Toward an Improved Nosology of Sexual Dysfunctions in DSM-V

Sexual dysfunctions as distinct syndromes were first identified in DSM-III in 1980. At that time, sets of criteria were specified for inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, dyspareunia, and functional vaginismus. The sexual dysfunctions roughly corresponded to the phases of the sexual response cycle introduced by Masters and Johnson¹ with the exception of disorders of sexual desire. The concept of inhibited sexual desire was separately introduced by Lief² and Kaplan³ in 1977. It is important to note that some have questioned the wisdom of anchoring the diagnoses of sexual dysfunction in the phases of sexual response cycle, since DSM-defined sexual dysfunctions frequently overlap, especially in the area of female sexual dysfunction.⁴

Subsequent revisions of these categories have consisted of name changes (eg, inhibited sexual desire being changed to hypoactive sexual desire disorder), the addition of sexual aversion disorder (a diagnosis rarely used), the addition of subtypes (lifelong vs acquired, generalized vs situational, due to psychological factors vs due to combined factors) and minor modification of criteria sets. In DSM-IV, 2 additional categories were added, namely substance-induced sexual dysfunction (eg, SSRI-induced anorgasmia) and sexual dysfunction due to a general medical disorder (eg, erectile dysfunction due to multiple sclerosis or due to diabetes mellitus). The diagnostic criteria for each sexual dysfunction are operationally defined in a similar way.

• Criterion A defines the specific psychophysiological impairment (for example, lack of orgasm or erectile dysfunction).
• Criterion B requires that the disturbance causes marked distress or interpersonal difficulty.
• Criterion C requires that the dysfunction is not better accounted for by another Axis I disorder or general medical condition and is not solely due to a substance effect (medication use or abuse).

The requirement of exclusion of sexual dysfunction due to another Axis I disorder is an interesting and puzzling concept. The association of sexual dysfunctions with various physical illnesses is well known and is basically acknowledged by the creation of the "sexual dysfunction due to general medical condition" diagnostic category. Lately, we have increasingly appreciated the association of sexual dysfunctions with various psychiatric disorders, eg, major depression (well known for a long time) or schizophrenia. It is a bit puzzling and inconsistent not to establish the diagnostic category of "sexual dysfunction due to mental disorder" (especially because sexual dysfunction due to substance abuse could be classified as such, and even subclassified as "with onset during intoxication").

As with other classes of disorders in DSM, the category of sexual disorder not otherwise specified is included at the end for those problems/behaviors that do not meet criteria for any specific sexual disorder, eg, marked feelings of inadequacy concerning sexual performance or other traits related to self-imposed standards of masculinity or femininity.

Since the publication of DSM-IV-TR, new research on sexual disorders has shed additional light on issues such as distress and duration. Research results will no doubt be reflected in the upcom- ing DSM-V. In this article, we briefly review the limitations of the current criteria for sexual disorders and suggest revisions that might be made in DSM-V.

Limitations of current criteria

Of interest, while DSM-IV and other criteria of sexual dysfunction are widely used, their validity and reliability have not been properly tested. DSM criteria also differ slightly from another set of sexual dysfunction diagnostic criteria-those of the ICD-10 Classification of Mental and Behavioural Disorders diagnostic criteria (the ICD-10 criteria include the duration criterion [6 months for most], which is not included in the DSM classification).

Through all of the iterations of the DSM classification of sexual dysfunctions, several pervasive problems have remained. One major issue is the absence of operational criteria for the disorders. For example, premature ejaculation is defined as "persistent or recurrent ejaculation before, on, or shortly after penetration and before the person wishes it." From this definition, it is unclear exactly what constitutes "shortly after penetration." At this point, data regarding the average ejaculatory latency of men in multiple countries including the United States exist and, thus, we should be able to set specific times from penetration to ejaculation for the diagnosis of premature ejaculation.⁵ Similar lack of specificity plagues the other diagnoses.

Many diagnoses in DSM-IV-TR have specific duration criteria before a diagnosis can be made (eg, a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting for at least 1 week for the diagnosis of a manic episode). Such duration criteria might help the clinician to distinguish between transient alterations in sexual behavior related to partner relational problems and transient stress from more persistent problems, which might require medical intervention.⁶ For example, findings from population studies undertaken by Oberg and colleagues⁷ show that most sexual problems last less than 6 months. The problems lasting 6 months or longer may represent a different group of individuals and constitute a more homogeneous group for study of the efficacy of treatment interventions. Similarly, population studies suggest that more severe sexual problems may be less frequent than less severe ones, again suggesting that severity might be a logical way to define homogeneous groups.⁸

Suggested revisions

As suggested above, operational criteria specifying frequency and duration of complaints are necessary to define homogeneous groups with a clear separation of severe, persistent sexual dysfunction from transient disturbances that may resolve without professional attention.

There are numerous other issues that need to be remedied in DSM-V. For example, DSM-IV-TR requires that the diagnosis of hypoactive sexual desire disorder be based on absent or deficient sexual fantasies and the desire for sexual activity. Studies indicate that many women who are sexually responsive do not report having sexual fantasies. Also, some women report responding to partner advances yet not being aware of desire for sexual activity before partner initiation. This controversy and lack of clarity has led some to propose adding the "lack of responsive desire" criterion to the diagnostic criteria for femalehypoactive sexual desire disorder.⁹

The diagnosis of vaginismus in DSM-IV-TR is based on "recurrent or persistent involuntary spasm of the outer third of the vagina." However, recent research suggests that involutary contraction of the musculature of the vaginal wall may be present in only a subgroup of women with vaginismus. Phobic avoidance of penetration may be the defining aspect of this syndrome.¹⁰

Another problematic issue in DSM-IV-TR is subtyping by causation. As we acquire more information about sexual disorders, it is clear that some disorders-especially hypoactive sexual desire disorder-are idiopathic.¹¹ Requiring a distinction between sexual disorders that are due to psychological factors and those due to combined factors implies a knowledge regarding causation that is often absent.

In addition, the question of whether classifying dyspareunia as a sexual dysfunction is appropriate has been raised and the suggestion made that it be classified instead as a pain disorder.¹² The area of female sexual dysfunction is perhaps the most problematic and confusing. Some experts have even questioned the existence of female sexual dysfunction and/or separate female sexual dysfunction entities and have suggested that the entire area of female sexual dysfunction diagnoses is at least in part created by the pharmaceutical industry.¹³ This viewpoint, although valid to some degree, is clearly an oversimplification of the issues.

Pharmaceutical companies, driven by the profit motive, discover interventions for conditions that previously were untreatable. Subsequently, the marketing arm of these companies tries to increase the population for whom a treatment may be given in order to expand the market for their products. It is the health care professional's role to be certain that any given interven- tion is indeed appropriate for each patient.

Concluding remarks

The DSM-V subgroup on sexual disorders should be convening in the near future. The group faces an exciting challenge because considerable information on the sexual disorders regarding issues such as distress and duration of sexual dysfunction has been reported since the publication of DSM-IV-TR. We now may be able to adapt meaningful operational criteria for these diagnoses and correct previous misconceptions about diagnostic criteria. It will also be especially challenging to address the biopsychosocial concept of sexual dysfunction, to face off demands of special interest groups, and to avoid both biological and psychological reductionism.

Hopefully, more precise criteria sets will facilitate clinical research and permit the development of meaningful treatment algorithms.

References:

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