ABSTRACT: The working definition of sexual health published in this issue of Sexual Addiction and Compulsivity promises to advance theory, research, practice, and training. The definition implicitly assumes that desire is a requirement of healthy sexuality. Recent emergence of research and advocacy for the asexual identity challenges the contemporary definition of sexual health and offers questions for reflective practice.
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The concept of “sexual health” is inherently fluid and dynamic, as it is constantly changing and shifting on both micro and macro levels. However difficult the task may be, a definition is necessary to provide a framework to assess client behavior, communicate the needs of clients and partners, and develop best practices to help clients achieve their goals. Further, a definition of sexual health provides a mechanism which prevents clinicians from pathologizing behaviors which may not in fact represent dysfunction or “problematic sexual behavior.” This is necessary given psychology's history of pathologizing what we have now come to understand as normal and healthy expressions of sexuality: BDSM, homosexuality, bisexuality, and polyamory.
Numerous agencies and organizations have attempted to define sexual health. These efforts are attempts to express and qualify this elusive “sexual health” definition. As the Society for the Advancement of Sexual Health stated, it is “…committed to an intentional effort to expand the scope of our work and contribute to an inclusive, contemporary view of sexual health.” (Southern, 2017 Southern, S. (2017). Editorial. Sexual Addiction and Compulsivity, 24(4), 241. doi:10.1080/10720162.2017.1408999, p. 241).
As clinicians and editorial assistants, we believe the definition of sexual health should contain an explicit mention of “asexual orientation.” The absence of asexuality speaks to the lack of understanding currently reported in the sexual health/addiction field. We believe the concept of asexuality and self-identification of an asexual lifestyle should be explored as a facet of sexual health.
Asexuality defined
There isn't a singular definition of “normal” asexuality. There are a range of experiences within the orientation: some asexual individuals engage in partnered sexual activity, solitary sexual activity, or abstain from sex completely (Bogaert, 2004 Bogaert, A. (2004). Asexuality: Prevalence and associated factors in a national probability sample. The Journal of Sex Research, 41(3), 279–287. doi:10.1080/00224490409552235) However, the common thread throughout is that asexuals have never experienced sexual attraction or sexual desire throughout the course of their life (Bogaert, 2015 Bogaert, A. (2015). Asexuality: What it is and why it matters. The Journal of Sex Research, 52(4), 362–379. Retrieved from. doi:10.1080/00224499.2015.1015713). And while sexual interest and desire naturally fit into the definition of sexual health, the absence of desire challenges the concept of sexual orientation being centered around the presence of sexual desire.
Recently, an organization called The Asexual Visibility and Education Network (AVEN), emerged with the goals to create awareness and promote acceptance of asexuality, while building community around the orientation (AVEN, n.d. Asexual Visibility and Education Network (AVEN). (n.d.). Overview. https://www.asexuality.org/?q=overview.html). AVEN defined the asexual orientation as follows,
An asexual is someone who does not experience sexual attraction. Unlike celibacy, which people choose, asexuality is an intrinsic part of who we are. Asexuality does not make our lives any worse or any better, we just face a different set of challenges than most sexual people. There is considerable diversity among the asexual community; each asexual person experiences things like relationships, attraction, and arousal somewhat differently. (AVEN, n.d. Asexual Visibility and Education Network (AVEN). (n.d.). Overview. https://www.asexuality.org/?q=overview.html)
The lack of sexual desire as reported by asexual people, means that these individuals can make meaningful relationships in their lives that are not based on sexual functioning. As a result, asexuality can be distinguished from inhibited or hypoactive sexual desire as they are described by the American Psychiatric Association (2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author). The distinction between a sexual desire disorder and an asexual orientation has significant implications for treatment and attitudes towards an asexual person.
Sexual desire disorder
Desire disorders include low sexual desire or interest within an individual or between partners in a sexual relationship. There are many theories or models that account for lack or loss of desire including biological, developmental, intrapsychic, relational, and cultural factors. Two specific diagnoses include Female Sexual Interest/Arousal Disorder (302.72) and Male Hypoactive Sexual Desire Disorder (302.71) (DSM-V; American Psychiatric Association, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author, p. 433–436; 440–443). It is not uncommon for one partner to report the other has low desire, which typically means less interest in sex than the one who applies the label. Therefore, diagnoses of sexual desire disorders must satisfy certain criteria.
Female Sexual Interest/Arousal Disorder blurs the sexual responses of interest and arousal. Low sexual desire in this context may be presented as lack of interest in sexual activity, absence of erotic or sexual thoughts, reluctance to initiate sex, and inability to respond to a partner's sexual invitations (APA, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author, p. 433). Female sexual interest/arousal disorder may be lifelong or acquired; generalized or situational; and range from mild to moderate or severe distress. Symptoms must have persisted for at least 6 months, and the symptoms cannot be better explained by a nonsexual medical or mental condition or by severe relationship distress such as partner violence. At least three of the following characteristics are required for diagnosis of the disorder (APA, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author, p. 433):
1. Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unresponsive to a partner's attempts to initiate.
4. 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).
5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or nongenital sensations during sexual activity in almost or all (approximately 75–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
Male Hypoactive Sexual Desire Disorder (APA, 2013 Gressgård, R. (2012). Asexuality: From pathology to identity and beyond. Psychology & Sexuality, 4(2), 179–192. doi:10.1080/19419899.2013.774166, pp.440–443) remains distinct from female sexual interest/arousal disorder in arousal/excitement and orgasm/ejaculation in sexual responding. Some of the shared criteria with female sexual interest/arousal disorder include: at least 6 months duration; lifelong vs. acquired; generalized vs. situational; and mild-moderate-severe distress. However, the major diagnostic feature places hypoactive sexual desire in context:
Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual's life. (APA, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author, p. 440)
Both male hypoactive sexual desire disorder and female sexual interest/arousal disorder are associated with five conditions in the DSM-V (APA, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author):
1. Partner factors (e.g., partner's sexual problems, partner's health status);
2. Relationship factors (poor communication, desire discrepancies);
3. Individual vulnerability factors (poor body image, history of sexual or emotional abuse) and/or psychiatric comorbidity (depression, anxiety) or stressors (job loss, bereavement);
4. Cultural/religious factors (attitudes, inhibitions or prohibitions against sexual activity); and
5. Medical factors (including effects of medication).
Sexual desire disorders are, by definition, distressing for the person experiencing them. The lack of desire is experienced as a loss or void for the person, and the ability to ethically and humanely treat the disorder offers the perspective that sexual desire disorders are change-worthy themselves. However, normal or healthy asexuality is not experienced as a problem, loss, or disorder. Brotto and Yule (2017 Brotto, L., & Yule, A. (2017). Asexuality: Sexual orientation, paraphilia, sexual dysfunction, or none of the above? Archives of Sexual Behavior, 46(3), 619–627. doi:10.1007/s10508-016-0802-7) found there is no evidence to suggest that asexuality is a psychiatric disorder, sexual dysfunction, or paraphilia. Rather, their data suggested that asexuality is a recognizable sexual orientation. As the asexuality definition proposed by AVEN (n.d. Asexual Visibility and Education Network (AVEN). (n.d.). Overview. https://www.asexuality.org/?q=overview.html) suggests, asexual people seek to inform clinicians and society-at-large that their sexual orientation is not a sexual desire disorder needing to be treated.
Excluding asexuality from sexual health may harm
The lack of sexual interest or desire that asexual people experience has historically been pathologized as a disorder (Gressgård, 2012 Gressgård, R. (2012). Asexuality: From pathology to identity and beyond. Psychology & Sexuality, 4(2), 179–192. doi:10.1080/19419899.2013.774166). The authors believe that this exclusion furthers the experience of invisibility described by asexuals and contributes to the discrimination which they experience. In a study investigating intergroup bias towards asexuals, asexuals were evaluated more negatively by participants. They were viewed as less human than other sexual minority groups, and contact with asexual people was considered less desirable than contact with homosexual and heterosexual people (MacInnis & Hodson, 2012 MacInnis, C., & Hodson, G. (2012). Intergroup bias toward “Group X”: Evidence of prejudice, dehumanization, avoidance, and discrimination against asexuals. Group Processes & Intergroup Relations, 15(6), 725–743. Retrieved from. doi:10.1177/1368430212442419). This recognizable bias fuels the pathologizing of asexuality and reinforces a need for the inclusion of the orientation in a contemporary definition of sexual health.
The exclusion of asexual people from the working definition of sexual health, presented in this issue by Southern (2018 Southern, S. (2018, in press). Recent perspectives on sexual health. Sexual Addiction and Compulsivity, 25(1), in press), erases any acknowledgement of the sexual experiences of asexuals. This exclusion can influence not only any positive and healthy sexual experiences, but also any negative or clinically significant ones. The result then, is that all data related to the sexual experiences of asexuals are not observed or studied, effectively disabling any definition from gaining a more nuanced understanding of sexual health for this emerging population.
Excluding or pathologizing of asexual experiences, reflects an implicit a disqualification of the subjective experience of persons choosing this lifestyle. Asexuality itself is not considered a “problem” within the asexual community (AVEN, n.d. Asexual Visibility and Education Network (AVEN). (n.d.). Overview. https://www.asexuality.org/?q=overview.html). While other sexual minorities may be validated in their sexual desires, a lack of sexual desire transgresses the social narrative that all people naturally have sexual desire. As such, to maintain the status quo, asexuals are placed into an “other” category and deemed pathologically troubled. It is this mindset, that all people must have sexual desire to be sexually healthy, that leads to the exclusion of asexual people from the current definition of sexual health.
It is important to include asexuality
The authors believe that there can be much learned about the nature of sexuality through the study and inclusion of asexuality. An example being clarity around the role of sexual desire in determining sexual health. The question, “Is someone who has sex for reasons other than sexual desire considered to be sexually healthy?” offers insight into how contemporary thought places sexual desire as a necessary component to sexual activity. Asexual persons do not consider their sexuality to be inherently “the problem.” In addition, they do not want to be seen as having hypoactive sexual desire and experience the shame that may come with psychiatric diagnosis.
It is also noteworthy that asexuals do enter romantic relationships. It has been found in a study done by Bogaert (2004 Bogaert, A. (2004). Asexuality: Prevalence and associated factors in a national probability sample. The Journal of Sex Research, 41(3), 279–287. doi:10.1080/00224490409552235), that up to 44% of identified asexual people in a British survey were currently in a long-term relationship or had been previously. For the asexual person, the major concern for them within the relationship could be the emotional connection, rather than the sexual one. The result, then, is that their engagement in sexual activity could be done to please their sexual partner, and possibly facilitate emotional connection (Bogaert, 2004 Bogaert, A. (2004). Asexuality: Prevalence and associated factors in a national probability sample. The Journal of Sex Research, 41(3), 279–287. doi:10.1080/00224490409552235). This dynamic can offer valuable insight into how emotional intimacy and connectivity can be facilitated with or without sexual desire being present.
By incorporating asexuality into a definition of sexual health, the importance of cultural competence when working with asexuals is stressed, facilitating sexual health professionals to seek out and gain knowledge about the asexual community. A culturally competent professional should recognize the difference between a sexual desire disorder and the asexual orientation. This distinction can be the difference between asexual people feeling comfortable entering therapy for any reason and accepted by the clinician.
Conclusion and recommendations
The inclusion of asexuality in the definition of sexual health can provide numerous benefits and insights into how sexual health is defined for both asexual and sexual people. As previously stated, the exclusion of asexual people from the working definition demonstrates a lack of understanding and consideration for the wide berth of sexualities. Recognizing that asexual people can maintain a healthy sexual life with or without sexual desire being present allows for a more nuanced and inclusive discussion about the role of sexual desire in sexual health. Ultimately, by providing space for asexual people within the sexual health definition, a community far too often overlooked is able to be recognized and respected.
As we continue to address the definition of sexual health, it will be helpful to expand the construct to include diversity in terms of gender, orientation, preference, and identity. The following questions may be helpful to encourage the advancement of sexual health in the association, consulting room, and community. Our goals are reflective practice and equity.
1. How does one define a constantly changing construct such as sexuality?
2. Within the current construct of sexuality, does sexual desire have to exist in order for intimacy and connectedness to be present within a relationship? And if so, does this reflect a personal bias or a necessary component to connection in the context of said relationship?
3. Does the thought that an individual can exist absent of sexual desire while still engaging in meaningful intimate connected relationship pose a threat to the field of sex therapy?
4. What are unique elements of sexual health for asexual people, that may be distinct from sexual people?
5. How can sexual health professionals develop cultural competence to better work with the asexual community?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-V). Arlington, VA: Author.
Asexual Visibility and Education Network (AVEN). (n.d.). Overview. Retrieved from https://www.asexuality.org/?q=overview.html
Bogaert, A. (2004). Asexuality: Prevalence and associated factors in a national probability sample. The Journal of Sex Research, 41(3), 279–287. doi:10.1080/00224490409552235
Bogaert, A. (2015). Asexuality: What it is and why it matters. The Journal of Sex Research, 52(4), 362–379. Retrieved from. doi:10.1080/00224499.2015.1015713
Brotto, L., & Yule, A. (2017). Asexuality: Sexual orientation, paraphilia, sexual dysfunction, or none of the above? Archives of Sexual Behavior, 46(3), 619–627. doi:10.1007/s10508-016-0802-7
Gressgård, R. (2012). Asexuality: From pathology to identity and beyond. Psychology & Sexuality, 4(2), 179–192. doi:10.1080/19419899.2013.774166.[Taylor & Francis Online], ,
MacInnis, C., & Hodson, G. (2012). Intergroup bias toward “Group X”: Evidence of prejudice, dehumanization, avoidance, and discrimination against asexuals. Group Processes & Intergroup Relations, 15(6), 725–743. Retrieved from. doi:10.1177/1368430212442419
Southern, S. (2017). Editorial. Sexual Addiction and Compulsivity, 24(4), 241. doi:10.1080/10720162.2017.1408999
Southern, S. (2018, in press). Recent perspectives on sexual health. Sexual Addiction and Compulsivity, 25(1), in press.
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