Women Who Want to Want

I found this a very interesting article, and would like to explore some of the issues raised with any readers also interested. I must add, that I found the way the writer structures his sentences interferred with the ease with which the material was absorbed. It is still worth the read.
Kentke

November 29, 2009

By DANIEL BERGNER


At her group therapy sessions for women despairing of low sexual desire, Lori Brotto likes to pass around a plastic tub of raisins. The women, usually six to a group, sit around two pushed-together beige tables in a fluorescently lighted conference room at the British Columbia Center for Sexual Medicine in Vancouver. A little potted tree is jammed randomly in one corner. Ragged holes scar one wall where a painting used to hang. The décor doesn’t speak of sensuality. That is the job of the raisin.




Brotto asks each woman to take a single raisin from the small tub. A slender, elegant 34-year-old psychologist, a mother of two with a third child on the way, she began her career studying the libidos of rats. She is now one of the world’s leading specialists in what is known as hypoactive sexual desire disorder in women. She is in charge of defining the condition’s criteria for the next Diagnostic and Statistical Manual of Mental Disorders, commonly called the D.S.M, which the American Psychiatric Association is preparing to publish in 2012 or 2013. The book is the bible of psychiatric diseases, from autism to sleepwalking, relied on by researchers and clinicians throughout the United States and Canada. Studies suggest that around 30 percent of young and middle-aged women go through extended periods of feeling dim desire — or of feeling no wish for sex whatsoever. “Black raisins,” Brotto said, laughing at her own arbitrary preference as she described her methods. “I don’t like brown raisins or green raisins or cooked raisins.”




She handed me the script she has developed for the exercise. We sat, in August, in her orderly, compact office, with a reproduction of “The Kiss,” by Gustav Klimt, mounted above her desk. She wore a blue paisley skirt and a cream-colored blouse; her short dark hair was cut stylishly and angled close to her jaw. The couple in the painting, with the woman either bending sublimely in the man’s emphatic embrace or wincing away from his lips, floated over Brotto’s copy of the current D.S.M., which lay open to the disorder that has become her obsession.
“I’d like you to start by examining your raisin,” the script reads. “Study its shape, its contours, its folds. Touch the raisin with a finger. Look into the valleys and peaks, the highlights and dark crevasses. Lift the raisin to your lips.”




MORE THAN BY any other sexual problem — the elusiveness of orgasm, say, or pain during sex — women feel plagued by low desire. The problems often overlap, but above all the others that can thwart an erotic life, the remoteness of lust is what impels women to seek treatment. And as Brotto discusses the disorder, she is not talking about something physical. She regularly wires the genitals of her patients to a photoplethysmograph to measure whether the women respond with surges of vaginal blood flow while they watch a pornographic video. Almost always, they do.




Brotto is dealing in the domain of the mind, or in the mind’s relationship to the body, not in a problem with the body itself. Beneath Klimt’s couple, she opened yellow case folders and described the desolation and bewilderment recorded in her notes. She spoke about a woman in her 40s who, years ago, had sex with her husband as often as seven times in a day but who now, more than a decade into a marriage with this still-handsome man, cringes at the very same gesture, the very same touch to her back, that once electrified her. Two or three months might go by now without their having sex. “It’s fine for me not to have sex at all,” Brotto quoted the wife, and commented, “I hear that from a lot of women.” And yet, at the same time, the lack of libido isn’t fine at all. “What exactly is turning me off?” Brotto read the wife’s plaintive question.




Brotto talked as well about another woman in early middle age, who had no period of lust to look back on, whose sexual indifference had prevailed throughout her long — and emotionally close — marriage, just as it had with her earlier partners. She told Brotto, “I’m actually O.K. with never having sex again.” But she, too, isn’t really. She longs to feel driven, to initiate, to ignite, Brotto said, and lately the woman visited an annual sex fair in Vancouver, with its booths of erotic books and lingerie, and gave a party at her home where a saleswoman peddled sex toys; she told Brotto she hoped that such adventures, along with Brotto’s help, would transform her. “I want to have sex where I feel like I’m craving it,” Brotto quoted from yet another file, giving voice to a desperation shared by many of her patients. “I want to feel horny. I want to want.”




As she considers her cases, as she carries out related research and pores over the studies of other sexologists and as she molds criteria for the next D.S.M., Brotto is careful to keep in mind that not all women who feel erotically uncharged are desperate to change. Some may not be dismayed in the least. As is so often true in the poorly financed realm of sex research, relevant surveys are scarce, and statistics can’t be cited with much confidence. But judging by what figures exist, Brotto says, between 7 and 15 percent of all young and middle-aged women — an age range that researchers generally set between the neighborhoods of 20 and 60 — feel distressed over the absence of desire.





Next to nothing is known, she adds, about a host of basic questions, like whether most women with the condition have been affected from the start of their sexual lives or became afflicted during the course of adulthood. She estimates that the hundreds of cases she has seen are divided about equally between the two categories but laments that there are no studies to supply a solid answer. Little is established, either, about why women may be somewhat more likely to become devoid of desire as they get deeper into middle age — and even this tendency itself is far from proven and is contradicted by some data. In any event, Brotto points out, while menopausal women generally lubricate less, their genitals still respond to with rushings of blood when they sit in front of erotic videos.




Brotto speaks, as well, about how varied the experiences of her patients with low desire can be, and about the “enormous heterogeneity” of women’s sexuality in general and thus the extreme difficulty of establishing meaningful norms or outlining dysfunctions. The current D.S.M.’s criteria for hypoactive sexual desire disorder, or H.S.D.D., criteria that apply for both women and men, are nothing if not terse: “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.” That is basically it. And Brotto talks about the sense, among an array of sexologists and therapists, including herself, that this language fails to reckon with women’s complex sexual beings — that the criteria are much too simple and maybe much too male.




All of the variations and unknowns and insinuations of patriarchal perspective help make Brotto’s work on the D.S.M. more than a little fraught. But then, the chapter called “Sexual and Gender Identity Disorders” in the 900-page manual barely holds an unfraught sentence. The American Psychiatric Association has appointed a panel of 13 psychologists and psychiatrists to revise the chapter for the new edition, to be titled the D.S.M.-V; it will be the fifth version (not counting a couple of intermediary alterations) since the A.P.A. put together the original manual in 1952 and the first since 1994. The 13 have divided the conditions according to their specialties, and as they aim to improve diagnostic language, they’re shadowed by sometimes-fierce detractors who argue that certain — or all — of the chapter’s disorders should be deleted.




The section on deviant desires, to take one example, is denounced by advocates for alternative sexuality as stigmatizing those whose lusts, no matter how unusual, are harmless, or those whose erotic play, no matter how unsettling, is consensual. Should a man with a foot fetish be branded as mentally ill? Should a woman who finds ecstasy in being elaborately bound and enduring denigration or pain? Should such people be labeled with psychiatric diseases, though the rest of their lives have no serious dysfunction?





Until 1973, homosexuality was among the D.S.M.’s disorders, and critics of the present chapter point to the condemnation the volume once inflicted on gay men and lesbians — condemnation that both reflected and bolstered the prevailing cultural perspective — by way of arguing that the current manual, the D.S.M.-IV, is full of unfounded and damaging sexual judgments. Many on the panel, which probably won’t, in the end, do much in the way of deleting conditions, maintain that the chapter on sexuality and gender identity doesn’t brand people too readily with disease.





They note that, aside from exceptions like patients with pedophilia, only those who are distressed meet the threshold for diagnosis. In turn, the critics respond that such distress stems not from within the individual but from the infliction of societal standards, from the culture’s disapproval and aversion and therefore, in part, from the D.S.M. itself. This, they emphasize, was why the A.P.A. finally removed a last remnant of the homosexuality diagnosis — what was known as “ego-dystonic” homosexuality — in 1987.




Though many therapists dismiss the manual as useful for only the numbered codes they scribble on reimbursement forms, subtly the D.S.M. permeates the consciousness of the profession. The book is required reading for almost every psychologist and psychiatrist in training. It delineates the conditions studied by researchers, and it quietly underlies our comprehension of ourselves. Its disorders define norms. Brotto has been constructing an expanded set of criteria for H.S.D.D. with the awareness that she may be shaping, amid a good deal of debate, the way vast numbers of women understand their sexual selves.




Brotto’s route toward such rumination — and toward the raisin exercise — was mapped out by chance. As a first-year undergraduate at the University of British Columbia, she knew only that she wanted to do research, any sort of research, no matter the discipline. She knocked haphazardly on office doors, hoping for a professor who would have her as an assistant. None would; she was too young. “Until,” she recounted, “I found myself in the office of someone who said, ‘Sure, I’ll take you on, as long as you don’t mind watching rats have sex.’ ”




She hadn’t considered studying sex at all. “I grew up,” she told me, “in a very strict Italian Catholic don’t-talk-about-sex environment.” A silver cross hangs on a slender chain from the rearview mirror of her car. But she agreed to the professor’s offer, and under his tutelage she sat in a chamber of cages, counting the copulations of male rats as she investigated the effects of antidepressants on their libidos. As she continued on toward a doctoral degree, she steered away from animal research and toward clinical work, in part, she said plainly, “because the rat room smelled.”




Brotto’s postdoctoral training included a stint in Seattle at the University of Washington with patients suffering from borderline personality disorder, a disease of severe anxiety and distorted self-image and often of self-inflicted injury — like cutting — that expresses a desperate need to replace infinite despondence with finite pain. Her supervisor in Seattle had developed a treatment for borderline-personality patients that borrowed from the Buddhist technique of mindfulness — the keen and soothing awareness of immediate and minute experience, down to the level of breath or the beating of your heart. The supervisor saw this as a way to ground the patients in the present and to relieve their feelings of interminable torment. And Brotto, who was also working with surgically treated gynecological cancer patients on their sexual issues and frequently on feelings of depleted desire had the idea that the method might help with this problem. Women who talk about having no libido, she recalled thinking at the time, describe their disconnection and despair during sex in something of the same way borderline-personality patients talk about their entire lives. Maybe mindfulness could help draw these women away from detachment and connect them to sensation.




Brotto did a bit of experimenting on herself. Not that she suffered from any disorder, but she talks of herself sometimes in a researcher’s terms as “an n of one,” a single subject on whom she likes to test her ideas. Along with mindfulness, the treatment Brotto’s supervisor devised for borderline personality uses cognitive therapy, which stresses altering patterns of thought to transform self-image and experience.





One day at yoga class, Brotto tried the combination. She went through her usual yoga poses, but with “a cognitive reframe,” she said. She told herself, “over and over like a mantra,” that she was an especially sexual woman, “capable of a high level of desire, a high level of response.” And, she recalled, “there was a deliberate intent not only to listen to my body even more than I normally would in yoga but also to interpret the signs from my body as signs of my sexual identity. So my breathing was not just breathing through the pose; it was breathing because I was highly sexual.” Sensation and self-image became linked. She was in a particularly awkward and taxing position, bent over and balanced on one foot and one inverted hand, when she had a profound moment. It wasn’t that anything she was trying mentally was itself so stunningly new. The power of positive thought is a cliché. And the acute concentration on the sensory echoes the sex therapy practiced by Masters and Johnson in the 1960s. Yet through melding the two something revelatory occurred. Suddenly her straining muscles and racing heart were affirmations “of my sexual vigor, my sexual arousability.” She finished class with a thrilling sense of her own body, her own erotic potency.




Brotto took what she learned in treating borderline personality, including the use of raisin exercises to foster mindfulness, and what happened in yoga class, and applied it first with her gynecological cancer patients, then with a wide range of women with weak desire. Her results, published in the leading journals of sexual research, have been promising, with her subjects reporting stronger libidos and better relationships, though there are caveats: that desire isn’t easy to measure; that patients are prone to report improvement on questionnaires given by those who treat them; that almost any method that gets people to think about sex may increase their interest in having it.





Brotto is now studying the effects of her group sessions on a sample of 70 women who have or will soon gather in the stark conference room around the pair of beige tables to be led through her program of mindfulness and cognitive therapy. They are sent home with assignments — to observe their bodies in the shower and describe themselves physically in precise and neutral language, in phrases that hold no judgment; and, after another session, to repeat over and over, “My body is alive and sexual,” no matter if they believe it. They are taught about research that shows that belief doesn’t matter, that the feeling will follow the declaration. And they are instructed, in their sessions, to place the raisins in their mouths, to “notice where the tongue is, notice the saliva building up in your mouth . . . notice the trajectory of the flavor as it bursts forth, the flood of saliva, how the flavor changes from your body’s chemistry.”




This exercise is among Brotto’s ways of training patients to immerse themselves in physical sensation. One hope is that such feelings will whisper to the women of their own erotic vitality. Another is that her patients will learn to be aware of the changes in their bodies — automatic reactions similar to salivating — before or during sex. An underlying theory is that while her patients’ genitals commonly pulse with blood in response to erotic images­ or their partners’ sexual touch, their minds are so detached — distracted by work or children or worries about the way they look unclothed, or fixated on fears that their libidos are dead — as to be oblivious to their bodies’ excitement, their bodies’ messages. The skill of fully attending to sensation is essential within Brotto’s vision of women’s desire — a vision that she imparts to her groups partly by introducing a diagram called “the Basson Sexual Response Cycle,” whose circles and arrows have lately been imprinting themselves on the field of sex therapy and helping to guide Brotto’s formulations for the next D.S.M.




he minimalism of the manual’s present criteria for H.S.D.D. —“persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity” — seems to presume that the workings of desire are straightforward, that healthy sexual beings are regularly sparked by lust, that they are busy imagining, and wishing for, erotic encounters.





Meanwhile the flow chart of women’s sexual experience created by Rosemary Basson, who is Brotto’s colleague at the Center for Sexual Medicine and at the University of British Columbia, with which the center is affiliated, is complex and a bit difficult to describe. Basson, a British medical doctor who has been at the center for more than two decades, was first drawn to the field of sexuality as an internist in England. Assigned to a ward for victims of spinal-cord injuries, a floor, as she remembers it, with a steady supply of men paralyzed in motorcycle accidents, she sometimes found herself with a patient who worked up the courage to ask about how or whether he could ever have sex. She sought out a supervisor for advice and was told, she recounted, imitating the clipped, almost panicked reply, “Change the subject, change the subject.” She has dealt directly with the subject of sex ever since.




“All through the ’90s I was scribbling my circles,” she told me in her wispy voice, as she penned out a diagram for me the way she long has for her female patients. She had on a pale flowing skirt with a pattern of leaves and wore her feathery brown hair cropped above her ears. There was something ethereal about her. Yet she drew with swift authority. A box with the phrase “reasons for sex” went at the top of the page. The beginnings of a large circle ran from one side of the box. And the diagram made clear that desire — at least the way many tend to think of it, as a lust or craving that spurs someone toward having sex — might or might not play a role in making a woman want sex and, in any case, isn’t at all necessary for the sex to be satisfying.




A different manifestation of desire — not initial hunger—– appears about two-thirds of the way around Basson’s circle. There, in the diagrams she began publishing in obstetrics and sexuality journals 10 years ago, come the words “responsive/triggered desire.” For Basson, this is necessary to satisfaction. But it comes after arousal starts. So a typical successful experience might proceed something like this: first a decision, rather than a drive, to have sex; next, as Basson puts it, a “willingness to be receptive”; then, say, the sensations of a partner’s touch; next, the awareness of being aroused; then the “responsive desire” along with increasingly intense arousal; and at last the range of physical and emotional payoffs that sex can provide and that offer positive reinforcement leading back to the top of the diagram, to the reasons for setting off on the circle to begin with.




All of this might seem awfully abstract, but Basson’s lesson for women, which has been distilled by sex therapists into three words, “desire follows arousal,” is a real rearrangement of expectation and a reweighting of sexual theory. The model with swollen red lips gazing out with molten need from the billboard or the MTV dancer pumping her half-covered hips at the camera — these icons in heat embody a cultural standard. And though some women, according to Basson, do feel such craving some of the time — at the beginning of a new relationship, for example, or possibly at a certain point in the menstrual cycle — and though a few women may sense such electricity surging regularly through them, these images, she suggests, are largely illusory ideals.





More likely for most women, Basson argues, the start of plenty — and maybe the great majority — of sexual encounters is defined not by heat but by slight warmth or flat neutrality. And there’s nothing wrong with this, she says, nothing disordered.




To reel back to the D.S.M.-III, published in 1980, is to recognize just how sizable a shift Basson’s vision represents. The 1980 version of H.S.D.D. was called “inhibited sexual desire,” and its simple criterion hewed close to its name. “Persistent and pervasive inhibition of sexual desire,” the diagnosis reads. The implication is that there is a force within all of us, a natural and powerful sexual drive, that can be inhibited, and this assumption lingers in the current language with its stress on fantasy, on lust burning from within. Basson sees things differently. Explaining her sense of how desire operates, most of the time, in women, she said to me, “We’re just not talking about innate hunger.”




Not all sexologists are convinced. Some fault Basson for supplying no data to prove that her ideas actually evoke women’s sexuality, for relying on clinical impressions rather than on hard science. Michael Sand, a clinical sexologist, and William Fisher, a psychologist, surveyed more than 130 women and found that it was primarily those with sexual dysfunctions, including low desire, who identified with Basson’s ideas. The rest subscribed to more traditional, straightforward models that place being turned on at the start of typical sexual encounters. Basson, along with Brotto, defends her vision by saying that Sand and Fisher’s study was flawed in its methods.





I talked a few weeks ago with Sand, who has, since completing this survey, become the director of clinical research at Boehringer Ingelheim, a German pharmaceutical company involved in developing a libido-augmenting drug. He challenged Basson to offer rigorous evidence supporting her model and warned that her unsubstantiated theories, despite their apparent sensitivity to women’s realities, may be distorting the truth of most women’s erotic lives and diminishing the relevance of basic randiness.




As she creates language for the D.S.M.-V, Brotto credits others as well as Basson for their influence. Ellen Laan, a Dutch sexologist, has been doing research for more than a decade that highlights the role of external stimuli — as opposed to internally generated urges that function more like hunger for food — in sexual motivation. Yet Basson’s insights, the allegiance her ideas have gained in the past several years among many sexologists and the happenstance of working with Basson at the center, have been crucial factors in forming Brotto’s approach.




Brotto has recently proposed, to a group of three fellow panelists whose agreement will be a first step toward the A.P.A.’s approval, an elaborate diagnostic system for H.S.D.D. Instead of the current brevity, she suggests using a list of six criteria, ranging from the rarity of fantasy, as in the D.S.M.-IV, to being “not receptive to a partner’s attempts to initiate.” A patient with any four of the six would meet the threshold for the illness. She has also recommended renaming the condition; she’d like to shed the word “desire,” with its overheated associations.





Brotto’s expanded criteria are meant, in part, to diminish the diagnostic importance of fantasy. Some data — however scant and even contradictory — hint that fantasy might not play as vital a role in women’s sexual psyches as in men’s. In women, erotic imagining may be less frequent — and its absence may not correlate well with women’s dissatisfaction over their levels of desire. Brotto doesn’t want the disorder of low desire to reflect primarily male standards of normality; she doesn’t want to pathologize women for what may be perfectly ordinary. Her system will prevent women from being labeled with a condition largely because their minds aren’t conjuring erotic situations.




One criterion Brotto advocates adding is a dim or missing sense of excitement during sex itself. This is one of her ways of including Basson’s thinking — that desire often arises during, not before. But it leads to a troubling question. What if the lack of excitement is due to a partner’s ineptitude? What if it’s caused by a lover’s emotional disconnection? Suddenly the realm of mental disorder, which is supposed to be delineated, as the introduction to the D.S.M. puts it, by “dysfunction in the individual,” is being distorted by the role of others. Is it the patient who has the condition, or the partner, or the couple? In building on Basson’s “responsive desire,” Brotto’s criteria run repeatedly into this fundamental problem. A partner’s involvement is more or less inescapable.




Brotto stares squarely at this conundrum, knowing, she told me, that it can’t be resolved, knowing that the best she can do is acknowledge it in some sort of introductory passage and continue on the path she thinks right. Meanwhile, the usual waning of erotic urgency over the course of long relationships, a decline that, according to many clinicians and one study, may beset women more steeply than men, could mean that proposed criteria like “absent/reduced sexual excitement/pleasure during sexual activity” are met by nearly everyone — another muddle of diagnostic logic. To address this problem, the disorder’s current language encouraging clinicians to take the context of their patients’ lives into account may need more emphasis in the D.S.M.-V.




Brotto knows too that there are sexologists who maintain that desire by any definition — whether the sheer lust Basson minimizes or the responsive variety she trumpets — is almost entirely a cultural invention rather than a biological reality; that it has been made to seem essential by the sex scenes in movies and the advice columns in magazines; and that it is best deleted from the D.S.M. Leonore Tiefer, a professor in the psychiatry department at New York University and the author of a collection of essays titled “Sex Is Not a Natural Act,” argues that the contrivance is compounded by the pharmaceutical industry, which offers research money to sexologists who find ways, no matter if unconsciously, to inflate hugely the numbers of women suffering from an already-fictive condition — a disorder that the drug companies intend to cure. High numbers help to increase awareness, which stokes demand.





To what extent this theory represents truth, as opposed to being merely plausible, is hard to sort out. When I spoke recently with officials at Boehringer-Ingelheim, which just announced the auspicious, if not overwhelming, results of large-scale trials of its desire-enhancing medication, Flibanserin, the officials were careful to cite only conservative figures on the women who might want such a pill. (Though the exact mechanisms of the drug are unclear, it seems to act on the brain’s serotonin and dopamine receptors.) Brotto, like all the specialists in all areas working on the new D.S.M., is allowed to receive no more than $10,000 per year from any source connected to the pharmaceutical industry. This is an A.P.A. rule. But Tiefer’s is hardly the only voice warning that, despite A.P.A. protections, drug-company influence can shape, indirectly as well as directly, the decisions of D.S.M. panelists.




Brotto is surrounded by skepticism. And she herself told me that it might take till the publication of the D.S.M.-VI, probably two decades from now, for science to establish sound norms for women’s desire. But all the logical entanglements and reasons for doubt haven’t worn her down in her work on the manual, not at all. Just before we met in August, she said, she slid out of bed in the middle of the night once again, struck by a moment of clarity, and added one of the criteria. And she’s forever captivated by the mysteries of her field. While she spends lots of time focusing on the possible benefits of Buddhist techniques in treating low desire, she talked with me in fascinated detail, full of expertise on specific neural receptors, about the perplexing role of hormones, among them testosterone.





Various pharmaceutical companies, at various times, have pursued testosterone as a remedy for women’s lack of desire, and some doctors prescribe it for the condition — Laura Berman, Oprah’s anointed sex expert, avidly promotes this method — though the Food and Drug Administration hasn’t approved this use. Brotto and Basson are about to publish research demonstrating that low levels of testosterone in women do not correspond with low libido. Yet there is a paradox. Brotto explained that giving extra testosterone to women with desire problems can, it appears, spike sexual interest.





For reasons unknown, the administered hormone has a unique effect. But there’s a further complication. In studies, women given a placebo report a similar result, not quite as marked but definitely not insignificant either. To add to the intrigue, the women using a placebo often report testosterone’s unwanted side effects: facial hair; acne. Speaking about all this, Brotto smiled in bewilderment — and in something close to awe at the inscrutability of the human mind, the organ that is the locus of desire.




Her face was alight, too, as she talked about the intricacies of her clinical cases — about a patient who lost her virginity in her 50s, about an unhappily married woman who has lately found something akin to sexual desire in her studio, in her painting. Thinking about the refrain that rises from the pages of her files, “I want to have sex where I feel like I’m craving it,” I asked Brotto whether she thought it was possible for counseling of any kind to grant access to rushes of sheer lust, the feeling many of her patients long for above all when they first arrive in her office.





She sighed. “I don’t know,” she said. Then, quickly, she steered the conversation back to the other version of desire, the sort that appears well along Basson’s circle, the kind Brotto is confident can be fostered, the desire that takes its time.






Daniel Bergner is a contributing writer for the magazine. His most recent book is “The Other Side of Desire: Four Journeys Into the Far Realms of Lust and Longing.” He last wrote for the magazine about female desire.