^Introduction

^{In recent years, publicity about new treatments for men's erection problems has focused attention on women's sexuality and provoked a competitive commercial hunt for "the female Viagra." But women's sexual problems differ from men's in basic ways which are not being examined or addressed.}

^{We believe that a fundamental barrier to understanding women's sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association (APA) for its Diagnostic and Statistical Manual of Disorders (DSM) in 1980, and revised in 1987 and 1994.(2)}

^{It divides (both men's and) women's sexual problems into four categories of sexual "dysfunction": sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. These "dysfunctions" are disturbances in an assumed universal physiological sexual response pattern ("normal function") originally described by Masters and Johnson in the 1960s(3). This universal pattern begins, in theory, with sexual drive, and proceeds sequentially through the stages of desire, arousal, and orgasm.}

^{In recent decades, the shortcomings of the framework, as it applies to women, have been amply documented.(4)
The three most serious distortions produced by a framework that reduces sexual problems to disorders of physiological function, comparable to breathing or digestive disorders, are:}

^{1) A false notion of sexual equivalency between men and women. Because the early researchers emphasized similarities in men's and women's physiological responses during sexual activities, they concluded that sexual disorders must also be similar. Few investigators asked women to describe their experiences from their own points of view. When such studies were done, it became apparent that women and men differ in many crucial ways. Women's accounts do not fit neatly into the Masters and Johnson model; for example, women generally do not separate "desire" from "arousal," women care less about physical than subjective arousal, and women's sexual complaints frequently focus on "difficulties" that are absent from the DSM.(5)}

^{Furthermore, an emphasis on genital and physiological similarities between men and women ignores the implications of inequalities related to gender, social class, ethnicity, sexual orientation, etc. Social, political, and economic conditions, including widespread sexual violence, limit women's access to sexual health, pleasure, and satisfaction in many parts of the world. Women's social environments thus can prevent the expression of biological capacities, a reality entirely ignored by the strictly physiological framing of sexual dysfunctions.}

^{2) The erasure of the relational context of sexuality. The American Psychiatric Association's DSM approach bypasses relational aspects of women's sexuality, which often lie at the root of sexual satisfactions and problems--e.g., desires for intimacy, wishes to please a partner, or, in some cases, wishes to avoid offending, losing, or angering a partner. The DSM takes an exclusively individual approach to sex, and assumes that if the sexual parts work, there is no problem; and if the parts don't work, there is a problem. But many women do not define their sexual difficulties this way. The DSM's reduction of "normal sexual function" to physiology implies, incorrectly, that one can measure and treat genital and physical difficulties without regard to the relationship in which sex occurs.}

^{3) The levelling of differences among women. All women are not the same, and their sexual needs, satisfactions, and problems do not fit neatly into categories of desire, arousal, orgasm, or pain. Women differ in their values, approaches to sexuality, social and cultural backgrounds, and current situations, and these differences cannot be smoothed over into an identical notion of "dysfunction"--or an identical, one-size-fits-all treatment.}

^{Because there are no magic bullets for the socio-cultural, political, psychological, social or relational bases of women's sexual problems, pharmaceutical companies are supporting research and public relations programs focused on fixing the body, especially the genitals. The infusion of industry funding into sex research and the incessant media publicity about "breakthrough" treatments have put physical problems in the spotlight and isolated them from broader contexts. Factors that are far more often sources of women's sexual complaints--relational and cultural conflicts, for example, or sexual ignorance or fear--are downplayed and dismissed. Lumped into the catchall category of "psychogenic causes," such factors go unstudied and unaddressed. Women with these problems are being excluded from clinical trials on new drugs, and yet, if current marketing patterns with men are indicative, such drugs will be aggressively advertised for all women's sexual dissatisfactions.}

^{A corrective approach is desperately needed. We propose a new and more useful classification of women's sexual problems, one that gives appropriate priority to individual distress and inhibition arising within a broader framework of cultural and relational factors. We challenge the cultural assumptions embedded in the DSM and the reductionist research and marketing program of the pharmaceutical industry. We call for research and services driven not by commercial interests, but by women's own needs and sexual realities.}

^{Sexual Health and Sexual Rights: International Views}

^{To move away from the DSM's genital and mechanical blueprint of women's sexual problems, we turned for guidance to international documents. In 1974, the World Health Organization held a unique conference on the training needs for sexual health workers. The report noted: "A growing body of knowledge indicates that problems in human sexuality are more pervasive and more important to the well-being and health of individuals in many cultures than has previously been recognized." The report emphasized the importance of taking a positive approach to human sexuality and the enhancement of relationships. It offered a broad definition of "sexual health" as "the integration of the somatic, emotional, intellectual, and social aspects of sexual being."(6)}
 

^{In 1999, the World Association of Sexology, meeting in Hong Kong, adopted a Declaration of Sexual Rights.(7)}

^{"In order to assure that human beings and societies develop healthy sexuality," the Declaration stated, "the following sexual rights must be recognized, promoted, respected, and defended":}

^{The right to sexual freedom, excluding all forms of sexual coercion, exploitation and abuse;}

^{The right to sexual autonomy and safety of the sexual body;}

^{The right to sexual pleasure, which is a source of physical, psychological, intellectual and spiritual well-being;}

^{The right to sexual information...generated through unencumbered yet scientifically ethical inquiry;}

^{The right to comprehensive sexuality education;}

^{The right to sexual health care, which should be available for prevention and treatment of all sexual concerns, problems, and disorders.}

^{Women's Sexual Problems: A New Classification}

^{Sexual problems, which The Working Group on A New View of Women's Sexual Problems defines as discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience, may arise in one or more of the following interrelated aspects of women's sexual lives.}

^{I. SEXUAL PROBLEMS DUE TO SOCIO-CULTURAL, POLITICAL, OR ECONOMIC FACTORS}

^{A. Ignorance and anxiety due to inadequate sex education, lack of access to health services, or other social constraints:}

^{1. Lack of vocabulary to describe subjective or physical experience.}

^{2. Lack of information about human sexual biology and life-stage changes.}

^{3. Lack of information about how gender roles influence men's and women's sexual expectations, beliefs, and behaviors.}

^{4. Inadequate access to information and services for contraception and abortion, STD prevention and treatment, sexual trauma, and domestic violence.}

^{B. Sexual avoidance or distress due to perceived inability to meet cultural norms regarding correct or ideal sexuality, including:}

^{1. Anxiety or shame about one's body, sexual attractiveness, or sexual responses.}

^{2. Confusion or shame about one's sexual orientation or identity, or about sexual fantasies and desires.}

^{C. Inhibitions due to conflict between the sexual norms of one's subculture or culture of origin and those of the dominant culture.}

^{D. Lack of interest, fatigue, or lack of time due to family and work obligations.}

^{II. SEXUAL PROBLEMS RELATING TO PARTNER AND RELATIONSHIP}

^{A. Inhibition, avoidance, or distress arising from betrayal, dislike, or fear of partner, partner's abuse or couple's unequal power, or arising from partner's negative patterns of communication.}

^{B. Discrepancies in desire for sexual activity or in preferences for various sexual activities.}

^{C. Ignorance or inhibition about communicating preferences or initiating, pacing, or shaping sexual activities.}

^{D. Loss of sexual interest and reciprocity as a result of conflicts over commonplace issues such as money, schedules, or relatives, or resulting from traumatic experiences, e.g., infertility or the death of a child.}

^{E. Inhibitions in arousal or spontaneity due to partner's health status or sexual problems.}

^{III. SEXUAL PROBLEMS DUE TO PSYCHOLOGICAL FACTORS}

^{A. Sexual aversion, mistrust, or inhibition of sexual pleasure due to:}

^{1. Past experiences of physical, sexual, or emotional abuse.}

^{2. General personality problems with attachment, rejection, co-operation, or entitlement.}

^{3. Depression or anxiety.}

^{B. Sexual inhibition due to fear of sexual acts or of their possible consequences, e.g., pain during intercourse, pregnancy, sexually transmitted disease, loss of partner, loss of reputation.}
 

^{IV. SEXUAL PROBLEMS DUE TO MEDICAL FACTORS}

^{Pain or lack of physical response during sexual activity despite a supportive and safe interpersonal situation, adequate sexual knowledge, and positive sexual attitudes. Such problems can arise from:}

^{A. Numerous local or systemic medical conditions affecting neurological, neurovascular, circulatory, endocrine or other systems of the body;}

^{B. Pregnancy, sexually transmitted diseases, or other sex-related conditions.}

^{C, Side effects of many drugs, medications, or medical treatments.}

^{D. Iatrogenic conditions.}

^Conclusion

^{This document is designed for researchers desiring to investigate women's sexual problems, for educators teaching about women and sexuality, for medical and nonmedical clinicians planning to help women with their sexual lives, and for a public that needs a framework for understanding a rapidly changing and centrally important area of life.}

^{-------------------------}

^{For further information about the Campaign for "A New View of Women's Sexual Problems," to obtain additional copies of this document, or to make a financial contribution, please contact:}

^{Dr. Leonore Tiefer, 163 Third Ave., PMB #183, New York, NY 10003, <LTiefer@Mindspring.com> or}

^{Dr. Carol Tavris, 1847 Nichols Canyon Road, Los Angeles, CA 90046, <CTavris@compuserve.com>}

^{October 25, 2000}

^{1.
Linda Alperstein, M.S.W., Assoc. Clin. Prof., Psychiatry, University of California at
San Francisco; Psychotherapy Practice, San Francisco, CA}

^{Carol Ellison, Ph.D., Author; Psychotherapy Practice, Oakland, CA}

^{Jennifer R. Fishman, B.A., Doctoral Candidate, Department of Social and Behavioral Science, UCSF, CA}

^{Marny Hall, Ph.D., Author; Psychotherapy Practice, San Francisco, CA}

^{Lisa Handwerker, Ph.D., M.P.H., Institute for the Study of Social Change, University of California at Berkeley, CA}

^{Heather Hartley, Ph.D., Ass't Professor, Sociology, Portland State University, OR}

^{Ellyn Kaschak, Ph.D., Professor, Psychology, San Jose State University, CA}

^{Peggy J. Kleinplatz, Ph.D., School of Psychology, Univ. of Ottawa, Ontario, Canada}

^{Meika Loe, M.A., Doctoral Candidate, Women's Studies Emphasis, Sociology, University of California at Santa Barbara, CA}

^{Laura Mamo, B. A., Doctoral Candidate, Department of Soc. and Behav. Sci., UCSF, CA}

^{Carol Tavris, Ph.D., Social Psychologist; Independent Scholar, Los Angeles, CA}

^{Leonore Tiefer, Ph.D., Assoc. Clin. Professor, Psychiatry, New York University School of Medicine and Albert Einstein College of Medicine, NY}

^{2. American Psychiatric Association (1980, 1987, 1994). Diagnostic and Statistical Manual of Mental Disorders, 3rd, 3rd-revised, and 4th editions. Washington, DC: APA.}

^{3. Masters, W. H. & Johnson,V. E. (1966) Human Sexual Response. Boston: Little, Brown, and Co.; Masters, W.H. & Johnson, V. E. (1970) Human Sexual Inadeqacy. Boston: Little, Brown, and Co.}

^{4. e.g., Tiefer, L. (1991) Historical, scientific, clinical and feminist criticisms of "the Human Sexual Response Cycle" model. Annual Review of Sex Research, 2, 1-23; Basson, R. (2000) The female sexual response revisited. J. Society Obstetrics and Gynaecology of Canada, 22, 383-387.}

^{5. Frank, E., Anderson, C., & Rubinstein, D. (1978) Frequency of Sexual dysfunction in "Normal" couples. New England Journal of Medicine, 299, 111-115; Hite, S. (1976) The Hite Report: A nationwide study on female sexuality. NY: Macmillan; Ellison, C. (2000) Women's Sexualities: Generations of women share intimate secrets of sexual self-acceptance. Oakland, CA: New Harbinger.}

^{6. WHO Technical Report, series Nr. 572, 1975. Full text available on the Robert Koch Institute sexuality website <www.rki.de/GESUND/ARCHIV/HOME.HTM>}

^{7. Full text available on the website listed in footnote 6 and also on the World Association of Sexology website <www.tc.umn.edu/~coleman001/was/wdecla/htm>. It is published in E.M.L.Ng, J.J. Borras-Valls, M. Perez-Conchillo and E.Coleman (Eds.) (2000) Sexuality in the New Millenium. Bologna, Editrice Compositori.}