Best Sex Writing 2009 (6 page)

I imagine a scene. To some eyes, it may look like a woman on her knees in a crack den, sobbing in shame with her hair full of piss, being mocked by a couple of thugs. But for plenty of people, suffering and degradation is intensely erotic. It’s the pleasure of unpleasure, of being split between yes and no. I like it there. I’m comfortable.The scented candles can go hang!

What’s “normal” sex?

Br ian Alexander

This month the American Psychiatric Association announced the names of “working group” members who will guide the develop- ment of the new
Diagnostic and Statistical Manual of Mental Disorders,
or
DSM,
the codex of American psychiatry.

Not surprisingly, given the
DSM’
s colorful history, particularly when it comes to sex, controversy erupted within days of the an- nouncement, especially over membership of the Sexual and Gender Identity Disorders working group, which will wrestle with ques- tions such as: Are sadomasochism or pedophilia mental disorders? Are dysfunctions like female hypoactive sexual desire disorder (low sex drive) psychiatric issues, or hormonal issues? Perhaps the most important question is whether, when it comes to many sexual in- terests and issues, it’s even possible or desirable to create diagnostic criteria.

At least one petition, spearheaded by transgender activists, is

being circulated to oppose the appointment of some members to the Sexual and Gender Identity Disorders work group and its chair, Kenneth Zucker, head of the Gender Identity Service at the Center for Addiction and Mental Health in Toronto, Canada.The petition accuses Zucker of having engaged in “junk science” and promoting “hurtful theories” during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy.

Zucker rejects the junk-science charge, saying that there “has to be an empirical basis to modify anything” in the
DSM.
As for hurting people, “in my own career, my primary motivation in working with children, adolescents, and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.”

That sex is controversial comes as no surprise to Dr. Darrel Regier, the vice-chair of the APA’s
DSM-V
Task Force, based in Arlington, Virginia.

Sex, he says, in an understatement,“is an area that obviously has lots of emotion attached to it.” But the APA, he says, is doing its best to put science and evidence first, both in who it appoints to work- ing groups and in the process it will use to create the
DSM-V
(so called because it is the fifth complete version). Each working group will accept input from many experts with varying views, reach a consensus on
DSM
content, and then put that work group’s prod- uct before the board of trustees of the APA and the APA assembly. All that may be true, but Regier does not expect such reas- surances to quell the forces already swirling around the
DSM-V
as it moves toward a 2012 publication date. Currently, the
DSM- IV
includes sex-related activities as varied as paraphilias like

voyeurism, klismaphilia (erotic use of enemas), and sadism, and functional disorders like dyspareunia (pain with intercourse), erec- tile disorders, and premature ejaculation.

The first
DSM
was issued in 1952. The idea was to create a more standardized way of talking about psychiatric disorders. As psychiatrist Dr. Gail Saltz, a “Today Show” contributor who also practices in New York, explains, the
DSM
is best viewed as “a lan- guage we have chosen to speak, a talking point we mental health professionals have created to communicate as well as we can with each other and with other professions.”

It is not a final arbiter of who’s crazy and who’s not. Saltz, who says she thinks the
DSM
can be limiting in clinical practice, prefers to take a holistic approach and look at each patient’s collection of symptoms and concerns without being restricted by the
DSM’
s various criteria.

Regier agrees that’s how doctors should use it, arguing that the
DSM
“really needs to be seen as a set of scientific hypotheses.” It is, he believes,“a living document” changeable with new research.

But if the
DSM
is a book of “hypotheses,” why the fuss? Does the
DSM
matter?

Yes. A lot.

The first reason why is prosaic. If you want your insurance to reimburse your visit to a mental health professional, you are prob- ably going to need a
DSM
code signifying a diagnosis.

But the more profound reason is that it shapes how doctors, and even the rest of society, view sexuality.

“A psychiatric diagnosis is more than shorthand to facilitate communication among professionals or to standardize research pa- rameters,” wrote Dr. Charles Moser and Peggy Kleinplatz in a 2005

paper published in the
Journal of Psychology and Human Sexuality.
“Psychiatric diagnoses affect child custody decisions, self-esteem, whether individuals are hired or fired, receive security clearances, or have other rights and privileges curtailed. Criminals may find that their sentences are either mitigated or enhanced as a direct result of their diagnoses. The equating of unusual sexual interests with psychiatric diagnoses has been used to justify the oppression of sexual minorities and to serve political agendas. A review of this area is not only a scientific issue, but also a human rights issue.”

There is no shortage of opinion on what ought to be changed, deleted, or included in the new
DSM-V.
Sandra Leiblum, formerly a professor at New Jersey’s Robert Wood Johnson Medical School and an expert in female sexual health who is now in private prac- tice in Bridgewater, New Jersey, says she wants to see a revision of diagnoses of female hypoactive sexual desire disorder, other female arousal disorders, and sexual pain like dyspareunia. For example, she wants language that would separate arousal disorders into genital (more biological in origin) and subjective subtypes.

Carol Queen, a sexologist, sexual rights activist, and cofounder of San Francisco’s Center for Sex and Culture, believes the new
DSM
should stress that sexual variances are only a problem “if they are problems in the life of the person showing up” in a psychiatrist’s office “so that when somebody is eroticizing something, or doing something in a consensual way, that’s not a problem” even if it may seem odd to most of us.

She also proposes an addition, a diagnosis of “absexual” (“ab” meaning “away from”). This would include those who appear to be “turned on by fulminating against it.” Examples could in- clude state governors who crusade against prostitution even while

paying hookers for sex, and religious leaders who wind up trying to explain engaging in the sex acts they preach against.

Moser, who is affiliated with the Institute for Advanced Study of Human Sexuality in San Francisco, and Kleinplatz, from the University of Ottawa, argue that all paraphilias, like sexual sadism, sexual masochism, and transvestism, should be removed from the
DSM,
insisting that “the
DSM
criteria for diagnosis of unusual sex- ual interests as pathological rests on a series of unproven and more importantly, untested assumptions.”

This does not mean, as opponents of this idea have suggested, that they somehow approve of sex between adults and children. “We would argue that the removal of pedophilia from the
DSM
would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes,” they wrote.“Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred.”

Most of these suggestions are inherently political, as much as the APA and most psychiatrists would wish to avoid politics. Sex exists as part of the culture, and it cannot be separated from it.

The
DSM
has reflected cultural shifts through its revisions and new editions. The most famous example is homosexuality. When the first
DSM
was created in 1952, homosexuality was declared a mental illness. By 1973, and after much heated debate and over objections from religious conservatives, the
DSM-II
excluded ho- mosexuality as a disorder with the exception of one variant, and that was soon dropped in an interim revision.

“Definitely a change in culture affects diagnoses,” Leiblum says. “We used to think oral-genital sex was deviant and we have em-

braced that. Masturbation was evidence of out-of-control behavior; now we see it as not only normative but to be encouraged.”

So if enough people start to do it, or are more public about do- ing it, does that mean it is no longer a disorder? “I think it probably affects the degree to which people are willing to look at scientific evidence,” Regier says.

This fuzziness is why, starting in the 1980s, the field moved to- ward adding the notion of “distress” to the
DSM.

“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” ex- plains Regier. “I would say also if there is no victim involved… this behavior is not imposing a person’s will on another per- son, that is a critical component when one looks at conditions in this area.”

If you aren’t distressed, and everyone is a consenting grown-up, then there probably isn’t a disorder. But things won’t be that simple for the creators of the new
DSM.

“How do you make a criteria that does not pathologize low de- sire?” Leiblum asks rhetorically. You add the need to be distressed about it. “But then whose distress should be looked at?” she asks, referring to a sexual partner. “You can have hypertension and not feel any distress because there is objective criteria for what is high blood pressure. But there is none of that for sexual diagnoses, even premature ejaculation.What constitutes premature?”

(At a press conference Monday, the International Society of Sexual Medicine made a stab at a definition, saying premature ejaculation is “a male sexual dysfunction characterized by ejacula- tion which always or nearly always occurs prior to or within about one minute of vaginal penetration; and, inability to delay ejacula- tion on all or nearly all vaginal penetrations; and, negative personal

consequences, such as distress, bother, frustration, and/or the avoid- ance of sexual intimacy.”)

This problematic lack of clarity, Leiblum argues, is especially acute for the paraphilias. Does the criteria amount to “If it’s mine it’s okay, but if it’s yours it’s kinky? These issues need to be grappled with.”

unleash the Beast

“J osephine t homas”

I am faithful to my husband for 2,292 days. But on the 2,293rd day, I have hormonal teenage sex with a veritable stranger in his divorced-bachelor pad by the train tracks. I’ve slept with some sixty men over two decades and yet it’s with this middle-aged man— graying, with wrinkles and soft muscles—that I truly discover sex.

He is a stranger, but we have a history. One day two years ago, we sat next to each other on the commuter bus, chatting, fl ting. I found him incredibly sexy. Our thighs touched in a way that suggested it wasn’t a coincidence. I fantasized about him a good deal in the fol- lowing weeks. I imagined that, engrossed in conversation, I’d miss my stop, and he’d offer, like a gentleman, to drive me home once we got to his place. Of course we’d have incredibly hot, animalistic sex on his enclosed sunporch, and there’d be nothing gentlemanly about it.

Now, all this time later, I am waiting one morning for the commuter train when I see him walk onto the platform. He

comes straight over to me, smiling broadly, as if we’re old friends. He’s just come from the chiropractor because he hurt his back. He looks good. He remembers my name. I learn within min- utes that he’s separated from his wife and is living a couple of blocks away. He neglects to mention that he has a steady girl- friend because, consciously or not, he knows what I know: We’re going to fuck. Soon.

The fact that I don’t feel one ounce guilty about contemplat- ing adultery should make me feel like a coldhearted sociopath, but it doesn’t. The plain truth is that I’ve had a problem with fidelity all my romantic life. I was never faithful to any of my boyfriends. I would cheat on current boyfriends with new ones, on new ones with exes. I once left a lover in my bed for a dalliance with another, then came back as if I’d just run down to the store for milk. In fact, infidelity is a pastime of which I am rather fond, a behavior that I tamped down when I exchanged vows with my husband but that I never truly buried.

The moment I see train-station man, with his impish grin, I am instantly my good old, bad old self again. Maybe it’s because he turned up after a long, tedious spell of monogamy. Maybe it’s because childbirth deeply wounded my body image, and his flattery is just the balm to soothe it. It’s also possible that I’m more resentful than I realize of my husband, who refuses to take a turn getting up early with the kids on weekends because he’s so tired from doing the very important job that pays for our really nice house.Whatever the rea- son, train-station man manages not only to revive my mischievous, affair-loving streak, but ultimately to open me up to something that is, oddly enough, new to me: the exquisite joy of sex.

His first email, later that day—after the train doesn’t show and he gives me a lift into the city—is fairly innocent but suggestive enough if I choose to take the bait:

What a treat to see you waiting for the train this morn- ing. I thought it would be nice to talk to you for a few minutes before it arrived. Little did I know I would get to have you all to myself for an entire car ride into the city. Now I’m glad I hurt my back. :)