A New View of Women's Sexual Problems: Why New? Why Now?

The Federal Drug Administration's (FDA) March, 1998 approval of sildenafil citrate, an oral drug to treat "erectile dysfunction" (the first approval went to Pfizer, Inc., which is using the brand name Viagra), capped a 15-year process of promoting a medical classification system, market, and scientific literature for men's sexual problems, a process I have chronicled for some time as "the medicalization of male sexuality" (Tiefer, 1986, 1994, 1995, 1996, 1999, 2000a). The process explicitly selected particular elements of men's sexual and reproductive potential as medically normal (just-right erection, just-right ejaculation and orgasm, just-right desire frequency and object), and promoted them as natural, universal, and sufficient for proper sexual conduct and experience. That this has happened during a period of rapid change in gender roles means that the medicalization of male sexuality also functions as part of the contemporary reshaping of masculinity (Seidler, 1997).

Beginning in the early 1990s, and escalating after the approval of sildenafil, urologists, pharmaceutical industry representatives, and some sexologists began to focus on women's sexual problems with a similar medical paradigm emphasizing physical causes, physical aspects of sexual experience, and physiological assessments and treatments for women's sexual problems (Basson et al., 2000; Berman & Berman, 2001; Berman, Berman, & Goldstein, 1999; Rosen & O'Leary, 1998; Tiefer, in press). This initiative has produced widespread media attention (e.g., Hitt, 2000; Kolata, 1998; Leland, 2000; Martindale, 2001; Rosner, 2001) and seems likely to create an atmosphere of medicalized thinking about women's sexuality, and a market for medical products, as happened for men (Tiefer, 2000b).

Only within academic areas of history, sociology, cultural studies, and science and technology studies has the triumph of a medical view of sexuality been seen as an active process, promoted by groups with particular political and socioeconomic interests, and not simply as an inevitable outgrowth of scientific and medical discoveries (e.g., Boyle, 1994; Irvine, 1990; Jackson & Scott, 1997; Mamo & Fishman, in press; McLaren, 1999). Scholars in those academic areas, as well as feminist and gay/lesbian political writers, have examined the disdvantages as well as the advantages of this dominant medical paradigm, and have argued that nonmedical frameworks for sexuality theory and research that privilege sexual rights, diverse cultural meanings, and humanistic therapies are equally valid (Kleinplatz, 2001; Parker, Barbosa, & Aggleton, 2000; Parker & Gagnon, 1995; Plummer, 1995; Weeks, 1985). As part of this movement, the "new view" of women's sexual problems (see Appendix) advocates for sexuality theory, research, education, and practice that are meaning-centered rather than function-centered, consciously political rather than passively apolitical, and grounded in humanistic rather than in biological foundations (Connell & Dowsett, 1992; Evans, 1993; Weeks, 1995).

PROBLEMS WITH MEDICALIZATION

The hallmarks of the medical model include mind-body compartmentalization, generalizations about human function and experience, and a focus on the individual, all of which create a universalized, function-focused sexuality in which physiology dictates sexual conduct (Boyle, 1994; Tiefer, 1995, 1996, 1999). This model has probably allowed at least some sex education and research in a culture still paralyzed by its history of prudery and hypocrisy in which embarrassment and value conflicts about sex remain pervasive (Money, 1985; Reiss, 1990). Medicalization offers a vocabulary of biological innocence--the kneebone is connected to the anklebone--to purge the lubriciousness from any discussion of sexuality, and there may have been advantages to that in the past.

But in the twenty-first century, sexual images permeate ads, films, television, and the internet; sexual issues are high on the global public health agenda; people travel, emigrate, and date partners with different sexual values; celebrities and politicians offer a kaleidoscope of messages about sex and gender; ordinary people are living longer, more vigorous lives--and both public and professionals need scientific and clinical models of sexuality and sexual problems to help them cope. The prevailing medical model and nomenclature, deriving from the work of Masters and Johnson (1966, 1970) and Kaplan (1974, 1977, 1979), and codified in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (1980, 1987, 1994), are inadequate to fill this tall order. They contain too many mistaken claims (errors of commission) and leave too much out (errors of omission) (Boyle, 1994; Tiefer, 1992, in press).

Recently, a group organized by urologists and sponsored by the pharmaceutical industry met in closed session to create new "consensus statement" nomenclature for women's sexual problems (Basson et al., 2000). Despite acknowledging that many areas of women's sexual experience and problems are poorly understood and difficult to assess, the document deviated very little from the prevailing APA norms of desire for sexual activity, attained and sustained arousal, and orgasm, and ended by strongly encouraging "clinical trials of vasoactive agents, steroidal therapies," and "psychosexual therapy alone or in combination with pharmacological treatment" (Basson et al., 2000, p. 891). That doesn't seem to acknowledge massive cultural changes in sexuality at all.

A subtle contradiction appears in the new consensus statement document which I believe can only be resolved by scrapping the medical nomenclature entirely and moving toward a "new view" such as the one we espouse (see Appendix). Consensus document authors repeatedly emphasize that "an essential element of the new diagnostic system is the `personal distress' criterion" (Basson et al., p. 888), such that a diagnosis of disordered desire, arousal, or orgasm is never made unless the problem causes a woman "personal distress." This requirement acknowledges women's new sexual agency, rights, and self-determination in a post-feminist world. Yet, ironically, the medical model and consensus document omit and ignore the nonmedical sexual problems, complaints, and difficulties which women repeatedly tell researchers are their primary areas of sexual distress (Ellison, 2000; Hire, 1976; Travis & White, 2000). The medical model pays only lip service to women's self-determination.

Problems of Commission--Negative Consequences

The prevailing medical model promotes a specific norm of sexuality--correct genital performance. The necessary and sufficient ingredients for successful sexual experience are desire (vaguely indicated as being "for sex"), genital arousal, a timely orgasm, and the ability to enjoy vaginal penetration. This impoverished "sex = intercourse" equation brings back the kinds of pregnancy and STD problems which the 1960s separation of sex and reproduction and the 1970s celebration of the clitoris were supposed to reduce or eliminate. It's overly genital, suspiciously phallocentric, and ignores subjectivity and meaning. If it's wet and hard and "works," it's normal; if it's not, it's not.

On the most practical level, a letter to the The New England Journal of Medicine drew attention to a worrisome increase in complaints of genital irritation by middle-aged women partners of men who use drugs to enhance erectile functioning (Little, Park, & Patton, 1998). The "sexuopharmacological" solution for such problems would be for the women to use hormones or other products to lubricate penetration. This could start a comical infinite regress. The man's pill makes the woman need a lubricant. The woman's lubricant makes the man need a penile sensory enhancer. The man's sensory enhancer makes the woman need a desire additive. The woman's desire additive makes the man need an energy stimulant. The man's energy stimulant makes him need antianxiety medication. And so on. This scenario is not quite as ridiculous as it sounds, since all drugs have side effects, and many non-sexuality drugs with sexual side effects are said to require sexuopharmaceuticals. The popular mood-altering SSRI drugs (selective serotonin reuptake inhibitors), for example, seem to interfere with desire or orgasm, and doctors now regularly add prescription antidotes (Ashton, Hamer, & Rosen, 1997; Rosenberg, 1999; Schaller & Behar, 1999). Anti-hypertensive medications usually affect genital bloodflow, requiring their own antidotes. And so forth.

In sexuomedicine, the amount of time devoted to getting the penis hard and the vagina wet vastly outweighs the attention devoted to assessment or education about sexual motives, scripts, pleasure, power, emotionality, sensuality, communication, or connectedness. Research produces more and more knowledge about the kneebone and the anklebone, while people remain stuck with only their pop-magazine or commonsense knowlege of the effects on sexuality of psychology, social class, education, cultural pressures, and media. The consequence of this imbalanced research is a perpetually gullible, anxious, and exploitable public, the perfect market for selling magical drugs.

Problems of Omission

The obsessive focus on getting the genitals to perform properly, if not perfectly, results in the neglect of much of what makes sexual problems so complex--personally and theoretically. First on this list would be the relational aspects of sexual experience. In my thirteen years' work in medical center urology departments (1983-1996), I repeatedly, even routinely, observed extensive penis function workups by doctors and technicians who had no knowledge of the penis owner's sexual relationship. It was as if they were car mechanics, and needed to know nothing whatsoever about the car's driver, any other passengers, how the car was driven, or where it was going in order to fix what was wrong.

It's the wrong model for sex, and drug companies know it. Consider the advertising campaign for Viagra. The mechanism of action of this drug is limited to the blood vessels of the penis. Yet the advertisements feature photos of couples dancing or hugging, smiling and touching. The promise is that of romance, fun, and intimacy, and it is probably aimed at women, who visit doctors more often and may be more willing to fill prescriptions. But, will a sex-enhancing drug deliver on that promise?

Most couples with sexual problems have never talked with anyone about their problems, and often not even with each other. The first empirical study I conducted in a urology setting, for example, documented significant discrepancies in the stories told by male patients and their female sex partners in 78% of a sequential sample of 40 cases (Tiefer & Melman, 1983). Simply handing out drug prescriptions is unlikely to help couples whose sexual life has come unraveled when they don't even agree on the nature of the problem. Moreover, a narrow medical approach to sexual problems is unlikely to allow women the opportunity to raise their sexual concerns, bypassing any opportunity to intervene in situations of sexual coercion or violence (Heise, 1995).

A second omission resulting from medicalization is disinterest in cultural variation in sexuality. Because normal genital function is said to be biologically universal ("an erection is an erection"), the medical model can demote factors such as culture or religion to minor background variables. This bypasses how meaning and motivation for sexual activity derive from cultural sexual scripts. I have treated too many couples in sex therapy to be sanguine about this problem. Cultural variations around sexual initiation, sexual expressiveness, and body comfort are commonplace, and when embarrassment compounds ignorance, cultural issues are neither discussed nor negotiated. A couple comes into treatment with a difficulty like premature ejaculation (PE) or lack of female orgasm. But their low sexual frequency and high dissatisfaction, which produce the PE and lack of orgasm, can be consequences of cultural issues. Handing such couples the latest drug because, of course, they are said to be too embarrassed to want to discuss their sexual lives, will either delay or suppress entirely their ability to resolve cultural and gender issues around sexuality.

The most grievous omission, at least from a feminist point of view, is medicalization's neglect and, to all intents and purposes, denial of issues of power. Recent editions of the Diagnostic and Statistical Manual of the APA (DSM-III, DSM-III-R, and DSM-IV) list sexual problems of "the vagina" and "the penis" as if sex were a function like respiration. Equal numbers of complaints are ascribed to men and to women, and there is an assumption that, therefore, men's and women's concerns are equally represented.

But men and women do not have equal political sexual power or, often, personal sexual power. Women's legacy of political and economic subordination is reflected in incomplete health care (limited access to abortion and poor insurance coverage for contraception); greater social pressure to marry and frequent trading of sex for socioeconomic advantages; greater burdens in homecare, child care, and eldercare that limit energy for sex and other pursuits of the self; limits in nonmarital sexual opportunities because of dangers to reputation and the threat of sexual violence; and loss of personal sexual power as a result of child sexual abuse, poor self-esteem, depression, and other problems not uncommon in women's lives. This political and economic subordination has repeatedly been documented by women's studies research over recent decades (e.g., Kramarae & Spender, 1992).

Understanding the impact of these issues on sexual life requires its own research literature and campaign to raise public awareness. Instead, gender inequality becomes woven into the social fabric, taken for granted and invisible, rarely named outside feminist scholarship, and transformed by popular media into stereotyped assumptions about men's and women's essential natures. This then results in popular sex advice books that focus on how men and women come from different planets and therefore have difficulty communicating and cooperating (Hare-Mustin, 1991). The unwillingness of media and many sex experts to grapple with gender and power has created a false picture of women's sexual reality which the current wave of medicalized thinking will only make worse.

A CRITIQUE AND A NEW VIEW

The escalating medicalization trend provoked me to think about a new view of women's sexual problems that would offer both a critique of the prevailing medical model and an alternative perspective. In summer, 2000, I convened a group of sympathetic social scientists and clinicians and the document we produced appears at the end of these comments (Appendix). After communicating via internet for months, the group met for a weekend to approve the final wording and to plan a campaign that would include academic presentations as well as publications in both academic and popular venues. We inaugurated the campaign with a Boston press conference in October, 2000, and offered the first presentation of our New View at the Female Sexual Forum conference organized by the Boston University Department of Urology (Eagen, 2000; FDA Week, 2000; Raab, 2000; Tiefer, Hall, & Tavris, 2000; Zamora, 2000). I coedited a collection of essays about the New View (Kaschak & Tiefer, in press) and the group is planning a multidisciplinary conference in San Francisco in March, 2002, titled "The New Female Sexual Dysfunction: Promises, Prescriptions, and Profits."

This New View campaign brings several strands of scholarship and activism to bear on the issue of women's sexual problems. From feminism comes the tradition of trying to see the subject from women's point of view rather than from some expert authority's point of view. What sexual problems do women themselves articulate? What framework would embrace women's concerns most completely? Our document is based on the psychobiosocial insights of feminist clinicians and theorists who locate women's sexual problems primarily in cultural and relational contexts. We adopted a social constructionist view of sexual experience that avoided any universal blueprint for successful or normal sexual experience (Tiefer, 1987). In our classification system, women could identify their own sexual problems, which we inclusively defined as "discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience." This definition avoided specifying any one particular pattern of sexual experience as normal--an important strategy of any demedicalization effort. We grounded the definition in the emerging discourse of sexual rights by citing both an influential 1974 World Health Organization document and a list of sexual rights approved in 1999 by the World Association of Sexology.

Following the woman-centered definition of sexual problems, our classification system embraced a familiar four-part psychobiosocial catalog of causes. The authors of the recent editions of the DSM, walking a fine line among competing theories in psychiatry, had avoided listing causes of any of their disorders, but our feminist framework required identifying causes for women's sexual problems. We felt it was critical to affirm that issues of social inequality and gender stereotyping related directly to private but pervasive sexual problems such as sexual embarrassment, anxiety, avoidance, and inhibition. Therefore, our category of sexual problems caused by sociocultural, political, or economic factors probably accounts for the largest number of sexual complaints of women. In this category we included such factors as inadequate sex education or lack of access to contraception, abortion, and STD care. We also felt it was important to point to factors of fatigue or lack of time due to family and work obligations as causes of women's sexual problems (Hochschild, 1989).

This first category allowed us to acknowledge that, while individual women do have problems with sexuality that may require professional intervention, the causes of such problems likely lie in social and cultural conditions that must be named and that can be alleviated, thus preventing such sexual problems in the future. The unfortunate consequence of the individualism of medical model thinking is to stigmatize and blame the individual for his or her condition (which tempts many to relieve their sense of responsibility by blaming their genes!). Feminism abjures woman-blaming by showing how broad social circumstances have consequences in individual lives, and this is never more true than in the case of sexuality.

The second category locates the causes of women's sexual problems in a multitude of specific partner and relationship issues, the third in various psychological conflicts and disadvantageous elements of personal history, and the fourth in medical and physical problems. These last three factors had all received attention in the literature and research of sexology and sex therapy, but the sociocultural and political issues had only been emphasized in the writings of feminist sex therapists (e.g., Cole & Rothblum, 1988).

Our hope is that this new view will influence sexuality theory, research, and education. Our critique of the pharmaceutical industry's undue influence dovetails with others emerging in journalism and medicine, and we call upon our sexological colleagues to assert their independence and vision strongly in the coming years (Angell, 2000; Bodenheimer, 2000; Relman, 2001; Tiefer, 2000a). Fortunately, the global feminist movement has produced an unshakeable commitment to women's sexual self-determination that can serve as both inspiration and gadfly as sexology navigates the challenges of sex in the twenty-first century.

I greatly appreciate the invitation from JSR editor John DeLamater to contribute this commentary.

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Manuscript accepted February 16, 2001

APPENDIX

A NEW VIEW OF WOMEN'S SEXUAL PROBLEMS(1)

by The Working Group on A New View of Women's Sexual Problems(2)

INTRODUCTION

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

We believe that a fundamental barrier to understanding women's sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association (APA) for its Diagnostic and Statistical Manual of Disorders (DSM) in 1980, and revised in 1987 and 1994.(3) It divides (both men's and) women's sexual problems into four categories of sexual "dysfunction": sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. These "dysfunctions" are disturbances in an assumed universal physiological sexual response pattern ("normal function") originally described by Masters and Johnson in the 1960s.(4) This universal pattern begins, in theory, with sexual drive, and proceeds sequentially through the stages of desire, arousal, and orgasm.

In recent decades, the shortcomings of the framework, as it applies to women, have been amply documented.(5) The three most serious distortions produced by a framework that reduces sexual problems to disorders of physiological function, comparable to breathing or digestive disorders, are:

1) A false notion of sexual equivalency between men and women. Because the early researchers emphasized similarities in men's and women's physiological responses during sexual activities, they concluded that sexual disorders must also be similar. Few investigators asked women to describe their experiences from their own points of view. When such studies were done, it became apparent that women and men differ in many crucial ways. Women's accounts do not fit neatly into the Masters and Johnson model; for example, women generally do not separate "desire" from "arousal," women care less about physical than subjective arousal, and women's sexual complaints frequently focus on "difficulties" that are absent from the DSM.(6)

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

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

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

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

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

SEXUAL HEALTH AND SEXUAL RIGHTS: INTERNATIONAL VIEWS

To move away from the DSM's genital and mechanical blueprint of women's sexual problems, we turned for guidance to international documents. In 1974, the World Health Organization held a unique conference on the training needs for sexual health workers. The report noted: "A growing body of knowledge indicates that problems in human sexuality are more pervasive and more important to the well-being and health of individuals in many cultures than has previously been recognized." The report emphasized the importance of taking a positive approach to human sexuality and the enhancement of relationships. It offered a broad definition of "sexual health" as "the integration of the somatic, emotional, intellectual, and social aspects of sexual being."(7)

In 1999, the World Association of Sexology, meeting in Hong Kong, adopted a Declaration of Sexual Rights.(8) "In order to assure that human beings and societies develop healthy sexuality," the Declaration stated, "the following sexual rights must be recognized, promoted, respected, and defended," including:

* The right to sexual freedom, excluding all forms of sexual coercion, exploitation and abuse;

* The right to sexual autonomy and safety of the sexual body;

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

* The right to sexual information ... generated through unencumbered yet scientifically ethical inquiry;

* The right to comprehensive sexuality education;

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

WOMEN'S SEXUAL PROBLEMS: A NEW CLASSIFICATION

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

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

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

1. Lack of vocabulary to describe subjective or physical experience.

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

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

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

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

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

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

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

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

II. SEXUAL PROBLEMS RELATING TO PARTNER AND RELATIONSHIP

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

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

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

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

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

III. SEXUAL PROBLEMS DUE TO PSYCHOLOGICAL FACTORS

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

1. Past experiences of physical, sexual, or emotional abuse.

2. General personality problems with attachment, rejection, cooperation, or entitlement.

3. Depression or anxiety.

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

IV. SEXUAL PROBLEMS DUE TO MEDICAL FACTORS

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

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

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

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

D. Iatrogenic conditions.

CONCLUSION

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

(1) This document is printed here in its original format, and therefore has not been formatted to conform to APA style.

(2) Linda Alperstein, M.S.W., Assoc. Clin. Prof., Psychiatry, University of California, San Francisco, CA; Carol Ellison, Ph.D., Psychotherapy Practice, Oakland, CA; Jennifer R. Fishman, B.A., Doctoral Candidate, Social and Behavioral Science, UCSF, CA; Marny Hall, Ph.D., Psychotherapy Practice, San Francisco, CA; Lisa Handwerker, Ph.D., M.P.H., Institute for the Study of Social Change, University of California at Berkeley, CA; Heather Hartley, Ph.D., Ass't Professor, Sociology, Portland State University, OR; Ellyn Kaschak, Ph.D., Professor, Psychology, San Jose State University, CA; Peggy Kleinplatz, Ph.D., Lecturer, School of Psychology, Univ. of Ottawa, Ontario, Canada; Meika Loe, M.A., Doctoral Candidate, Women's Studies Emphasis, Sociology, University of California at Santa Barbara, CA; Laura Mamo, B. A., Doctoral Candidate, Social and Behavioral Sciences, UCSF, CA; Carol Tavris, Ph.D., Social Psychologist; Independent Scholar, Los Angeles, CA; Leonore Tiefer, Ph.D., Assoc. Clin. Professor, Psychiatry, New York University School of Medicine and Albert Einstein College of Medicine, NY.

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

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

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

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

(7) WHO Technical Report, series Nr. 572, 1975. Full text available on the Robert Koch Institute sexuality website www.rki.de/GESUND/ARCHIV/HOME.HTM.

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

Address correspondence to Leonore Tiefer, Ph.D., 163 Third Ave. #183, New York, NY 10003, USA; e-mail: [e-mail].