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Editorial   |    
Issues for DSM-V: Sexual Dysfunction, Disorder, or Variation Along Normal Distribution: Toward Rethinking DSM Criteria of Sexual Dysfunctions
Richard Balon, M.D.; R. Taylor Segraves, M.D., PH.D.; Anita Clayton, M.D.
Am J Psychiatry 2007;164:198-200. doi:10.1176/appi.ajp.164.2.198

Human sexuality lately has become one of psychiatry’s Cinderellas. That status has been reflected, among others, in the lack of movement in sharpening and redefining of the diagnostic criteria, and the lack of operational criteria for diagnosing human sexual dysfunctions/disorders similar to the operational criteria for diagnosing other mental disorders.

In our view, three important issues that need to be addressed in the next revision of DSM are 1) when does a sexual problem become a sexual dysfunction (1), 2) whether there should be a specific duration criterion for sexual dysfunction(s) akin to the duration criterion for many other mental disorders, and 3) whether distress (used across DSM) should be used as a diagnostic criterion of sexual disorders. These issues are actually intertwined.

According to the analysis by Laumann et al. (2) of the National Health and Social Life Survey, the prevalence of sexual dysfunction in the United States is 43% for women and 31% for men. However, as Bancroft et al. (1) pointed out, it is not clear what proportion of problems identified in this and other epidemiological studies as sexual dysfunction could be best identified as “adaptive or understandable reactions to current circumstances.” Discussing methodological problems across epidemiological studies, such as questions about the frequency of dysfunction and different periods of duration (e.g., previous year [2] or previous 3 months [3]), Bancroft et al. suggested that we need to be cautious about estimating the prevalence of “sexual dysfunction” in the population. We propose that sexual dysfunction needs to be separated from transient alterations of sexual behavior related to life stress, interpersonal problems, or due to various other disorders (which could be defined, for example, as adjustment disorder with sexual dysfunction, sexual dysfunction due to mental disorder, or sexual dysfunction due to a general medical condition).

The DSM criteria for many disorders include the duration of illness or disturbance, ranging from weeks to 6 months. However, duration is not a part of the diagnostic criteria for sexual dysfunctions. Yet, including a duration criterion of 6 months, for example, may help to identify more homogenous group(s) and distinguish sexual dysfunction(s) from transient alterations of sexual behavior due to stress. In a study by Mercer et al. (4), persistent sexual problems lasting at least 6 months in the preceding year (6.2% of men and 15.6% of women) were less frequent than sexual dysfunction lasting 1 month and less frequent than estimates of sexual dysfunction in other studies (e.g., 31% and 43% respectively in the Laumann et al. study [2]). We believe that the duration criterion of 6 months should be added to the future diagnostic criteria together with a refined (e.g., frequency or occurrence at a specific percentage of the time) definition of specific sexual dysfunction.

Marked distress or interpersonal difficulty is a criterion of all DSM-defined sexual dysfunctions. Intuitively this criterion helps to delineate a disorder or dysfunction from a normal variant of functioning. However, some studies (e.g., that of Bancroft et al. [1]) that estimated the prevalence of sexual dysfunction did not ask about distress, or found that a significant portion of those suffering from sexual dysfunction were not distressed by it. Oberg et al. (5) noted that less than 45% of Swedish women with manifest low interest and orgasm perceived these dysfunctions as distressing. Waldinger and Schweitzer (6, 7) argue that the distress criterion is not useful in defining premature ejaculation, since there are many men with this dysfunction without marked distress or interpersonal difficulty. This way men whose time to ejaculation is 2 minutes may be grouped with men whose time to ejaculation is more than 12 minutes because of poor specificity combined with the distress criterion. They also suggest that in some men, premature or rapid ejaculation is not based on neurobiological or psychological pathology but is rather a normal variant of sexual performance. We propose that the addition of distress/interpersonal difficulty to the diagnostic criteria of sexual dysfunctions be reevaluated in view of the evidence that some persons with sexual dysfunction are not distressed by it. If this criterion is retained, the distress should be clearly defined in terms such as causing concerns, worry, or anxiety or disrupting the nonsexual aspects of the relationship. As Waldinger and Schweitzer suggest (7), the severity of the dysfunction could also be expressed by different degrees of distress and interpersonal difficulty.

A whole host of other issues could be reevaluated. Some (8) believe that female sexual dysfunction does not exist as a specific diagnosis, since it is a spectrum of disorders with extensive overlap between them. The diagnostic criteria of sexual dysfunctions are anchored in the particular phases of the sexual response cycle. However, frequently, sexual dysfunction does not happen in isolation as a dysfunction of only one phase of the sexual response cycle. Furthermore, an international group of experts (9) recently suggested reevaluating the entire area of female sexual dysfunction. They proposed adding a lack of responsive desire to the criteria of female hypoactive sexual desire disorder. This group also noted that cognitive and genital measures of arousal are poorly correlated and thus suggested creating diagnostic categories such as subjective sexual arousal disorder, combined genital and subjective sexual arousal disorder, and genital sexual arousal disorder. Another proposal for change comes from Binik (10), who suggests that dyspareunia should not be classified as a sexual dysfunction but as a pain disorder. We also feel that the area of diagnosis of female sexual dysfunction should be evaluated carefully in view of a controversial suggestion that the pharmaceutical industry has created a new “disease” of female sexual dysfunction (11).

We hope that at least the issues of sexual problem versus sexual dysfunction, duration of sexual dysfunction, and the use of distress as a diagnostic criterion will be addressed in the next DSM edition. As for the remaining issues, we can only hope that they will also be discussed and evaluated as the diagnosis of sexual dysfunction is refined.

1.Bancroft J, Loftus J, Long JS: Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003; 32:193–208
 
2.Laumann EO, Paik A, Rosen RC: Sexual dysfunction in the United States. prevalence and predictors. JAMA 1999; 281:537–544
 
3.Dunn KM, Croft PR, Hackett GI: Sexual problems: a study of the prevalence and need for health care in the general population. Family Practice 1998; 15:519–524
 
4.Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall W, McManus S, Nanchahal K, Erens B: Sexual function problems and help seeking behaviour in Britain: National Probability Sample Study. BMJ 2003; 327:426–427
 
5.Oberg K, Fugl-Meyer AR, Fugl-Meyer KS: On categorization and quantification of women’s sexual dysfunctions: an epidemiological approach. Int J Impotence Res 2004; 16:261–269
 
6.Waldinger MD, Schweitzer DH: Changing paradigms for a historical DSM-III and DSM-IV view toward an evidence-based definition of premature ejaculation, part I: validity of DSM-IV-TR. J Sex Med 2006; 3:682–692
 
7.Waldinger MD, Schweitzer DH: Changing paradigms for a historical DSM-III and DSM-IV view toward an evidence-based definition of premature ejaculation, part II: proposals for DSM-V and ICD-11. J Sex Med 2006; 3:693–705
 
8.Gierhart BS: When does a “less than perfect” sex life become female sexual dysfunction? Obstetrics & Gynecology 2006; 107:75–751
 
9.Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, Grazziotin A, Heiman JR, Laan E, Meston C, Schover L, van Lankveld J, Schultz WW: Revised definitions of women’s sexual dysfunction. J Sex Med 2004; 1:40–48
 
10.Binik YM: Should dyspareunia be retained as a sexual dysfunction in DSM-V? A painful classification. Arch Sex Behav 2005; 34:11–21
 
11.Moynihan R: The making of a disease: female sexual dysfunction. BMJ 2003; 326:45–47
 

Address correspondence and reprint requests to Dr. Balon, UPC-Jefferson, 2751 E. Jefferson #200, Detroit, MI 48207; rbalon@wayne.edu (e-mail).

Dr. Balon reports serving on the local Speakers bureau of GlaxoSmithKline and receiving research funding from Janssen. Dr. Segraves reports serving as a consultant for or receiving research funding from Abbott, AstraZeneca, Berlex, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Organon, Parke Davis, Pentech, Pfizer, Syntex, TAP, and Upjohn. Dr. Clayton reports serving as a consultant, advisor, or speaker for or receiving research funding from Boehringer-Ingelheim, Bristol-Myers Squibb, Cypress, Eli Lilly, Forest, GlaxoSmithKline, Kramer-Fabre, Neuronetics, Novartis, Pfizer, Sanofi-Aventis, Vela, and Wyeth. Dr. Freedman has reviewed this editorial and found no evidence of influence from these relationships.

Editorials discussing other DSM-V issues can be submitted to the Journal at http://appi.manuscriptcentral.com. Submissions should not exceed 500 words.

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References

1.Bancroft J, Loftus J, Long JS: Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003; 32:193–208
 
2.Laumann EO, Paik A, Rosen RC: Sexual dysfunction in the United States. prevalence and predictors. JAMA 1999; 281:537–544
 
3.Dunn KM, Croft PR, Hackett GI: Sexual problems: a study of the prevalence and need for health care in the general population. Family Practice 1998; 15:519–524
 
4.Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall W, McManus S, Nanchahal K, Erens B: Sexual function problems and help seeking behaviour in Britain: National Probability Sample Study. BMJ 2003; 327:426–427
 
5.Oberg K, Fugl-Meyer AR, Fugl-Meyer KS: On categorization and quantification of women’s sexual dysfunctions: an epidemiological approach. Int J Impotence Res 2004; 16:261–269
 
6.Waldinger MD, Schweitzer DH: Changing paradigms for a historical DSM-III and DSM-IV view toward an evidence-based definition of premature ejaculation, part I: validity of DSM-IV-TR. J Sex Med 2006; 3:682–692
 
7.Waldinger MD, Schweitzer DH: Changing paradigms for a historical DSM-III and DSM-IV view toward an evidence-based definition of premature ejaculation, part II: proposals for DSM-V and ICD-11. J Sex Med 2006; 3:693–705
 
8.Gierhart BS: When does a “less than perfect” sex life become female sexual dysfunction? Obstetrics & Gynecology 2006; 107:75–751
 
9.Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, Grazziotin A, Heiman JR, Laan E, Meston C, Schover L, van Lankveld J, Schultz WW: Revised definitions of women’s sexual dysfunction. J Sex Med 2004; 1:40–48
 
10.Binik YM: Should dyspareunia be retained as a sexual dysfunction in DSM-V? A painful classification. Arch Sex Behav 2005; 34:11–21
 
11.Moynihan R: The making of a disease: female sexual dysfunction. BMJ 2003; 326:45–47
 
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