Psychology & Sexuality
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Why is absent/low sexual desire a mental disorder
(except when patients identify as asexual)?
Leslie Margolin
To cite this article: Leslie Margolin (2023) Why is absent/low sexual desire a mental disorder
(except when patients identify as asexual)?, Psychology & Sexuality, 14:4, 720-733, DOI:
10.1080/19419899.2023.2193575
To link to this article: https://doi.org/10.1080/19419899.2023.2193575
© 2023 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 28 Mar 2023.
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PSYCHOLOGY & SEXUALITY
2023, VOL. 14, NO. 4, 720–733
https://doi.org/10.1080/19419899.2023.2193575
Why is absent/low sexual desire a mental disorder (except when
patients identify as asexual)?
Leslie Margolin
Department of Counselor Education, University of Iowa, Iowa City, IA, USA
ABSTRACT
ARTICLE HISTORY
This analytic essay challenges the psychiatric practice of treating absent/
low sexual interest/desire/arousal as a mental disorder. It does so by
calling attention to the fact that asexuality is treated differently than
other non-heterosexual orientations. The current DSM contains no psy­
chiatric diagnosis which has, as its primary symptom, same-sex sexual
desire. Yet, the same DSM offers diagnoses such as male hypoactive sexual
desire disorder and female sexual interest/arousal disorder which have, as
their primary symptom, absent/low sexual interest/desire/arousal. One of
the unfortunate consequences of treating absent/low sexual desire as
a mental disorder is that it perpetuates the false belief that those who
experience their sexuality differently than the heterosexual ‘sexusociety’
norm are less healthy and more dysfunctional. It is also troubling because
of the implied gender bias: women are more likely to experience absent/
low sexual interest/desire/arousal than men and more likely to be diag­
nosed with a sexual interest/desire/arousal disorder. Women’s sexual
desires, or the absence thereof, are, thus, more likely to be seen as
abnormal. Since that judgment has long been used to pressure women
to engage in sex they do not want, the unavoidable inference is that the
psychiatric tradition of diagnosing absent/low sexual desire as pathologi­
cal has placed, and continues to place, women at greater risk of sexual
exploitation and abuse. The remedy: stop treating absent/low sexual
desire as pathological. Recognize that people are sexually different and
are entitled to desire sex a lot, a little, or not at all—whatever feels right for
them.
Received 22 June 2022
Accepted 11 March 2023
KEYWORDS
Asexuality; sexual identity;
sexual orientation; gender;
psychiatry
The Diagnostic and Statistical Manual for Mental Disorders (APA) has consistently assumed that the
absence of sexual desire is not normative (MacNeela & Murphy, 2015; Prause & Graham, 2007,
pp. 341–342). The DSM has treated absent/low sexual desire as a pejorative – a sign of dysfunction­
ality (Cerankowski & Milks, 2010, p. 653). Heterosexual desire, by contrast, has never been treated as
inherently pathological. While homosexual desire had been defined as a mental disorder in the DSMII (American Psychiatric Association, 1968), in 1973, the members of the American Psychiatric
Association voted to remove homosexuality from their diagnostic manual. A residual diagnosis
‘sexual orientation disturbance’ was retained for those who experienced their homosexuality as
distressing. That diagnosis would go through two more name changes – from ‘homodysphilia’ to
‘homosexual conflict disorder’—until finally settling on ‘ego-dystonic homosexuality’, but that too
was dropped from the DSM in 1987 (American Psychiatric Association).
CONTACT Leslie Margolin
IA 52242, USA
leslie-margolin@uiowa.edu
Department of Counselor Education, University of Iowa, Iowa City,
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.
0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which
this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
PSYCHOLOGY & SEXUALITY
721
These diagnoses (sexual orientation disturbance, homodysphilia, homosexual conflict disorder,
and ego-dystonic homosexuality) were eliminated as part of psychiatry’s efforts to normalise homo­
sexual desire, which raises the questions: Why hasn’t psychiatry made similar efforts to normalise
absent/low sexual desire, and why has psychiatry consistently promoted the idea that absent/low
sexual desire is pathological? These questions are concerning because the sexual interest/desire
diagnosis is disproportionately assigned to women (Brotto & Velten, 2020; Krasnow & Maglio, 2019;
Laumann et al., 1999; Meston & Stanton, 2017; Shifren et al., 2008) and because individuals with
absent/low sexual desire are often denigrated as psychologically and functionally impaired
(Brunning & McKeever, 2021; Gupta, 2017a,b).
In this essay, I argue that treating absent/low sexual desire as a psychiatric symptom is wrong –
wrong whether patients identify as asexual or experience distress in relation to their absent/low
sexual desire. However, before I begin, for the sake of transparency, I first explain how I came to do
this research and take these positions.
My research primarily involves using historical materials to critically reframe contemporary
issues – what Foucault (1971, 1977b, 1977a) calls ‘genealogy’. That may explain how my discovery,
several years ago, of an article in the British Journal of Psychiatry (Cooper, 1969) launched this study.
The article from the British Journal describes how a behavioural sex therapist – a psychiatrist –
advised a husband how to deal with a wife who found intercourse profoundly unappealing. The
psychiatrist suggested that the husband use force: he advised him to rape his wife. This surprising
discovery prompted me to explore mental health journals from the Victorian era to the present to
see if there were more articles like this. I found there were: many case studies depicting psychiatrists
and other mental health practitioners pressuring sexually reluctant wives and girlfriends, as part of
their treatment, to have sex with their presumably normal male partners (Margolin, 2021a, 2021b).
These studies helped me understand that treating absent/low sexual desire as a psychiatric disorder
had been, and continues to be, an unrecognised form of oppression, particularly the oppression of
women.
My second reason for undertaking this research has to do with my background in Freudian
psychology. In the 1970s, I trained at a psychoanalytic institute and for years was a passionate
follower of Freud. But as time passed, that passion dissolved, except, that is, for one Freudian tenet:
the belief that everyone is sexual, the idea that psychological normality is contingent on sexual
desire. That belief eventually dissolved too, not only because of the historical evidence that
individuals with absent/low sexual desire are oppressed, but because of my experience teaching
human sexuality, where many students came out to me and my classes as asexual. My students
prompted me to study asexuality and to gather evidence for a formal repudiation of Freud’s (and my
former) belief in the importance – the necessity – of sexual desire.
Asexual identity
The DSM-II (1968, American Psychiatric Association) defined homosexuality as a disorder in which
individuals’ sexual interests are ‘directed primarily towards objects other than people of the opposite
sex, towards sexual acts not usually associated with coitus’ (p. 44). Homosexual pathology, in other
words, was to be diagnosed on behavioural evidence alone – strictly on the presence or absence of
same-sex sexual interest and activity. That changed in 1973, when members of the American
Psychiatric Association voted to drop homosexuality from its list of psychiatric disorders, replacing
it with ‘sexual orientation disturbance’ later called ‘ego-dystonic homosexuality’, a psychiatric dis­
order defined less by behavioural evidence than by the incompatibility between the individual’s
sexual identity and their same-sex interests/desires/arousal. To illustrate how this kind of incompat­
ibility should figure into the diagnostic process, the American Psychiatric Association published
a case study of a 23-year-old schoolteacher diagnosed with ego-dystonic homosexuality who
rejected his homosexual interests and desires: ‘Now, although he has not yet had any overt
homosexual experience, he is constantly preoccupied with a physical desire for homosexual contact.
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L. MARGOLIN
Yet, in a social sense, he is repulsed by the idea, finds it totally shameful and unacceptable to his
social and cultural goals’ (DSM-III Case Book, Spitzer et al., 1981, p. 82). While this case study does not
describe the patient’s sexual identity as either homosexual or heterosexual, it does emphasise the
misalignment between his sexual desires and self-image – his belief that homosexuality represents
behaviours totally at odds with the ways he imagines himself navigating his life.
We can see a similar concern with the issue of alignment/misalignment between sexual desire
and sexual identity in contemporary psychiatry as represented by the DSM-5 and DSM-5-TR
(American Psychiatric Association, 2013, 2022), but unlike the psychiatry represented by the DSMIII (1980, American Psychiatric Association) which was concerned with how well an individual’s samesex sexual desire aligns with their homosexual identity, contemporary psychiatry is concerned with
how well an individual’s absent/low sexual desire aligns with their asexual identity. According to the
current DSM, ‘self-identified asexuals’ and those who experience a ‘lifelong lack of sexual desire’ are
normal – they should not be diagnosed with a mental disorder – relative to ego-dystonic asexuals,
individuals who experience absent/low sexual desire but who do not identify as lifelong asexuals.
This is consistent with the Asexuality Visibility and Education Network’s (AVEN’s) policy that only
individuals can decide for themselves whether they are asexual. In the words of AVEN’s FAQ: ‘Only
you can decide to use asexual as a label for yourself’. Thus, those who seek psychiatric treatment to
‘cure’ themselves of their absent or weak sexual interest/desire/arousal – those who do not identify
as asexual – fall outside the asexual umbrella.
Distinguishing between asexuality (the sexual orientation) and absent/low sexual desire (the
symptom of pathology) represents progress, according to several scholars and clinicians, because: (1)
absent/low sexual desire is changeable and treatable when occurring among individuals who do not
identify as asexual, but not so among self-identified asexual people (Bogaert, 2006, 2008; Gupta,
2017a); (2) those who identify as asexual, unlike individuals with absent/low sexual interest/desire
who do not so identify, do not experience their absent/low sexual interest/desire as distressing
(Brotto & Yule, 2011; Brotto et al., 2010, 2015; Prause & Graham, 2007); (3) self-identified asexual
people favour maintaining psychiatric diagnoses for those with absent/low sexual desire who do not
identify as asexual; they believe the latter may benefit from treatment (Gupta, 2017b); and (4)
distinguishing between self-identified asexual people and those with absent/low sexual desire
who do not so identify is a method of establishing the legitimacy of asexuality – a method of
‘encouraging people to think about asexuality as a sexual orientation, thereby encouraging people
to think about asexuality with terms similar to other non-heterosexual sexual orientations . . . ’. It is
a method of encouraging people to think about asexuality in terms ‘such as the importance of
acceptance, understanding, respect, not assuming pathology, not trying to change orientations, etc’.
(Hinderliter, 2013, p. 172).
The two-tiered classification system, which treats self-identified asexual people as normal and
others with absent/low sexual desire as mentally disordered may seem like progress to some, but it
has a serious downside. The main problem is that while it appears to support the normality of selfidentified asexual people, it also rejects the normality of those who do not identify as asexual, even
though the latter may score similarly low on sexual interest/desire. By implication, under this
classification system, other marginalised sexual identities on the ace spectrum who may have low
sexual desire but do not identify as asexual (e.g. demisexuals) could be seen as mentally disordered.
By the logic of DSM, clinicians may feel obligated to pathologize opposite-sex desire if their
patient does not identify as heterosexual. But so far, concern over the alignment/misalignment
between an individual’s sexual desires and their sexual identity has only been used to pathologize
sexual minorities: first with ego-dystonic homosexuality (people with same-sex desire who do not
identify as homosexual) and now with ego-dystonic asexuality (people with absent/low desire who
do not identify as asexual). Consider the wording in both the DSM-5 (2013) and DSM-5-TR (2022): ‘If
the man’s low desire is explained by self-identification as an asexual, then a diagnosis of male
hypoactive sexual desire disorder is not made’ (pp. 443, 501). That can be translated to mean: ‘If
a man’s low desire is not explained by self-identification as an asexual, then a diagnosis of hypoactive
PSYCHOLOGY & SEXUALITY
723
sexual desire disorder is made’. Similarly, for women, ‘If a lifelong lack of sexual desire is better
explained by one’s self-identification as “asexual”, then a diagnosis of female sexual interest/arousal
disorder would not be made’ (pp. 434, 490). To translate: ‘If a lifelong lack of sexual desire cannot be
explained by one’s self-identification as “asexual”, then a diagnosis of female sexual interest/arousal
disorder can be made’.
A second problem with this two-tiered classification scheme is that it represents a departure from
the ways other non-heterosexual sexual orientations are understood and managed. For example, we
cannot say we are ‘encouraging people to think about asexuality as a sexual orientation with terms
similar to other non-heterosexual orientations’ (Hinderliter, 2013, p. 172), when the quality which
most defines asexuality – absent/low sexual interest/desire/arousal – is treated as pathognomonic,
as if it is the distinguishing symptom of a mental disorder. Consider that the current DSM contains no
psychiatric diagnosis which has, as its primary symptom, same-sex sexual desire; it has nothing that
says individuals who are sexually attracted to members of their own sex warrant (or should be
considered for) a psychiatric diagnosis. Yet, the same DSM offers diagnoses which have, as their
primary symptom, absent/low sexual interest/desire/arousal.
Another difference between asexuality and the other non-heterosexual sexual orientations is that
asexuality is a relatively new term. As Brunning and McKeever (2021) note, ‘many people simply
haven’t heard of asexuality or ever met anyone who identifies as asexual’ (p. 511). According to one
survey, only 25% of respondents were aware that asexual people do not experience sexual attraction
(Young, 2019). This suggests that a substantial proportion of those who experience absent/low
sexual attraction may not identify as asexual because they are uninformed. Does this mean that
these individuals are not asexual? And if they are not – if their absent/low sexual desire is defined as
pathological because they lack asexual identity – would treatment consist of helping them identify
as asexual? These questions parallel the debate over whether, before the terms ‘homosexual’,
‘heterosexual’, and ‘bisexual’ came into use, it would make sense to say there were no homosexuals,
heterosexuals, or bisexuals. Even now, it is likely that some individuals who are sexually attracted to
members of the opposite sex may not think of themselves as ‘heterosexual’ or ‘bisexual’ due to their
unfamiliarity with these terms, suggesting that the significance of asexual self-identification (and,
indeed, the significance of homosexual, bisexual, and heterosexual self-identification) is far from
clear (Mustanski et al., 2014; Wilkinson & Kitzinger, 1994, p. 310).
A related problem with using asexual self-identification as a criterion for determining the
psychiatric status of individuals with absent/low sexual desire is that asexuality is not an either/or
phenomenon. It’s not a uniform category. While Bogaert’s (2004) groundbreaking study of the
demography of asexuality defined it in absolute terms as a lifetime absence of sexual attraction ‘to
anyone at all’, more recent studies have treated it as a phenomenon that occurs on a spectrum, with
asexual individuals experiencing a range of romantic and sexual feelings which differ both quantita­
tively and qualitatively (Brotto et al., 2010; Dawson et al., 2016; Haefner & Plante, 2015; Van
Houdenhove et al., 2014; Vares, 2017). For Chasin (2011), this diversity suggests that ‘it makes
more sense to think of asexual as a meta-category, just like sexual, encompassing the same kind of
smaller categories’ (p. 721). It also suggests that individuals who experience absent/low sexual
interest/desire but who do not identify as asexual should not be denied a place in the asexual metacategory. Lastly, it suggests that a person’s ‘lifelong lack of sexual desire’, as specified in the current
DSM, should not be regarded as a more legitimate measure of asexuality than lack of sexual desire
which is briefer and more situational, especially in light of research which finds that asexuality, like
other sexual orientations, can change over time (Cranney, 2016). To say otherwise – to say that
a person who identifies with lifelong asexuality is more genuinely asexual than other asexual types –
suggests that asexuality is an essential attribute that does not vary across history and culture (Cowan
& LeBlanc, 2018, p. 32). To say self-identification as asexual is fixed, or should be fixed, overlooks the
fact that there is little in theory or experience to support the judgement that it is easy for people to
attain objective self-knowledge – to know the truth about themselves. As philosopher Harry
G. Frankfurt (2005, pp. 66–67) opined, ‘Facts about ourselves are not peculiarly solid and resistant
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L. MARGOLIN
to sceptical dissolution. Our natures are, indeed, elusively insubstantial – notoriously less stable and
less inherent than the nature of other things’.
Asexual distress
After ego-dystonic homosexuality was dropped from the DSM, the only sexual orientation that
continued to be treated as a mental disorder is asexuality in the form of ego-dystonic
asexuality. This is not because the DSM has ever contained a diagnosis titled ‘ego-dystonic
asexuality’, but rather because the DSM-5 (p. 433) and DSM-5-TR (p. 489) maintain that
individuals who are distressed over a substantial period of time about their ‘absent/reduced
interest in sexual activity’ and ‘absent/reduced sexual/erotic thoughts or fantasies’ can be
diagnosed with a psychiatric disorder. In other words, according to the DSM-5 and DSM-5-TR,
the disorder comes, not from individuals’ lack of sexual interest per se, but from the fact that
they are deeply uncomfortable (distressed) about their lack of sexual interest – it feels egodystonic – and they want it to change. Following the DSM-5 and DSM-5-TR, then, those who
feel clinically significant distress over their absent/low interest in sex, much like those who felt
distress over their same-sex attraction between the years 1973 and 1987, can be diagnosed as
mentally disordered.
Certainly, there are individuals with absent/low sexual desire who do not identify as asexual and
for whom absent/low sex drive constitutes a problem – it feels distressful. But that does not make it
a mental disorder. Jack Drescher (2015) and several other psychiatrists (Cabaj, 2009) have argued
that using distress as a primary criterion for ego-dystonic homosexuality, or, indeed, as a primary
criterion for any other psychiatric diagnosis, makes little sense because it opens up endless possi­
bilities for creating new psychiatric disorders: ‘“Should people of colour unhappy about their race be
considered mentally ill”? What about short people unhappy about their height? Why not egodystonic masturbation’? (Drescher, 2015, p. 571).
Apart from the seeming absurdity of labelling some human conditions psychiatric disorders
based on their association with distress, the American Psychiatric Association removed the
ego-dystonic homosexuality diagnosis from the DSM for three main reasons: (1) the lack of
evidence that psychiatric treatment can change a person’s sexual orientation, (2) the growing
evidence that attempting to change a person’s sexual orientation is psychologically harmful,
and (3) the idea that when homosexuals grow up in a homonegative society, as ours is, ‘egodystonia, or a period of finding out you’re gay and wishing you weren’t, is quite normal’
(Cabaj, 2009, p. 91). As psychiatrist Judd Marmor (1980) explained, ‘In a society . . . where
homosexuals are uniformly treated with disparagement or contempt – to say nothing about
outright hostility – it would be surprising indeed if substantial numbers of them did not suffer
from impaired self-image and some degree of unhappiness with their marginalised status’
(p. 400).
Many people who belong to a sexual minority feel distress at some point in their lives due to
discrimination. Asexuality is no exception. In a society where those who do not desire sex are treated
with disparagement or contempt – where they are rated as less human and less valuable than
heterosexuals and other sexual minorities who do desire sex (MacInnis & Hodson, 2012)—it would be
surprising indeed if substantial numbers of them did not suffer from elevated distress. In other
words, distress among individuals with absent/low sexual interest/desire should not be treated as
the deciding factor in diagnosing them as mentally disordered given their position in what Ela
Przybylo (2011) calls ‘sexusociety’, a virulent pro-sex culture preoccupied with sexual deeds, desires,
and thoughts, where, in Dworkin’s (1985) words, ‘there is the nearly universal conviction . . . that sex
(fucking) is good and that liking it is right: morally right; a sign of human health; nearly a standard of
citizenship’ (p. 59).
In sexusociety, where everyone is presumed to be sexual, those who deny sexual interest/activity
are often seen as fraudulent or sick or both. To illustrate, Przybylo (2011) provided the example of
PSYCHOLOGY & SEXUALITY
725
how David Jay, the founder of AVEN, was treated on the ABC talk show, The View. On the one hand,
the show’s host, Joy Behar, found it hard to accept that David Jay, or anyone else, could identify as
asexual. How is it possible, she asked, if ‘[w]e are, by nature, sexual beings?’ On the other hand, Behar
suggested that asexuals such as David Jay must have something to hide:
But maybe it’s repressed sexuality rather than, you know, that you’re just like a normal guy walking around.
Maybe it’s repressed because you don’t want to face what the sexuality might look like. Could that be? Lie down.
Just lie down. That will be a hundred dollars [Laughs from audience] . . . Because if you were having sex with
yourself, excuse me one more question, that would mean that you had sexual feelings . . . . I am trying to get to
the bottom of this . . . . So what are you just lazy or what? . . . But how does that work? I don’t get this. A guy.
I could see for a woman. But you? (David Jay, quoted in Przybylo, p. 450.)
The disbelief and cynicism directed at David Jay represents what Miranda Fricker (2007) calls
‘epistemic injustice’, a form of discrimination in which members of a marginalised group are denied
the capacity to define who they are – a microaggression in which individuals are rendered less
credible than others, less conscious and self-aware. As we will see, epistemic injustice and three other
interrelated disadvantages (social isolation, romantic/sexual conflict, and pathologization) are often
associated with absent/low sexual desire. While these disadvantages are no more essential to
asexuality than homonegativity/homophobia is essential to homosexuality, examining how they
correlate with asexuality not only reveals how many individuals who share this trait come to
experience elevated distress, but also how it makes little sense to classify them as mentally
disordered for this reason.
Epistemic Injustice. Several researchers (Brunning & McKeever, 2021; Gupta, 2017a; Robbins et al.,
2016) have found that epistemic injustice endures as a routine part of asexual people’s lives because
when coming out, they are often silenced, judged, and patronised. They are often asked, ‘How do
you know you don’t like it if you haven’t tried it?’ (Carrigan, 2012). Or they are told that their
asexuality is merely a phase, a reflection of their social immaturity, a condition they’ll grow out of
(Cerankowski & Milks, 2010; Dawson et al., 2016): ‘You just haven’t met the right guy yet. When you
meet the right man everything will work out and you’ll enjoy having sex’ (Robbins et al., 2016, p. 756).
As one participant in MacNeela and Murphy’s (2015) study summed up, ‘Most of the time, people
find a way to dismiss asexuality so that they can continue to claim that all human beings are
fundamentally sexual creatures’ (p. 803).
Anticipating that disclosure of their sexual orientation will be met with bafflement and will be
seen as bizarre (MacNeela & Murphy, 2015), many asexual people choose to remain in the closet. As
one explained, ‘I have not come out to anyone . . . because I do not think there is very much
acceptance of asexuality as a valid sexual orientation. I am afraid that my friends would think
there is something wrong with me . . . ’. (Robbins et al., 2016, p. 755). That psychiatrists and other
mental health professional operate as if there is something wrong with individuals who say they
experience little or no desire for sex – that they treat low/absent sexual desire as a mental disorder –
represents another expression of epistemic injustice (Fricker, 2007).
Social Isolation. Asexual people’s anxiety over coming out increases the likelihood that they will
keep their sexual identity to themselves, creating a barrier between them and others, including close
friends and family members (Gupta, 2017a). That barrier – that experience of involuntary social
isolation – represents another possible source of distress. Because asexual people are at heightened
risk of social isolation, they are at heightened risk of going without a support network of people who
can understand who they are and what they are going through (MacNeela & Murphy, 2015, p. 804).
They are more likely to be excluded from conversations about sex and from social activities, such as
parties, where the goal is to find a sexual partner. And because asexual people are rarely represented
in books, movies, and TV – because there are few characters who openly identify in as asexual in
popular culture – they often wonder whether they will ever be able to form the kinds of close human
connections that non-asexuals have, the kinds that get talked about, celebrated, and prioritised (Jay,
2015).
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Romantic/Sexual Conflict. Most asexual people seek companionship in romantic relationships that
do not involve sexual activity (Brotto et al., 2010, p. 610), but they often have difficulty finding such
relationships. This is largely because asexual people represent a small minority, so small it can be
quite a challenge to find a suitable partner in the limited pool of candidates. As a result, asexual
people may feel their romantic lives have been effectively reduced to two choices: either give up the
‘dating game’ entirely or settle for a non-asexual partner. Consider how a research subject from an
article on asexual dating framed the problem:
Like it gets quite lonely, if you know what I mean and [. . .] I’ve been on Tinder and things like that but it’s difficult
to be in the dating game and try and be in a relationship when [. . .] you want to find a partner and not have sex
with them because everybody, I just feel like everybody, is out for it, pretty much (Vares, 2017, p. 524).
Because it is so hard to find a partner who wants a romantic relationship but does not want sex,
asexual people often mismatch with partners who want a degree of sexual interest/activity that
exceeds their comfort level. This results in several possible kinds of distress. One is fear that when the
asexual person comes out to their non-asexual partner, the relationship will end (Van Houdenhove
et al., 2014). Another is that the non-asexual partner will pressure the asexual partner to seek
treatment for what is presumed to be their sexual problem (Gupta, 2017a). A third is that the
asexual’s partner will demand more sexual interest/activity than the asexual partner is capable of
feeling or giving (Van Houdenhove, et al., 2015, p. 270): the non-asexual partner may nag or threaten,
or even use physical force such as ‘corrective rape’ (Mosbergen, 2013). This may explain why women
with low sexual desire who are partnered with men report significantly higher levels of distress, as
much as 4.63 times higher, than women who are single (Shifren et al., 2008).
The pressure to engage in unwanted sex in a pro-sex society can also come from asexual people
themselves; it can be self-imposed, as when they believe their partner won’t like/love them if they
don’t feign sexual interest or make some other kind of accommodation to meet their partner’s sexual
needs (Fahs, 2010). They may feel it’s their duty to have sex – it’s what they signed up for in having
the relationship – even if the sex is unwanted. The diagnostic problem here is, how can we say that
these self-imposed efforts to perform unwanted/undesired sexual acts reflect mental health issues:
‘how do we disentangle women’s distress about desire from political and interpersonal pressures to
project and enact a socially desirable sexual self?’ (Thomas & Gurevich, 2021, p. 91).
This is how one asexual woman explained why she consented to unwanted sex with her
boyfriend:
The guy I lost my virginity to, I had been in a relationship with him for about a year and I guess I just felt like, well,
you know, I need to do this . . . . I should have said no, but I didn’t. I thought that this is what everybody did in
their free time, and so I was trying to be like everybody else (Gupta, 2017a, p. 998).
Dawson et al. (2016) correctly assert that consenting to unwanted sex is not unique to asexual
people since all couples, to one degree or another, make accommodations for their sexual partners.
At the same time, it is important to acknowledge that not all sexual accommodations are equal.
Some are significantly less tolerable than others: when, for example, going along with unwanted sex
does not feel like a choice – when it feels like something you must do or else—a mode of
accommodation particularly common among women (Gavey, 2005, p. 136; Impett & Peplau, 2003),
which may explain why women are more likely to fake sexual arousal and orgasm (Fahs, 2011;
Muehlenhard & Shippee, 2010; Wiederman, 1997), tolerate sexual pain (Elmerstig et al., 2008); and
prioritise a partner’s pleasure over their own (Elmerstig et al., 2013; McClelland, 2011; Nicholson &
Burr, 2003).
Pathologization. This source of distress can be traced back to the first half of the twentieth century
when mental health professionals began to promulgate the idea that everyone has an omnipresent
and innate need for sex, and that those who do not express that need – those who deny, repress, or
suppress their libido – are neurotic and require treatment (Freud, 1905/1962), an idea that continues
to have great deal of currency. So that when Erik, a participant in Haefner and Plante’s (2015) study of
PSYCHOLOGY & SEXUALITY
727
asexuality, came out to his family, their reaction, ‘You should see a shrink. That can’t be normal’, not
only pathologized and invalidated him, it also, presumably, increased his sense of social isolation
(p. 280). To compound the problem, according to a study by Foster and Sherrer (2014), when asexual
people go to mental health professionals for help, they anticipate that the professionals will reflect
the same cultural bias: the belief that everyone is (and should be) sexual; they anticipate that
professionals will see them as psychologically impaired and will attempt to treat their asexuality
with some kind of intrusive, unwarranted therapy. Thus, one self-identified asexual person wrote, ‘It
seems like therapists might be more interested in “fixing” my asexuality rather than just allowing me
to explain how I feel’ (Foster & Sherrer, 2014, p. 426).
To summarise, if people with low/absent sexual desire are more likely to be silenced, excluded,
misrepresented, and denigrated because of their sexuality – if they are more subject to negative
judgement – they can be expected to experience more distress. Their distress, then, should not be
seen as a sign of psychiatric dysfunction. It should be seen as a sign of social dysfunction – a sign of
undue cultural, political, and interpersonal discrimination.
A presumption of pathology
Psychiatry has long promoted the idea that people with absent/low sexual interest/desire/arousal
are mentally disordered whether they experience distress or self-identify as asexual. This section
illustrates how this bias against absent/low sexual desire operates by examining two case studies –
the only case studies – published by the American Psychiatric Association to serve as guides in
diagnosing absent/low sexual interest/desire/arousal.
Case Example 1. This case study was originally published in the APA’s DSM-III Case Book: A Learning
Companion to the Diagnostic and Statistical Manual in 1981 (Spitzer et al.), and was reproduced, word
for word, in the 1989 DSM-III-R Case Book (Spitzer et al.), the 1994 DSM-IV Case Book (Spitzer et al.), the
2002 DSM-IV-TR Case Book, and the fifth edition of Comer’s Abnormal Psychology (2003). The case
study concerns a married couple, Mr. B. and Ms. B., who ‘presents with the complaint that Ms. B. has
been able to participate passively in sex “as a duty” but has never enjoyed it since they have been
married’ (2002, p. 251). What should be noticed about this case study is that it consists almost
entirely of a listing of the many ways that Ms. B. is indifferent to and/or repulsed by sex:
Although she periodically passively complied with intercourse, she had almost no
spontaneous desire for sex. She never masturbated, had never reached orgasm,
thought all variations such as oral sex as completely repulsive, and was
preoccupied with a fantasy of how disapproving her family would be if she ever
engaged in any of these activities (2002, p. 251).
The information contained in this excerpt – the documentation of Ms. B’.s negative feelings about
sex – was the only information factored into her psychiatric diagnosis. Thus, the case study
concluded, ‘The persistent absence of sexual fantasies and desire for sexual activity justify the
diagnosis of Hypoactive Sexual Desire Disorder . . . . When she does have sexual intercourse, she
probably does not become sexually excited, so the additional diagnosis [should be considered] of
Female Sexual Arousal Disorder’ (2002, p. 252).
The most noteworthy feature of this case study is that it includes no information on (or inquiry
into) how disliking sex impairs Ms. B.’s mental or social functioning. The case study simply assumes
that absent/low sexual desire represents an abnormal behaviour variant and contains no discussion
of how disliking sex increases Ms. B.’s distress or keeps her from performing life-enhancing activities
outside of sex. And, despite the evidence of friction between Mr. B. and Ms. B. around the topic of sex
(‘Her husband, although extraordinarily tolerant of the situation, is in fact very unhappy about their
sex life’), at no point does the case study reflect the possibility that Ms. B.’s negative feelings about
sex arise from the ways she and her husband interact. Was M. B. a difficult sex partner? Was he
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sexually inconsiderate or offensive in some ways? While Thomas and Gurevich (2021) argue that ‘It is
important to consider whether low interest and arousal cause decreased satisfaction or whether less
satisfying relationships lead to decreased interest and arousal’ (p. 83), the case study fails to
acknowledge those distinctions. At no point does the case study reflect the possibility that Ms. B.’s
unsatisfying relationship with her husband or with anyone else may have limited her capacity to
enjoy sex. All that appeared to matter, in determining Ms. B.’s psychiatric diagnosis, is the absence of
sexual interest/desire/arousal.
Case Example 2. This case study was published in the APA’s DSM-5: Clinical Case Studies (2014) and
features an engaged couple, Ms. Olsen and Mr. Nelson, who have been bickering over the frequency
of sexual activity. According to Ms. Olsen, her fiancé’s sexual needs are excessive: he wants sex every
time they get together, often twice in the same night. On the other hand, he complains that she
needs to get drunk before she can tolerate intercourse. Try as he might, nothing he does succeeds in
bringing her to orgasm or arousing her sexually.
The case study concludes that Ms. Olsen does not meet the DSM-5 guidelines for female sexual
interest/arousal disorder or female orgasmic disorder because, on the one hand, she has never
enjoyed sex (‘her sexual issues have been lifelong, as opposed to acquired’) and because, on the
other hand, ‘all these diagnoses’, according to the DSM-5, ‘require distress’ (Graham, 2014, p. 232).
Mr. Nelson may feel unhappy about Ms. Olsen’s lack of sexual interest, but she does not. She appears
to accept her status as a person with absent/low sexual interest – it feels ego-syntonic to her – and
thus does not meet the DSM-5 threshold for a mental disorder. From a feminist perspective, this
looks like progress. Ms. Olsen’s absent/low sexuality did not seem to warrant a psychiatric diagnosis.
Her partner’s complaint was not treated as the final word on how to judge her sexuality.
At the same time, it is important to consider that while Ms. Olsen never complained about her
own sexuality, the case study’s author always treated her sexuality as questionable or marginal.
Indeed, the entire case study was devoted to sifting through the available evidence to confirm or
disconfirm the possibility that Ms. Olsen suffers from ‘female sexual/interest/arousal disorder’. She
was always treated as potentially dysfunctional/mentally disordered. While Ms. Olsen appeared to
have had as many complaints about her fiancé’s sexuality as he had about hers, only she was
considered for a psychiatric diagnosis.
From a diagnostic perspective, the most obvious issues surround Ms. Olsen . . . .
Looking at her issues from a DSM-5 perspective, Ms. Olsen has diminished
interest in sexual activities and reduced enjoyment of sex, which indicates the
possibility of female sexual interest/arousal disorder. She also does not
experience orgasm during sexual activity, which could indicate the possibility of
female sexual interest/arousal disorder (Graham, p. 232).
Consistent with the way psychiatry has assessed absent/low sexual desire for the past century, in this
instance, the absence of sexual desire was treated only as a pejorative – as a sign of dysfunctionality.
Mr. Nelson, the individual who wants sex every night and sometimes twice a night, was considered
normal from the outset. His sexual behaviour was never questioned as a possible sign of a mental
disorder, while the sexual behaviour of the one who found his sexual demands excessive and
objectionable was treated as highly suspicious, requiring close psychiatric scrutiny.
Discussion
Psychiatry, as represented by the DSM-5 and DSM-5-TR, now accepts absent/low sexual interest/
desire/arousal as normal when it occurs among individuals who identify as asexual. It also accepts
absent/low sexual interest/desire/arousal as normal among individuals who, like Ms. Nelson, do not
express dissatisfaction/distress about their sexuality. What remains unclear is why psychiatry
PSYCHOLOGY & SEXUALITY
729
continues to consider absent/low sexual interest/desire/arousal as an indicator of treatable abnorm­
ality in individuals who express dissatisfaction/distress and do not identify as asexual.
To be sure, psychiatrists and psychologists have long assumed that sexual desire can be
influenced by psychotherapy (see Hitschmann & Bergler, 1936, Frigidity in Women: Its
Characteristics and Treatment). Nonetheless, mental health professionals recognise that efforts
to change an individual’s sexual orientation or implant sexual desire through psychotherapy
have little or no scientific foundation (Haldeman, 1994). Even Masters and Johnson (1976),
founders of the sex therapy discipline, asserted that the reflex pathways of sexual interest/
desire/arousal are innate and cannot be instilled or taught: ‘This is like believing that we can
be taught how to sweat or make our hearts beat’ (p. 549). Similarly, Brotto and Luria (2014) found
little scientific basis for attempting to treat sexual desire: ‘Although the nonpharmacological
treatments such as sensate focus, CBT, and mindfulness skills have a long history, evidence of
their efficacy in the scientific literature is minimal’ (p. 35). Ter Kuile et al.’s (2012) assessment of
the knowledge base for treating sexual interest/desire/arousal problems is even more guarded.
Citing the almost complete absence of controlled outcome studies, randomised trials, and single
subject and group experimental designs, the authors concluded there are no evidence-based
psychological interventions for treating disorders of sexual desire (p. 421). Why, then, do
psychiatrists and other mental health professionals continue to regard absent/low sexual inter­
est/desire/arousal as a treatable mental disorder, particularly when assessing women’s sexual
health?
One answer is that it represents a tradition – a time-honoured theoretical and clinical bias. Since
Freud, mental health professionals have regarded sexual experience as natural, necessary, and
healthful, and those who abstain, either because they lack interest, find sex aversive, or cannot
become aroused, have been defined as either physically ill or psychologically repressed. As Flore
(2014, p. 17) put it, ‘At the heart of scientific research and documentation of human sexuality is the
presumption of a hidden, yet discoverable innate sexual desire . . . . Hence those individuals whose
sexualities or absence thereof, do not fit into a scientific model of sexual normalcy appear in
psychiatric frameworks . . . as disordered and pathological’.
A second reason why absent/low sexual desire continues to be regarded as a treatable psychiatric
disorder, despite scientific evidence to the contrary, is that many people – particularly women –
identify, and are identified, with it. It is a problem for which there is no shortage of clientele, with an
estimated prevalence rate among women of thirty to fifty-five percent (Krasnow & Maglio, 2019). As
Brotto and Velten (2020) explain, ‘A lack of interest in sexual activity that creates personal distress
and strains relationship satisfaction is the most common reason women seek sex therapy’ (p. 14).
While women are much more likely than men to see a therapist for absent/low sexual interest/desire/
arousal, it is important to consider that they do so, only rarely, when single. According to Both et al.
(2017), ‘Usually the complaint comes from women in a steady [heterosexual] relationship and is
related to differences in sexual desire between her and her partner’ (p. 12). Apparently, heterosexual
women who seek help with absent/low sexual desire feel obligated to coordinate their sexual needs
and responses to those of their male partner. This is consistent with the DSM-5’s and DSM-5-TR’s
(pp. 433, 489) stance that a woman’s lack of sexual responsiveness – the fact that she is ‘typically
unreceptive to a partner’s attempts to initiate’ sex – should be seen as a reason for diagnosing her
with ‘female sexual interest/arousal disorder’. By contrast, neither the DSM-5 or DSM-5-TR assume
that a man’s lack of sexual ‘receptivity’ or ‘responsiveness’ should be seen as a sign of pathology.
Women’s sexual normality, according to these guidelines, thus derives from their willingness to
respond to their partner’s sexual demands, but men’s sexual normality does not.
We can see how this gender bias operates in clinical practice: in studies of sex therapy involving
couples who show a discrepancy in sexual interest (where one partner wants more sex and the other
less), therapists typically affirm men’s right to abstain from sex with their female partner but do not
extend that right to heterosexual women seeking to abstain from sex. Instead, sex therapists often
pressure women to be responsive/receptive to men’s sexual needs. The psychiatric stance which
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measures a woman’s sexual health by how receptive she is to her partner’s sexual needs may not
have been designed to extort women’s sexual conformity, but that may be how it works. Therapists
seem to assume that it is reasonable to ask a woman who shows little or no interest in sex to adjust to
her male partner’s sexual expectations (Margolin, 2021a, 2021b).
Why does psychiatry and other mental health professions continue to treat absent/low sexual
desire as a mental disorder, especially when the presumed disorder concerns women’s lack of desire?
Leonore Tiefer (2002) provides one possible answer: ‘I think one can make a compelling argument
that the main outcome has been to preserve “expert” authority over the new sexual opportunities
being constructed by modern changes in gender, worklife, leisure and the self (cf. Cushman, 1995),
and that medicalisation serves primarily to benefit practitioners and medical industries’ (p. 128).
Hare-Mustin and Marecek (1990) provide another possible answer: ‘As long as male behaviour
remains the standard in culture, women’s differences from men will be regarded as deficiencies’
(p. 14). To redefine asexuality as a normal psychological variant – to say that, other things being
equal, among heterosexual couples, the partner who does not want sex is no less healthy and no
more mentally disordered than the partner who wants sex – would require a potentially radical break
in the way women’s and men’s sexual obligations and privileges are defined. In sex, like other
domains of life in which men set the standard, more often than not, women are judged normal to the
degree they match men’s expectations.
Conclusion
This historical comparison between how psychiatry has treated same-sex sexual desire and how it
has treated absent/low sexual desire reveals that, while same-sex interest/desire/arousal was once
seen as symptomatic of mental disorder but no longer is, absent/low sexual interest/desire/arousal
continues to be treated as a diagnosable mental disorder. This inconsistency is troubling in and of
itself but especially because it perpetuates the false belief that those who experience their sexuality
differently than the heterosexual ‘sexusociety’ norm are less healthy and more dysfunctional. It is
also troubling because of the implied gender bias. Women are more likely to experience absent/low
sexual interest/desire/arousal than men and are more likely to be diagnosed with a sexual interest/
desire/arousal disorder (Brotto & Velten; Krasnow & Maglio, 2019; Laumann et al., 1999; Meston &
Stanton, 2017; Shifren et al., 2008). Women’s sexual desires, or the absence thereof, are, thus, more
likely to be seen as abnormal. Since that judgement has long been used to pressure women to
engage in sex they do not want, the unavoidable inference is that the psychiatric tradition of
diagnosing absent/low as pathological has placed, and continues to place, women are at greater
risk of sexual exploitation and abuse.
The remedy: stop treating absent/low sexual desire as abnormal. Put to rest the Freudian myth
that someone who enjoys sex is healthier and more normal than someone who does not. Recognise
that people are sexually different and are entitled to desire sex a lot, a little, or not at all – whatever
feels right for them.
Disclosure statement
No potential conflict of interest was reported by the author.
ORCID
Leslie Margolin
http://orcid.org/0000-0001-5635-3778
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