Intended or Unintended Consequences? The Likely Implications of Raising the Bar for Sexual Dysfunction Diagnosis in the Proposed DSM-V Revisions: 1. For Women with Incomplete Loss of Desire or Sexual Receptivity

Abstract

Introduction Combining female sexual desire and arousal disorders is proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Brotto et al. challenged our findings that the proposed criteria could potentially exclude from diagnosis or treatment a large number of women with distressing loss of function or in sexual desire, because (i) our samples were insufficiently severe; (ii) we sought to retain the current diagnostic criteria, whereas they contend that “the bar should be raised”; and (iii) the current sexual function diagnostic criteria are unreliable. Aim Here we provide additional data to support our view suggesting that the proposed criteria would potentially exclude large numbers of women from diagnosis or treatment if they have moderate-to-marked (rather than severe) hypoactive sexual desire disorder (HSDD), or HSDD with incomplete loss of receptivity. Methods In nontreatment validation studies of 481 women in North America and Europe, 231 women diagnosed with HSDD only were compared to women with no female sexual desire. Main Outcome Measures Clinicians experienced in sexual medicine determined the severity of HSDD using the standard Clinical Global Impression of Severity. Rating scale data were also used, including the clinician-rated Sexual Desire and Interest Inventory-Female and the self-rated Female Sexual Function Index, Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, and an e-Diary about desire during sexual events. Results The severity of the HSDD was rated by clinicians as generally moderate-to-marked, not mild. The women with HSDD scored as manifestly sexually dysfunctional and significantly sexually distressed, and reported markedly fewer satisfying sexual events compared to age-matched, non-dysfunctional controls, even for those with moderate or milder degrees of severity, providing compelling evidence that our sample of women with HSDD had clinically disordered sexual function. Yet the proposed criteria would apparently allow diagnosis (and therefore treatment) of only severe desire dysfunction. Conclusion It would be counterproductive to combine the two disorders, to make individual criteria for the disorders more stringent or to require more such criteria for a diagnosis because such disorders tend to be distinct in presentation, in treatability with currently available therapies, and in logical approaches to be tested to improve therapy.

DSM-5 Changes in Diagnostic Criteria of Sexual Dysfunctions

“…Sarin et al disputed the aforementioned claims and argued that the new criteria excluded an excessively large number of low desire and arousal patients [15]. Clayton et al further argued that the combination of the two diagnoses was counterproductive because patients with hypoactive sexual disorder often presented with incomplete loss of receptivity and were therefore likely to be excluded using the new criteria [16]. Moreover, they contended that most women with sexual arousal disorder met none of the proposed "A" criteria for female sexual interest/arousal disorder and would also be left out [17].…”

Hypoactive sexual desire in women

“…39,40 provided evidence that the DSM 5 11 would raise the bar so high for diagnosis that many of the women who would otherwise have met the DSM-IV-TR 12 criteria for FSAD or HSDD would no longer meet the criteria for the DSM 5 11 FSIAD and thus would be undiagnosed and untreated. 39,40 provided evidence that the DSM 5 11 would raise the bar so high for diagnosis that many of the women who would otherwise have met the DSM-IV-TR 12 criteria for FSAD or HSDD would no longer meet the criteria for the DSM 5 11 FSIAD and thus would be undiagnosed and untreated.…”

Bringing the body of the iceberg to the surface: the Female Sexual Dysfunction Index-6 (FSDI-6) in the screening of female sexual dysfunction

“…The decision to combine the two diagnoses is based on the conclusion that the two disorders cannot be reliably differentiated [16]. However, it has also been argued that this new criterion could be counterproductive, because women with low desire often complain only of reduced receptivity, and were, therefore, likely to be excluded [17]. Hence, we decided to maintain a question related to genital sensation and lubrication during sexual activity.…”