One of the very first things that got brought up when Mikey Boy was announced as 45’s running mate was his past endorsement of conversion therapy, or in more honest terms, torturing people psychologically and physically in an attempt to make them straight.

When most people think of conversion therapy, they think of electroshock treatments and brutal beatings, and that absolutely happens, and it’s just as horrifying as it sounds. But acting like that’s always what conversion therapy looks like lets many of the forms it comes in go unchecked.

So let’s talk about the DSM for a second.

The Diagnostic and Statistical Manual of Mental Disorders, or DSM, was first published in 1952 by the American Psychiatric Association (APA), and like a surprising number of things in the US, was created in order to simplify the census, all the way back in 1840. Many people found “Are you insane or not?” to be lacking, and the literature kept expanding until it became the official DSM. It has since been revised four more times, the latest being the DSM-5, published in May of 2013.

As you can imagine, many diagnoses have changed between 1952 and 2013. “Sociopath” has become “antisocial personality disorder”, “hysteria” is now known as “mental disorders women have”, and of course, “homosexuality: the sociopathic personality disturbance” is now “homosexuality: it be like that sometimes”.

And in between those two, there was a lot of fighting, even after just the first printing. Homosexuality: A Psychoanalytic Study of Male Homosexuals by Irivng Bieber et.al. in 1962 helped solidify the idea of homosexuality being a mental disorder, caused by parent-child trauma in early stages of development. The study has since been proven to be flawed, obviously, but at the time, most psychologists ate it up. Evelyn Hooker, however, performed her own study, where she compared the happiness of heterosexual men to homosexual men of similar backgrounds and general levels of adjustment, and surprise! There was no difference. It didn’t change the DSM overnight, by any means, but it did set the precedent for change.

Evelyn Hooker immediately after drinking Bieber’s tears

Throughout the late 60’s and 70’s, there was a huge pushback against the psychiatric field and mental illness classification in general, especially from the post-Stonewall LGBT+ community. Thanks to the APA deciding in 1970 to hold their conference in San Francisco, one of the gayest if not THE gayest city in the US, protests were made easy. It was such a huge turnout that the following year, gay rights activist Frank Kameny worked with the Gay Liberation Front to put together an even bigger demonstration, which included Kameny grabbing the microphone to say:

“Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”

These demonstrations combined with the continued research of Evelyn Hooker and others led to the sixth printing of the DSM-II (yeah, I don’t get how that works, either) to remove homosexuality from the list of disorders.

Problem solved, right? Yeah, no.

It was replaced with “sexual orientation disturbance” in the DSM-II, followed by “ego-dystonic homosexuality” in the DSM-III, with both hanging onto “gender identity disorder”. The diagnosis of these “disorders” claims that homosexuality or being transgender itself is not a problem, but if a person’s gender or orientation causes “significant distress and anxiety”, then it should be treated, even cured. This prevents queer people who are comfortable with themselves from being put through any kind of conversion therapy, which is a good thing. However, many queer people face “significant distress and anxiety” in regards to their orientation or gender. This isn’t due to their queerness being ~so confusing and scary and unnatural~, but because society at large views it, and subsequently that person, as being confusing and scary and unnatural. Being ostracized and othered by society can make you anxious. Whoda thunk?

These diagnoses can and have preyed on those who are questioning, and put them on medications and through therapies that did more harm than good. And that’s not even getting into the medical bills.

Luckily, “ego-dystonic homosexuality” was replaced with “sexual disorder not otherwise specified” in later printings of the DSM-III, and seems to have been quietly erased in IV and V. And the DSM-V has replaced “gender identity disorder” with “gender dysphoria”, which isn’t perfect, but focuses less on making the patient cis and more on helping the patient transition. Progress is slow and frustrating, but it is chugging along.

Unless you’re asexual, that is.

“Inhibited sexual desire disorder” was the first incarnation of pathologizing asexuality, in the DSM-III. In the DSM-IV, it was changed to “hypoactive sexual desire disorder”, or HSDD. The name has changed again in the DSM-V, which we’ll get to, but colloquially, it’s still often referred to as HSDD.

It’s classified as a sexual dysfunction, which is also what erectile dysfunction and vaginismus fall under. Its defined by a lack of sexual fantasies or interest in sexual contact that can’t be attributed to other factors such as drug use, depression, or issues in the relationship. And once again, we have our disclaimer: it only counts as a disorder if it causes “marked distress or interpersonal difficulties”. Incidentally, the word “asexual” is never used anywhere in the details.

This has changed in the DSM-V, but it’s more like two steps forward, one step back. The DSM-V now includes another disclaimer on the listing, saying that if a patient identifies as asexual, the diagnosis does not apply and treatment is not needed. Again, this is a great step, as it keeps well-adjusted aces from avoiding the doctor for fear of being diagnosed with HSDD.

However.

This disclaimer only appears in the full version of the DSM-V, not the pocket version. Why is there a pocket version, you may ask? Because the full version looks like this:

The pictures don’t do the size of this book justice. It is a monster. It’s like Les Mis and all the Harry Potter books combined and bound in hardback. You could weight train with that thing. Of course there needs to be a pocket version, and most doctors, counselors, and pharmacists will look at it for an overview, if not stop there.

There’s also the fact that, while it’s gotten better in the last five years, the existence of asexuality is not common knowledge. Many ace people don’t even know their experience falls under any kind of queer umbrella, much less know what asexuality is and whether it fits them. If they go to a therapist or a doctor for answers, the term “asexual” may never come up for either of them, and both will be left scratching their heads.

And finally, this is made more complicated by that one step back I mentioned — HSDD has now been split into two separate disorders: male hypoactive sexual desire disorder and female sexual arousal/interest disorder.

Like, where do I even start. For one thing, the splitting of it leaves out nonbinary patients. For another, why do they have different names? Female sexual arousal disorder already exists, so why is interest now tacked on at the end to make it seem like vaginismus and asexuality are the same thing? And the symptoms aren’t that much different on either end, so why is it split up to begin with?

Well, it might have something to do with the drug that came out to cure it.

Filibanserin (brand name Addyi) is the first drug ever marketed explicitly to cure HSDD in women. Yes, women exclusively. Their website doesn’t explain why that is. Does it react badly with testosterone? In that case, many trans women might be at risk if they’re not informed of that. Maybe it messes with penises? In that case, many trans dudes would be fine, and many trans women wouldn’t. And what about femme-presenting nonbinary patients? Do you need to find another drug if you’re butch? You won’t get an answer from the company on any of these.

Filibanserin is an NDDI, or norepenepherine-dopamine disnihibitor. Now, I have a Theater degree, so I can’t tell you exactly what that means, but I do know that there is interest in NDDI’s as antidepressants, specifically as an alternative to the behemoth that is SSRI’s. So far, there has been only mild success, but many drug companies are still scrambling to have the first viable NDDI antidepressant.

Beohringer Ingleheim, which is apparently the name of a drug company and not the name of a stuffy German aristocrat villain in a kid’s movie, started development on the drug, but after failing an evaluation by the FDA, it was handed over to Sprout Pharmaceuticals.

Speaking of FDA disapproval, filibanserin failed FDA approval twice, once from Beohringer and once from Sprout. Both times, they cited “an inadequate risk/benefit ratio”, which means not only did the drug not work, but the side effects were even worse. It passed its third driving test with a surprising vote of 18–6 in favor, though this was only with the caveat that patients were told about the side effects in plain terms, both on the company’s website and in person. It passed despite the fact that, even now, patients only see a 0.5% difference taking filibanserin compared to a placebo.

Its passing might have been helped by an advocacy group called Even the Score, which called for the passing of filibanserin on the grounds that there was no female equivalent of Viagra, and that this drug would fill that need. It claimed that this was an issue of equality, even a feminist issue.

But two things. First, filibanserin is not and never claimed to be a drug for curing issues with sexual AROUSAL, but sexual INTEREST. Filibanserin, as mentioned, is essentially an antidepressant. It works on the brain, not on the genitals.

And second, the advocacy group was literally created by Sprout, who might possibly maybe have an interest in making sure the drug got approved. And before you call me a hard-hitting journalist for unmasking this conspiracy, this fact is listed both on the Wikipedia page for the drug and in a story in the New York Times as it happened. It was common knowledge then, it’s common knowledge now, and yet it got the drug approved regardless.

Pictured: the embodiment of the term “conflict of interest”

Now, I mentioned side effects earlier, and given what a big deal the FDA made of them, you’re probably wondering what they are. Luckily, as is required by law, it’s written in nice bold letters on Addyi’s website.

Low blood pressure, fainting, and loss of consciousness.

And this isn’t some “this might happen, so keep an eye on it!” sort of thing. Patients are told to only take Addyi right before bed, or if they can’t, not to do anything strenuous or involving heavy machinery for SIX HOURS after taking it. You have to tell your doctor any other medications you’re on, from Pepto to Prozac, in case there’s a reaction that makes you even more at risk.

Oh yeah, and if you decide to take Addyi, you can never drink alcohol again. Ever. You literally have to sign a piece of paper that says you won’t even sip on hard lemonade again.

And the thing is, I’m not totally convinced this side effect isn’t the only effect. There’s no cute little “Here’s how it works!” section on Addyi’s website, and trying to work out the activity profile as someone who only barely passed high school Chemistry is an absolute nightmare.

This is a drug marketed exclusively to women who don’t feel like having sex, and its primary function is making them lose consciousness.

Think about how abusers could push this drug on their partners. Think about how spiking the non-alcoholic drink of a woman who’s on this could potentially kill her. Think about how many women who say no could be dismissed with, “Geez, take your pink pill and loosen up!”(Oh yeah, the pill’s pink, because of course it is.)

This drug puts all women at risk, but especially asexual women, and especially asexual women who don’t even know they’re in the closet yet.

The only bright spot is that Addyi isn’t selling too well. Not surprising, considering not only everything I listed above, but the fact that doctors have to go through a ten-minute online training course before they’re even allowed to prescribe it, plus the price tag ($800 for one month’s supply, without insurance). But it is still selling. The company is still in business, and the drug is still on the market.

Because there are women out there who look at all this and decide it’s still worth it, if there’s a chance it will make them “normal”. Because they have no idea there’s a whole community of people out there who know exactly what they’re going through, who can tell them it’s okay, that they’re not broken or defective or weird.

Medicine and psychology has been failing the LGBT+ community since medicine and psychology were invented. Whether you work in those fields or not, don’t let this continue.

And if you already are advocating for psychiatric justice for the community at large, please add Sprout Pharmaceuticals to The List for me.