Sandra R Leiblum
The diagnosis of sexual behavior as either healthy or dysfunctional is mutable and subject to varying social and cultural expectations about sexual conduct, as well as being affected by greater sophistication of scientific knowledge, sexual psychophysiology, and current clinical practice. Consequently, it should come as no surprise that the classification of female sexual dysfunction is somewhat arbitrary, imprecise, and changeable.
In fact, the classification and diagnosis of sexual disorders are a challenging undertaking. Certain behaviors that were once considered aberrant are now widely accepted as normal (e.g., homosexual behavior), and what once was considered normal (e.g., lack of sexual enthusiasm or interest in women) has come to be considered dysfunctional. Women who displayed too much sexual interest were considered to be nymphomaniacs a century ago and were the object of medical attention and concern. Nowadays, hypoactive rather than hyperactive sexual desire is the most common female sexual dysfunction.1,2
Despite the fact that classification systems are changeable, they are necessary. They help order our knowledge and understanding of behavior. The classification of sexual disorders helps differentiate sexual complaints, that is, short-lived and transient disruptions or dissatisfactions with current sexual function, from sexual dysfunctions, persistent problems causing genuine personal distress (see Chapters 2.1—2.4 in this volume).
Thoughtful diagnoses help legitimatize sexual disorders as warranting attention and intervention from health professionals. A sound sexual nosology helps justify treatment reimbursement by insurance carriers and/or managed care providers. Identification of agreed-upon diagnostic entities serves as a stimulus for research and treatment. Well-defined diagnoses of sexual problems permit the development of assessment instruments and help with the identification of reasonable endpoints for treatment, whether pharmacologic or psychologic (see Chapter 16.1). A widely accepted diagnostic nomenclature provides a common language for communication between health-care professionals involved in the remediation of those disorders. Perhaps most important in recent years has been the recognition that accurate, reliable, and valid diagnoses are essential for determining inclusion or exclusion into research or clinical trials that investigate new pharmacotherapy, and hormonal or psychologic treatment interventions (see Chapter 11.2).
In reviewing how definitions of sexual dysfunction have evolved over the last 50 years, changes in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) provide a good starting point. In the first edition (DSM-I), which appeared in 1952,3 there were no diagnostic terms for sexual dysfunction, although the manual did include a section on sexual deviations. The second edition (DSM-II) (1968) included two sets of diagnostic terms for sexual disorders, which appeared in the section entitled “Psychophysiologic disorders”. These were described as physical symptoms caused by emotional factors involving a single organ system, as in relation to menstruation, micturition, and the two sexual disorders of dyspareunia (painful intercourse) and impotence (difficulties in obtaining or maintaining an erection). There was no identification of possible problems involving sexual drive, orgasm, or early or delayed ejaculation. The underlying hypothesis guiding these terms was the belief that the problems were basically psychophysiologic in nature, although both DSM-I and DSM-II were based on psychoanalytic theories. This approach to psychiatric diagnosis was abandoned by American psychiatry in 1980 with the publication of the third edition (DSM-III).
The nomenclature of female sexual dysfunction changed dramatically as a consequence of the publication of Human Sexual Response by Masters and Johnson in 19664 and their subsequent volume, Human Sexual Inadequacy (1970).5 Masters and Johnson described a sexual response cycle which they considered characteristic of both men and women. It consisted of four phases: excitement, plateau, orgasm, and resolution. Shortly after their description of the sexual response cycle, Helen Singer Kaplan (1977)6 amended it to include a salient missing phase, namely, that of sexual desire (see Chapter 1.1).
Sexual dysfunctions were then linked to each phase, and these became the foundation on which the psychosexual diagnoses described in the third edition of the DSM (DSM-III, 1980) were based. Inhibition of the appetitive or psychophysiologic changes that characterize the normal sexual response cycle was considered pathologic. However, the diagnosis of a psychosexual dysfunction was not made if the disorder was considered to be primarily due to organic factors such as a physical disease or condition, medication, or another Axis I disorder.
DSM-III included five terms for psychosexual disorders: inhibited sexual desire, inhibited sexual excitement (variously described as frigidity or impotence), inhibited female orgasm, inhibited male orgasm, premature ejaculation, functional dyspareunia, and functional vaginismus. In order to qualify for diagnosis, the disorder had to be due to something other than organic factors.
A notable change occurred in the revision of the third edition of the DSM (DSM-III-R), published in 1987. What had formerly been described as psychosexual dysfunction were now described as “sexual dysfunctions”, but the essential feature of diagnosis remained the belief that the responsible agent underlying dysfunction was psychologic inhibition. Interestingly, DSM-III-R acknowledged that, while there was no empirical evidence of an association between personality traits and sexual dysfunction, it was clear that anxiety, high internal standards for sexual performance, and unusual sensitivity to real or imagined rejection by a sexual partner predisposed the individual to the development of sexual disorder.
DSM-III-R did include greater recognition of subjective experience as relevant to diagnosis. For instance, in the diagnosis of female arousal disorder, “persistent or recurrent lack of a subjective sense of sexual excitement and pleasure during sexual activity” was integral to diagnosis. However, the definition of orgasmic disorders retained the term “inhibited”, suggesting an underlying psychologic etiology.
Things changed significantly with the publication of the fourth edition (1994) of the DSM (DSM-IV), which devoted an entire section to the diagnosis of sexual disorders. The belief that psychologic inhibition interfers with the ability to experience orgasm had not been supported by an evidence-based review of the literature; therefore, the diagnosis of orgasmic disorders was substantially changed. The idea that psychopathologic disorders are caused primarily by psychologic inhibition was abandoned. Psychosexual disorders were described as distur bances, in sexual desire and in the psychophysiologic changes that characterize the sexual response cycle, which cause marked distress and interpersonal difficulty.
There was no attempt to specify a specific frequency of sexual behavior or activity as normative or deviant. Rather, the determination of whether a condition warranted diagnosis was to be made by the clinician, taking into account such factors as the age and experience of the individual, the frequency and chronicity of symptoms, the degree of subjective distress, and the impact on other areas of function. In addition, the clinician was advised to consider the contributions of an individual’s ethnic, cultural, religious, and social background which might influence sexual desire, expectations, and attitudes to sexual performance.
With the growing recognition that general medical conditions and substance use affect sexual function, DSM-IV includes diagnoses for sexual dysfunction caused by a medical condition and substance-induced sexual dysfunction. The essential feature of sexual dysfunction caused by a general medical condition was the assumption that the sexual dysfunction was a result of the direct physiologic effects of a generalized medical condition: “there must be evidence from the history, physical examination, or laboratory findings that the dysfunction is fully explained by the direct physiologic effects of a general medical condition”.3
It is now widely acknowledged that it is nearly impossible to separate conditions that are primarily due to organic causes from those with psychologic etiologies, since the overlap is so considerable.7 Indeed, in most instances, the exact pathogenesis of sexual dysfunction is uncertain, and multiple psychologic, interpersonal, and organic contributions are involved.
Female sexual dysfunction reconsidered: recent developments
Many clinicians and researchers were dissatisfied with the DSM-IV diagnoses of female sexual problems.8,9 They objected to the heterosexist, phallocentric model of sexual behavior on which the diagnoses were based, with intercourse being considered the reference standard or referent for many of the diagnoses. They believed that it was inaccurate to present male and female disorders as parallel representations of the same phenomenon when, in fact, women’s arousal and pain disorders were quite different from those experienced by men.
The diagnostic categories in DSM-IV were organized in such a way as to suggest that sexual response unfolded in a clear- cut linear sequence of desire, arousal, and orgasm, although there was evidence that a more circular and interactive model applied with arousal and desire influencing and stimulating each other. Moreover, research evidence indicated that diagnoses tended to co-occur, with desire and arousal being particularly difficult to separate.10
Of particular importance was the lack of recognition of the emotional and interpersonal aspects of sexual exchange. There was little acknowledgment that sexual behavior usually occurs in an interpersonal context and that the adequacy and acceptability of past and current relationship, partner function/ dysfunction, sexual incentives and motivation, adequacy of stimulation, and other environmental and contextual variables are crucial in assessing and evaluating sexual function or dysfunction.
Finally, the DSM-IV separation of disorders into those due primarily to either medical or psychologic factors was felt to be unjustified, since as noted above, the etiology of nearly all sexual dysfunctions tends to be a complicated admixture of organic, psychogenic, and interpersonal factors.
Consensus conferences to reconsider diagnosis of female sexual dysfunction
With these limitations in mind, a consensus conference was convened by the sexual function health council of the American Foundation for Urologic Disease in 1998 to review and update the classification of female sexual disorders.11 A multidisciplinary group of European and North American academic and clinical experts in the field of women’s sexuality reviewed the published evidence, debated and discussed the current nosology, and recommended modifications of the DSM- IV definitions of female sexual dysfunction.
Although the resulting document continued to rely on the traditional model of sexual response, small but important modifications were made to each definition. For example, the DSM-IV definition of hypoactive sexual desire was amended to emphasize the importance of receptive as well as intrinsic desire for women. In DSM-IV, hypoactive sexual desire disorder was defined as “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity”. The consensus conference redefined the disorder as “persistent or recurrent deficiency (or absence) of sexual fantasies, and/or desire for, or receptivity to, sexual activity which causes personal distress”.11 This was based on research highlighting the finding that many women do not routinely experience spontaneous sexual desire but are receptive to, and interested in, sexual activity once underway and subjective sexual excitement is experienced.12
The revised definition of orgasmic disorder emphasized the importance of sufficient sexual stimulation and sexual arousal as intrinsic to the diagnosis of orgasmic disorder. If sexual arousal is insufficient or inadequate, the appropriate diagnosis would be arousal disorder.
The sexual pain disorders were extended to include a third category of pain, noncoital sexual pain, to acknowledge that pain may be experienced and reported by the woman during sexual activities other than intercourse.
Female sexual arousal disorder proved to be the sexual dysfunction most difficult to describe accurately, since, historically, it had rarely been diagnosed independently of desire or orgasm disorders. While the presence of lubrication was generally seen as the hallmark of sexual arousal, a sizeable body of psychophysiologic research highlighted the fact that the correlation between lubrication or vasocongestion and women’s report of subjective arousal was rather inconsistent.13-16 In order to acknowledge the importance of mental or subjective arousal as primary when making a diagnosis, the new definition of female sexual arousal disorder became “persistent or recurrent inability to attain or maintain sufficient sexual excitement causing personal distress. It may be expressed as a lack of subjective excitement or a lack of genital lubrication/swelling or other somatic response.”11
Each specified disorder had to be accompanied by the women’s report of personal distress about the complaint. This was emphasized in order to avoid pathologizing normative variations in female sexual response and to underline the fact that women experience alterations in their sexual life that are often not experienced as personally distressing even though they may be distressing to a partner (e.g., failure to attain an orgasm during intercourse).
Subtypes of disorders were to be specified as either lifelong or acquired, generalized or situational. In order to acknowledge that the causes of sexual dysfunction are often unknown, it was suggested that a new category be added to the list of etiologic determinants. Thus, the etiologic specifiers of a disorder became organic, psychogenic, mixed, or unknown. It was hoped that the addition of the “unknown” category would stimulate innovative research.
Problems with diagnoses remain
While these changes were valuable, there remained dissatisfaction with the revised diagnoses. In part, the problem stemmed from the continued reliance on what was seen to be an invalid model of women’s sexual response cycle. The traditional model, namely, that described by Masters and Johnson in 1966,4 seemed to fit men better than women with its inherent linearity and sequential stages of desire, arousal, and orgasm.1 Basson17 and others18,19 challenged the assumption that desire invariably precedes arousal when, in fact, sexual arousal appears to trigger awareness and feelings of sexual desire for many women. Further, the lack of specificity regarding the various presentations of sexual arousal problems was viewed as problematic, since deficits in genital arousal are typically due to different causes and necessitate different interventions than deficits in subjective or mental arousal.
In light of these shortcomings, a second consensus conference was convened by the Sexual Health Council of the American Foundation of Urologic Diseases in 2003. The group was charged with undertaking a comprehensive review of the evidence supporting or refuting the existing definitions and was asked to offer recommendations for revision.
Latest recommendations proposed by the second consensus conference on female sexual nosology (2003)
As with the first consensus conference, an international and interdisciplinary group of clinical and research experts in female sexuality was recruited to revise and update the diagnoses. After a comprehensive, evidence-based review of published research, the following revisions in the diagnostic nomenclature of women’s sexual dysfunctions were made (Table 9.1.1).7
Hypoactive sexual desire disorder was renamed “women’s sexual interest/desire disorder” and was defined as follows: absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and lack of responsive desire. Motivation (here defined as reasons/incentives) to attempt to become sexually aroused is weak or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.
The word “interest” was used along with the word “desire” in the new definition to reflect the fact that many women engage in sex for reasons other than intrinsic physical desire. In fact, a multiplicity of motives for initiating or engaging in sex exist apart from physical desire, including such incentives as wanting to please or placate a partner, wanting a “reward” from a partner, or, more negatively, wanting to forestall anticipated anger or punishment.19-21
The new definition acknowledges that there are fluctuations in desire that occur with age, life cycle, and relationship duration as well as with current contextual factors, and that lack of desire may be normative and even adaptive depending on the circumstances of a woman’s life. Furthermore, the de-emphasis on sexual fantasies or thoughts as a hallmark of desire was deliberate, since many women report a total absence of sexual thoughts and/or fantasies despite good arousal and receptive desire.22-24 What is considered crucial in the new definition is the persistent absence of receptive desire and motivation to be sexual along with personal distress about the condition.
Considerable changes were made in the diagnoses of sexual arousal (Table 9.1.2). In order to highlight the repeated observation that subjective arousal does not always strongly correlate with genital congestion,13-16 the definition of female sexual arousal disorder was subdivided into three specific categories: subjective, genital, and combined. The new definitions are as follows:
• “subjective sexual arousal disorder”: absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.
• “genital sexual arousal disorder”: complaints of absent or impaired genital sexual arousal. Self-reports may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital sexual stimuli.
• “combined genital and subjective arousal disorder”: absence of, or markedly diminished feelings of, sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).
While genital and combined arousal disorders reflect complaints that are quite common among certain populations of women (e.g., those who have undergone surgical menopause without hormonal replacement, who are receiving chemotherapy, or who have sustained autonomic nerve impairment), women who complain about lack of mental excitement or subjective arousal often report no problems with vaginal lubrication. In fact, they may have perfectly adequate vasoconges- tion but feel an absence of mental excitement or a feeling of being “turned on”. Consequently, the treatment of women who lack mental excitement may be quite different from that of women who report lack of genital arousal. The former group of women may benefit from treatment that helps them better focus on their sexual arousal and overcome existing feelings of guilt, inhibition, or distraction due to their past history or present circumstance, whereas women with genital or combined arousal disorders may derive greater benefit from hormonal therapy or pharmacotherapy.24
The combined subjective/genital arousal disorder is the most common sexual arousal complaint and is usually comorbid with a lack of sexual desire/interest that must be treated along with (or instead of) the arousal complaint.
Finally, a new category of female arousal disorder was described and recommended for provisional inclusion in the revised diagnostic system, namely, persistent sexual arousal syndrome.25,26 This syndrome was based on the reports of many clinicians who had seen (or were seeing) women who complained of excessive and persistent vaginal and clitoral sexual arousal in the absence of conscious feelings of sexual desire. The feelings of genital arousal were described as unwanted and intrusive and did not subside with one or more orgasms. A normal refractory or resolution period was missing, and the feelings of genital vasocongestion and tingling occurred without an identifiable stimulus or trigger.
“Persistent sexual arousal disorder” was defined as spontaneous, intrusive, and unwanted genital arousal (e.g., tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one or more orgasms, and the feelings of arousal persist for hours or days.
It was hoped that by offering a provisional definition of this complaint, research in the etiology, epidemiology, and treatment of persistent arousal would be stimulated.
The definition of orgasmic disorder was clarified in order to emphasize that adequate sexual arousal must be present before making the diagnosis, since, in the past, the criterion of high or “adequate” arousal was often ignored.
The revised diagnosis of “women’s orgasmic disorder”
(Table 9.1.3) now specifies that, despite the self-report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation.
The definitions of dyspareunia and vaginismus were updated and amended (Table 9.1.4).
“Dyspareunia” is defined as persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse. This definition avoids the emphasis on pain during coitus as being essential to the diagnosis, since pain may be experienced with any attempt at vaginal insertion or even with only the anticipation of vaginal pain from past experiences.
The new definition of “vaginismus” is persistent difficulty in allowing vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance, and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed. The new definition avoids the suggestion that a vaginal spasm is responsible for the inability to tolerate vaginal insertion, given the recent empirical finding that the vaginal muscle spasm is unreli- able.27 Rather, reflexive involuntary contraction of the pelvic muscles in addition to thigh adduction, contraction of the abdominal muscles, and the description of fear and/or anxiety are associated with attempts to insert any object, be it a penis, tampon, speculum, or finger, into the vaginal introitus. When accompanied by great discomfort and pain, vaginismus may be diagnosed even if vaginal insertion is possible.
Table 9.1.1. Changing definitions of women's sexual desire disorders
DSM-IV-TR30 definition of hypoactive sexual desire disorder
Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning such as age and the context of the person's life. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Consensus Conference 2000 definition of hypoactive sexual desire disorder
The persistent or recurrent deficiency (or absence) of sexual fantasies/ thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress.
Consensus Conference 2003 definition of women's sexual interest/desire disorder
Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies and a lack of responsive desire. Motivations (here defined as reasons/incentives), for attempting to become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.
DSM-IV-TR definition of sexual aversion disorder
Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital contact with a sexual partner. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction).
Consensus Conference 2000 definition of sexual aversion disorder
Persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.
Consensus Conference 2003 definition of sexual aversion disorder
Extreme anxiety and/or disgust at the anticipation of/or attempt to have any sexual activity.
Table 9.1.2. Changing definitions of women's sexual arousal disorders
DSM-IV-TR30 definition of female sexual arousal disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response to sexual excitement. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Consensus Conference 2000 definition of female sexual arousal disorder
The persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses.
Consensus Conference 2003 definition of subjective sexual arousal disorder
Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.
Consensus Conference 2003 definition of genital sexual arousal disorder
Absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital sexual stimuli.
Consensus Conference 2003 definition of combined genital and subjective arousal disorder
Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).
Consensus Conference 2003 definition of persistent sexual arousal disorder (provisional diagnosis)
Spontaneous, intrusive and unwanted genital arousal (e.g., tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one or more orgasms, and the feelings of arousal persist for hours or days.
Finally, sexual aversion disorder was retained as a sexual diagnosis, although some felt that it might be better seen as a phobia and treated as such. The decision to retain it as part of sexual nosology was based on the sexual context in which the symptoms occur, its typical etiology, and the reliance on sex therapy interventions for successful resolution.
Table 9.1.3. Changing definitions of female orgasmic disorder
DSM-IV-TR30 Definition of female orgasmic disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. The disturbance causes marked distress or interpersonal difficulty. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Consensus Conference 2000 definition of female orgasmic disorder
Persistent or recurrent difficulty, delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.
Consensus Conference 2003 definition of women's orgasmic disorder
Despite the self-report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation.
Table 9.1.4. Changing definitions of women's sexual pain disorders
DSM-IV-TR30 definitions of sexual pain disorders
Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse. The disturbance causes marked distress or interpersonal difficulty. The disturbance is not caused exclusively by vaginismus or lack of lubrication, is not better accounted for by another Axis I disorder (except another sexual dysfunction), and is not due exclusively to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. The disturbance causes marked distress or interpersonal difficulty. The disturbance is not better accounted for by another Axis I disorder (e.g., somatization disorder) and is not due exclusively to the direct physiologic effects of a general medical condition.
Consensus Conference 2000 definitions of sexual pain disorders
Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse.
Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.
Noncoital pain disorder: recurrent or persistent genital pain induced by noncoital sexual stimulation.
Consensus Conference 2003 definitions of sexual pain disorders
Dyspareunia: persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.
Vaginismus: persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the woman's expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance, and anticipation/fear/ experience of pain. Structural or other physical abnormalities must be ruled out/addressed.
“Sexual aversion disorder” was defined as extreme anxiety and/or disgust at the anticipation of/or attempt to have any sexual activity.
Etiologic specifiers recommended
In addition to revising the existing definitions of female sexual dysfunction, the committee felt it was important to include some indication as to the possible etiologic or maintaining factors associated with the problem. It was believed that if the significant contextual and interpersonal contributions to the problem could be determined at the time of diagnosis, more relevant and sensible treatment interventions could be offered.
It was recommended that the following three classes of specifiers or descriptors be included when making a diagnosis:
I. Negative upbringing/losses/trauma (physical, sexual, emotional), past interpersonal relationships, cultural/religious restrictions
II. Current interpersonal difficulties, partner sexual dysfunction, inadequate stimulation, and unsatisfactory sexual and emotional contexts
III. Medical conditions, psychiatric conditions, medications, substance abuse.
For many women, all three classes of factors are implicated in the development and maintenance of a problem: a developmental history marred by loss, trauma or inhibition, an unsatisfactory partner relationship characterized by conflict or partner sexual dysfunction, and medications which interfere with sexual desire or arousal. In these cases, all three descriptors should be given along with the diagnosis.
As in the past, it was recommended that disorders be identified as either lifelong or acquired, generalized, or situational.
Assessment of distress
Finally, in light of the fact that women report varying levels of distress associated with sexual difficulties, it was recommended that an indication of relative distress be included as part of the diagnosis. Ratings of subjective distress may have important implications for treatment motivation and outcome. At the simplest level, it was recommended that a rating of none, mild, moderate, or severe distress might suffice, based on the women’s self-report, although validated distress measures were seen as preferable, such as the Female Sexual Distress Scale28 or the Sexual Satisfaction Scale for Women, which includes measures of personal and interpersonal distress.29
As is evident from this brief review of changes in the conceptualization and description of women’s sexual response cycle and definition of female sexual disorders, reasonable and accurate diagnosis of sexual dysfunction in women is a challenging undertaking. As greater sophistication and understanding of the biologic, neurologic, psychologic, interpersonal, and cultural contributions to women’s sexuality occur, there will be a need for still more diagnostic amendments.
The recently revised definitions of female sexual disorders are certainly an improvement over earlier definitions. They are based on a model of women’s sexual response cycle that is a more accurate depiction of women’s sexual reality, as well as being based more closely on evidence-based research. The revised definitions provide greater specificity in and refinement of the variety of sexual arousal disorders in women that should prove helpful in guiding both research and clinical intervention. Although the diagnoses are more specific and detailed than earlier iterations, they do reflect the complexity of women’s sexuality and are currently guiding the development of standardized diagnostic interviews.
However, the revised diagnoses remain recommendations at this time. They have not yet been officially adopted by the DSM or the World Health Organization’s International Classification of Diseases. At present, the most widely accepted nomenclature for the diagnosis of women’s sexual disorders continues to be those found in the “Text Revision” of DSM-IV (DSM-IV-TR), published in 2000, or the first consensus conference.11
Finally, these definitions will undoubtedly continue to evolve with new research and clinical data illuminating the anatomic, neurologic, physiologic, psychologic, interpersonal, and cultural contributions to women’s sexual function.
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