fantasies (Bogaert, A.F., 2012; Storms, 1980). Are these differences distinct enough to complicate asexuality into distinct orientations (similar to the relationship between bisexuality and pansexuality) or is there an underlying connection between the states? Perhaps not only aces experience what Bogaert terms as “autochrissexuality” and this is a third dimension to consider for erotic orientation. By only examining low sexual desire as a medical problem, researchers are missing an increasingly complicated view of (a)sexuality that would help refine HSDD.
Resolving Conflict: A Vision for the DSM-6
Understanding the current research on asexuality and HSDD, we can now examine their relationship in the framework provided by the interactions of homosexuality in the DSM. First, it is important to note that a 2012 study on the potential for discrimination of “‘Group X’” found that those identifying on the asexual spectrum face an elevated level of bias compared with other sexual minorities, especially because they are sometimes considered less human due to their lack of sexual attraction (MacInnis, C.C. & Hodson, G., 2015). Revealing the pervasiveness of believing sexuality to be the only natural state, this adds pressure to the decisions of the APA with respect to asexuality due to the rising potential for human rights abuses if this bias spreads. While comparable with “anti-homosexual social stigma”, these beliefs reveal a more dangerous undercurrent of dehumanization not noted with homosexuality independent of, but not aided by, the existence of HSDD, MHSDD, and parts of FSIAD (Drescher, 2015).
Using the criteria identified in the case of homosexuality and the DSM, it is clear that the “natural variation” of asexuality is not so easily dismissed. The earlier notation of those we would consider aces by today’s standards as Kinsey’s group X and the well-documented resistance of identified “asexual” rams and those diagnosed with HSDD in general support an unexplainable resistance towards becoming “sexual” when considering it the only natural state (Kinsey et al., 1948; Kinsey et al., 1953; Pinckard et al., 2000). Taken together, the research assembled presents a case for a in-born quality to the orientation similar to homosexuality that caused the APA to remove it from the DSM-III (Drescher, 2015). By extension, the APA should consider removing the “lifelong” MHSDD and FSIAD variants from the DSM-6. Are all of the other components of MHSDD and FSIAD (arising from HSDD) good diagnostic tools?
A key aspect of “disorders” is that they address personal or social distress even when addressing a natural state (ex. autism, attention deficit hyperactivity disorder (ADHD)). Research comparing people who were identified as “asexual” according to a verified Asexuality Identification Scale (AIS) regardless of self-identity with people diagnosed with HSDD provides interesting insights by revealing the differences between the two samples (Brotto, L.A., Yule, M.A., & Gorzalka, B.B., 2015). The researcher found that: 1) those diagnosed with HSDD were more likely to experience symptoms of depression; and 2) there were no statistically significant differences alexithymia or desirable responding between the asexual and control groups (Brotto et al., 2015). This means that those with HSDD and those who were asexual were only significantly different with regards to the depression of HSDD patients. To accurately predict between HSDD diagnosis and asexuality, the regression required four different factors (“relationship status (long-term dating/married), sexual desire, sex-related distress, and lower alexithymia scores”) (Brotto et al., 2015). While some people consider asexuality a variant of HSDD, the groups have only slight differences with the HSDD group having apparently worse social distress (as indicated by the depression scores) (Brotto et al., 2015). While this research further supports asexuality as a non-distressing orientation, there are further interesting implications for HSDD and its derivative diagnoses.
Chasin, a self-identified asexual in applied social psychology, presents four hypothetical patients who meet the criteria for a diagnosis of HSDD: 1) a life-long, happy asexual – “Asexy Aeron”; 2) a life-long asexual unhappy with their level of sexual desire – “Lonely Laurn”; 3) someone who no longer experiences sexual desire but who is happy or indifferent about it – “Chipper non Randy” and “Blazay non Randy”; and 4) the non-asexual distressed about experiencing a new lack of sexual desire – “Gloomy non Randy” (2013). In light of research presented in this paper, it becomes clear that “Asexy Aeron” is not distressed and therefore not diagnosed and “Lonely Laurn” is distressed about an unchangeable identity aspect should not be validly diagnosed either. “Chipper non Randy” and “Blazay non Randy” are not distressed, similar to “Asexy Aeron”, but relationships with partners may cause them to seek out treatment in spite of this (Chasin, 2013). Kaplan herself mentioned the importance of relationship factors in determining issues of sexual desire dysfunction; most of these symptoms became topic of interests, after all, at the cajoling of the hyposexual (or asexual) person’s significant other (Kaplan, 1977). Chasin argues that it is a similar case for “Gloomy non Randy”, that unmet social expectations for “idealized” sexual desire are what actually cause a “Chipper” or “Blazay” to become a “Gloomy” (Chasin, 2013).
While Chasin’s theory contradicts with the normal desirable responding scores found across all groups by Brotto et al., her theory may not be completely unfounded (2015; Chasin, 2013). Kaplan acknowledged in her original proposal that there was considerable anxiety surrounding sexual dysfunctions as a category and in particular admitting to low-sexual desire (1977). Using the second proposed mechanism, considering the dysfunction a form of a social anxiety disorder, may be a more productive way to understand individuals who (unwelcomely) lose sexual desire (Belkin et al., 2014). Combined with the high depression scores of those diagnosed under HSDD, these two facets suggest that HSDD is a sexual dysfunction only insomuch as it relates to sexual desire; otherwise, the cause of HSDD appears to be mood or anxiety linked with sexual symptoms (Brotto et al., 2015). This shift might help to reduce bias against the asexual community by shifting the focus of the new hypothetical disorder away from the symptom and towards some root cause which might help others accept low sexual desire as a natural state not inherently problematic (MacInnis et al., 2015). By critically examining Kaplan’s original proposal, we have been able to think about the disorders in more productive ways and suggest a new perspective under which to discuss research.
This paper has examined the diagnosis of HSDD (and MHSDD and aspects of FSIAD appearing in the DSM-5) as in intersects with the increasingly prominent sexual orientation of “asexuality”. Using the intersection of homosexuality and the DSM as a case study, we discovered standards set by the APA with regards to dismissing a disorder as a sexuality. By examining research on both asexuality and HSDD, we were able to see that treatments for the disorder have poor prognoses, likely due to an inborn facet of asexuality. This has led to the conclusions that “lifelong” HSDD diagnoses are less productive in discussion than asexuality. Further analysis suggests that HSDD as a diagnosis would be better envisioned possibly as an anxiety or mood disorder to lower potential for discrimination against asexuals and better meet the needs of the patient.
Appendix 1: Complete Diagnostic Criteria of Disorders
HSDD (DSM-IV-TR, p. 539)
The essential feature of Hypoactive Sexual Desire Disorder is a deficiency or absence of sexual fantasies and desire for sexual activity (Criterion A). The disturbance must cause marked distress or interpersonal difficulty (Criterion B). The dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (including medications) or a general medical condition (Criterion C).
FSIAD (DSM-5, p. 433)
- Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:
- Absent/reduced interest in sexual activity.
- Absent/reduced sexual/erotic thoughts or fantasies.
- No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.
- Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75% – 100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
- Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual).
- Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75% – 100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
- The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
- The symptoms in Criterion A cause clinically significant distress in the individual.
- The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g. partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.
MHSDD (DSM-5, p. 440)
- Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgement of deficiency s made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio-cultural contexts of the individual’s life.
- The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
- The symptoms in Criterion A cause clinically significant distress in the individual.
- The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to thes [sic] effects of a substance/medication or another medical condition.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., test rev.). Washington, DC.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
Balon, R. & Clayton, A.H. (2014). Female Sexual Interest/Arousal Disorder: A Diagnosis Out of Thin Air. Archives of Sexual Behavior, 43, 1227-1229.
Belkin, Z.R., Krapf, J.M., & Goldstein, A.T. (2014). Drugs in early clinical development for the treatment of female sexual dysfunction. Expert Opinion on Investigational Drugs, 24, 159-167.
Bogaert, A.F. (2012). Asexuality and Autochrissexualism (Identity-Less Sexuality). Archives of Sexual Behavior, 41, 1513-1514.
Brotto, L.A., Yule, M.A., & Gorzalka, B.B. (2015). Asexuality: An Extreme Variant of Sexual Desire Disorder? Journal of Sexual of Medicine, 12, 64-660.
Chasin, C.J.D. (2011). Theoretical Issues in the Study of Asexuality. Archives of Sexual Behavior, 40, 713-723.
Chasin, C.J.D. (2013). Reconsidering Asexuality and its Radical Potential. Feminist Studies, 39, 405-426.
Drescher, J. (2015). Out of the DSM: Depathologizing Homosexuality. Behavioral Sciences, 5, 564-575.
Dziegielewski, S.F., Resnick, C., Nelson-Gardell, D., & Harrison, D.F. (1998). Treatment of Sexual Dysfunctions: What Social Workers Need to Know. Social Work Practice, 8, 685-697.
Hacking, I. (1999). Making Up People. In M. Biagioli (Eds.), The Social Studies Reader (pp. 161-171). New York: Routledge.
Kaplan, H.S. (1977). Hypoactive sexual desire. Journal of Sex & Marital Therapy, 3, 3-9.
Kim, S.W., Schenck, C.H., Grant, J.E., Yoon, G., Dosa, P.I., Odlaug, B.L., … & Pfaus, J.G. (2013). Neurobiology of sexual desire. NeuroQuantology, 11, 332-359.
Kinsey, A.C., Pomeroy, W.B., & Martin, C.E. (1948). Sexual Behavior in the Human Male. Philadelphia: W.B. Saunders Co.
Kinsey, A.C. & Institute for Sex Research (1953). Sexual Behavior in the Human Female. Philadelphia: W.B. Saunders Co.
Kraft-Ebbing, R. (1901). Psychopathia Sexualis (10th ed.; F. J. Rebman, Trans.). Chicago: W. T. Keener & Co. (Original work published 1901).
MacInnis, C.C. & Hodson, G. (2015). Intergroup bias toward “Group X”: Evidence of prejudice, dehumanization, avoidance, and discrimination against asexuals. Group Processes & Intergroup Relations, 6, 725-743.
Parish, S.J. & Hahn, S.R. (2016). Hypoactive Sexual Desire Disorder: A Review of Epidemiology, Biopsychology, Diagnosis, and Treatment. Sexual Medicine Reviews, 4, 103-120.
Pinckard, K.L., Stellflug, J., & Stormshak, F. (2000). Influence of castration and estrogen replacement in sexual behavior of female-oriented, male-oriented, and asexual rams. Journal of Animal Science, 78, 1974-53.
Storms, M.D. (1980). Theories of Sexual Orientation. Journal of Personality and Social Psychology, 38, 783-792.
This paper represents my own work in accordance with university regulations. –Katherine Stiefel
 The title “DSM” is used to refer to the entire body of works published by the American Psychological Society (APA) while the title “DSM-” is used to refer to a specific edition published. Every couple of years, the APA releases a new edition to keep their explanations in-line with current research.
 See “Appendix 1: Complete Diagnostic Criteria of Disorders” for more information on the specific diagnoses.
 There is consensus across many scholars that the founding of AVEN was a crucial point in the formation of the “asexual” orientation community because its message boards allowed many isolated individuals to talk with others for the first time about their experiences with asexuality.
 The term “sexual orientation” or “sexual identity” is best understood as an individual’s overall label for their sexuality. This is an explanation of their sexual attraction, a shorthand way of describing the individual’s sexual preferences. This is often, but not always, the same as their “romantic orientation”, which is a way to explain who the individual desires emotional bonds with (e.g. “crushes”). For the majority of people, their sexual attractions are the same as their romantic attractions (ex. a homosexual homoromatic person as opposed to a homosexual heteromantic), and their identity is often compressed into a single label of “sexuality”. This is not possible with asexuals since their romantic attraction can be totally different from their (a)sexual attraction (Chasin, 2011).
 The modern view of sexuality, however, relies on spectrums as opposed to absolutes (Storms, M.D., 1980). Just as some people may be more predisposed towards one type of sexual attraction but not exclusively, some people on the “asexual” spectrum still experience varying levels of sexual attraction.
 I will not discuss the validity of the aspects of FSIAD that arise from the diagnosis FAD, as FAD has more physiological symptoms to it that would lead to a different conversation. I merely want to address the mental states associated with not experiencing sexual desire.
 Kaplan analogized these forces to disorder eating whereby anxieties and thoughts prevent the expression of a deeply seated physical drive to eat (1977, p. 4). Coupled with a later assertion that sexual dysfunctions are ultimately a result of anxieties, it is safe to conclude that “psychic forces” refers to an anxiety response (1977, p. 8).
 “Sensual” desire is desire to be touched – not necessarily in a sexual manner. It can manifest as a desire to hug or cuddle someone, for example. See the AVEN website for more information on non-sexual desires.
 This term is often used to refer to anyone in the asexual community including those that who do not identify specifically as “asexual” (Chasin, 2013). See the AVEN website for more information on non-asexual ace identities.
 Almost androgenic hormones (testosterone, estrogen, progesterone, etc.) can be metabolized into other androgens in mammals. The study specifically gave the sheep exogenous estradiol-173 (E2) (Pinckard et al., 2000).
 “Erotic orientation” is a term used to describe the content of a subject’s erotic fantasies and is closely related to sexual orientation. The relationship between them are primarily defined by Alfred Kinsey’s work, notably that erotic orientation gives rise to sexual orientation (Storms, 1980).
 Alexitheymia is a “tendency not to feel emotions” as described by the researchers (Brotto et al., 2015).
 The researchers were also examining whether it was likely those identified as “asexual” were concealing their “sexual (dis)interest” to better observe social norms by determining the participants’ likelihood of choosing “desirable” answers (Brotto et al., 2015).