Classifying Sexual Dysfunction
Although the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (1994) is the currently accepted system for classifying women's sexual dysfunction, there have been criticisms of that system. In particular, the criticism stems from the fact that it is based on a model of sexual response that assumes women first experience sexual desire, then move on to the experience of sexual arousal, followed by orgasm. This linear step-by-step progression through sexual response is challenged by the finding that many women engage in sexual activity despite not experiencing sexual desire at the outset. Instead, they may experience sexual desire after the sexual encounter has begun. Some have termed this type of desire as "responsive desire".
Although there have been numerous challenges to the current DSM taxonomy and some have proposed alternative classification schemes from which to understand women's sexual complaints, one system that resulted from meetings of an international classification committee, sponsored by the American Foundation for Urologic Diseases in 2003, retained the general 4-category system of the DSM while making revisions to the individual diagnoses within each category. It is noteworthy that these are not adopted by the DSM, which is currently revising its manual and is expected to be published in 2013.
The current Sexual Dysfunctions workgroup committee for DSM-5 has proposed that "Hypoactive Sexual Desire Disorder" and "Female Sexual Arousal Disorder" be replaced with "Sexual Interest/Arousal Disorder" (www.dsm5.org). This diagnosis would require women to experience any 3 of 6 symptoms for at least a 6 month period, and these symptoms must evoke significant distress. The proposed criteria for Sexual Interest/Arousal Disorder are:
- Lack of sexual interest/arousal of at least 6 months duration as manifested by at least 3 of the following indicators:
- Absent/reduced frequency or intensity of interest in sexual activity
- Absent/reduced frequency or intensity of sexual/erotic thoughts or fantasies
- Absence or reduced frequency of initiation of sexual activity and is typically unreceptive to a partner's attempts to initiate
- Absent/reduced frequency or intensity of sexual excitement/pleasure during sexual activity on all or almost all (approximately 75%) sexual encounters
- Sexual interest/arousal is absent or infrequently elicited by any internal or external sexual/erotic cues (e.g., written, verbal, visual, etc.)
- Absent/reduced frequency or intensity of genital and/or nongenital sensations during sexual activity on all or almost all (approximately 75%) sexual encounters
- The problem causes clinically significant distress or impairment.
- The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition
Subtypes: Early-Onset (Lifelong) vs Late-Onset (Acquired)
- Generalized vs. Situational
- Partner factors (partner's sexual problems, partner's health status)
- Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
- Individual vulnerability factors (e.g., poor body image, history of abuse experience) or psychiatric comorbidity (e.g., depression or anxiety)
- Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
- With medical factors relevant to prognosis, course, or treatment
The committee has welcomed considerable feedback on this proposal. The DSM-5 will be published in May 2013.