CORE Metadata, citation and similar papers at core.ac.uk Provided by Brunel University Research Archive The DSM Diagnostic Criteria for Female Sexual Arousal Disorder Cynthia A. Graham1,2 1Oxford Doctoral Course in Clinical Psychology, Warneford Hospital, Oxford, England 2To whom correspondence should be addressed at Oxford Doctoral Course in Clinical Psychology, Isis Education Centre, Warneford Hospital, Headington, Oxford OX3 7JX, England; e-mail: [email protected] 2 ABSTRACT This article reviews and critiques the DSM-IV-TR diagnostic criteria for Female Sexual Arousal Disorder (FSAD). An overview of how the diagnostic criteria for FSAD have evolved over previous editions of the DSM is presented and research on prevalence and etiology of FSAD is briefly reviewed. Problems with the essential feature of the DSM-IV-TR diagnosis--“an inability to attain, or to maintain…an adequate lubrication-swelling response of sexual excitement”--are identified. The significant overlap between “arousal” and “desire” disorders is highlighted. Finally, specific recommendations for revision of the criteria for DSM-V are made, including use of a polythetic approach to the diagnosis and the addition of duration and severity criteria. KEY WORDS: Sexual Arousal Disorder; DSM-V; sexual problems; women 3 INTRODUCTION “…diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organizing and explaining the complexity of clinical experience in order to derive inferences about outcome and to guide decisions about treatment.” (Kendell & Jablensky, 2003, p. 5) The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1980) was the first to include the category of Psychosexual Disorders, defined as “inhibitions in sexual desire or the psychophysiological changes that characterize the sexual response cycle” (p. 261). Utilizing the human sexual response cycle (HRSC) model developed by Masters and Johnson (1966) as the framework, “inhibition” could occur at any one or more of the following “phases”: appetitive, excitement, orgasm, and resolution. The most recent edition of DSM (DSM-IV-TR) (American Psychiatric Association, 2000) preserved this basic structure, classifying sexual dysfunctions into the following categories: Sexual Desire Disorders, Sexual Arousal Disorders, Orgasmic Disorders, Sexual Pain Disorders, Sexual Dysfunction due to a General Medical Condition, Substance-Induced Sexual Dysfunction, and Sexual Dysfunction Not Otherwise Specified. The purpose of this paper is to review and critique the DSM diagnostic criteria for Female Sexual Arousal Disorder (FSAD). An overview of how the diagnostic criteria for FSAD have evolved over the last three editions of the DSM will first be presented. Following this, research on the prevalence and etiology of FSAD will be reviewed, and the relationship between arousal problems and distress discussed. Previous critiques of DSM and revised definitions that have been put forward will be reviewed. The specific diagnostic criteria for FSAD will be critically examined and key issues that should be considered for DSM-V identified. Finally, recommendations will be made for revision of the criteria. REVIEW OF THE DIAGNOSTIC CRITERIA FOR FSAD (DSM-III, DSM-III-R, AND DSM-IV) 4 The DSM-III diagnostic criteria for “Inhibited Sexual Excitement” are presented in Table 1. Note that, unlike subsequent editions of DSM, the same diagnostic label was used for men and women. This reflected the assumption at the time that male and female sexual response were similar and that vaginal lubrication was the counterpart to male penile erection. Although the DSM-III text described the excitement phase as consisting of “a subjective sense of sexual pleasure and accompanying physiological changes” (p. 276), the diagnostic criteria themselves only required impairment in genital arousal (penile erection in the male and lubrication/swelling in the female). In DSM-III-R (American Psychiatric Association, 1987), the Sexual Arousal Disorders were subdivided into Male Erectile Disorder (302.72) and Female Sexual Arousal Disorder (302.72). There was one important change in the diagnostic criteria for both sexes: Criterion A now required either impaired genital response (lubrication/swelling in the case of women, erection for men) or “persistent or recurrent lack of a subjective sense of sexual excitement and pleasure...during sexual activity” (see Table 2). The DSM-III-R text noted that, “In most instances there will be a disturbance in both the subjective sense of pleasure or desire and objective performance” (p. 261). In DSM-IV and DSM-IV-TR (American Psychiatric Association, 1994, 2000), lack of subjective excitement and pleasure was dropped from Criterion A for both male and female arousal disorders. Thus, in women, the diagnosis of FSAD could be made solely on the basis of impairment of “an adequate lubrication-swelling response” (see Table 3). In contrast with earlier DSM-III and III-R texts (which referred to subjective pleasure and non-genital physiologic changes such as breast tumescence), the emphasis in the DSM-IV text also shifted to genital changes associated with sexual arousal. For example, the “major” changes associated with sexual excitement were described as: “vasocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genitalia” (p. 494). The one mention 5 of subjective response in the text on FSAD reflects the lesser importance ascribed to subjective pleasure and excitement compared to genital arousal: “The individual with Female Sexual Arousal Disorder may have little or no subjective sense of sexual arousal” (p. 501) (my emphasis). The Work Group recommended that rather than retain the concept of subjective excitement and pleasure in the diagnostic criteria, diminished subjective sexual feelings are listed as an example of a Sexual Dysfunction Not Otherwise Specified (SDNOS) (302.70). It is interesting to consider the rationale for this increased focus on genital indicators of arousal and the removal of subjective feelings of sexual excitement and pleasure from the DSM-IV criteria. The DSM-III-R criteria were considered problematic for two reasons: (1) the vagueness of the criteria and the extent to which clinician judgement was required to make a diagnosis and (2) the combination of both subjective and physiological symptom criteria, particularly when studies had found poor concordance between subjective measures of arousal and genital measures, such as vaginal pulse amplitude (VPA), in women (Segraves, 1996a). Examination of the DSM-IV Sourcebook (Segraves, 1996a) reveals that, in the lead-up to DSM-IV, three options were considered: (1) deletion of the FSAD diagnosis (on the grounds that there was little evidence either of the clinical utility of the diagnosis or that FSAD existed as a “discrete syndrome”); (2) retention of the FSAD diagnosis and the DSM-III-R criteria; (3) modification of the criteria so that Criterion A include only impaired vaginal lubrication and not subjective response. Interestingly, although a literature review carried out supported deletion of the FSAD category (Option 1), the Work Group recommended Option 3 on the grounds that this would maintain “compatibility between the sexes and between the DSM-IV and ICD-10” (Segraves, 1996a, p. 1006). The Work Group recommendations pertaining to Male Erectile Disorder (ED) also called for the diagnostic criteria to be modified so that only erectile failure (and not reduced subjective excitement) 6 was required. The justification here was that in research studies the diagnosis of ED was based on “objective criteria alone” and that, clinically, “there is no evidence that men exist who have decreased sexual arousal in the absence of desire or orgasm dysfunction” (Segraves, 1996b, p. 1110). The International Statistical Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization, 1992) does have a diagnostic category of “Failure of Genital Response” (F52.2), but there is also a separate category labelled “Sexual Aversion and Lack of Sexual Enjoyment” (F52.1). Thus, although the Work Group sought “full compatibility with ICD-10” (Segraves, 1996a), this was not, in fact, what was achieved by removing subjective excitement and pleasure from the FSAD criteria. Another major change in DSM-IV was the inclusion of Criterion B (i.e., the requirement that the problem causes “marked distress or interpersonal difficulty”); this criterion was added to the criteria sets for all the sexual dysfunctions in DSM-IV. The relationship between distress and symptoms of FSAD will be discussed below. Criterion C of DSM-IV criteria for FSAD restricted the diagnosis to those cases where “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 physiological effects of a substance…or a general medical condition.” In DSM-III-R (American Psychiatric Association, 1987), subtyping (lifelong or acquired; generalized or situational; psychogenic only or psychogenic and biogenic) had been added. Although these subtypes were retained in DSM-IV-TR, “psychogenic only” was renamed “due to psychological factors” and “psychogenic and biogenic” changed to “due to combined factors.” Although more precise duration and severity criteria were considered by the DSM-IV Work Group for some of the sexual dysfunctions (e.g., ED) (Segraves, 1996b), the lack of 7 empirical data on the relationship between severity and duration criteria and treatment outcome ruled this out. For FSAD, however, the DSM-IV text included this statement: “Occasional problems with sexual arousal that are not persistent or recurrent…are not considered to be Female Sexual Arousal Disorder” (p. 501). Similarly, a diagnosis of FSAD should not be given if the problems in arousal are “due to sexual stimulation that is not adequate in focus, intensity, and duration” (p. 501). BACKGROUND Concept of Sexual Arousal and Underlying Mechanisms The term sexual arousal has been used in a variety of ways (Bancroft, 2005; Singer, 1984). Although some authors discuss sexual arousal as if it is synonymous with genital arousal, the concept is much broader than this. It has been defined as “a state motivated towards the experience of sexual pleasure and possibly orgasm, and involving (i) information processing of relevant stimuli, (ii) arousal in a general sense, (iii) incentive motivation and (iv) genital response” (Bancroft, 2005, p. 411). A distinction can be made between the “state” of sexual arousal and “sexual arousability,” with the latter referring to an individual‟s disposition to respond to sexual cues with sexual arousal, which varies across and within individuals (Bancroft, 2005; Laan & Both, 2008). The Masters and Johnson HSRC model and Kaplan‟s (1974) model of human sexual response characterized sexual response as a universal, essentially linear progression from sexual desire, through the stages of arousal, orgasm, and resolution. These stages were conceptualized as discrete phases, with the possibility of specific impairments at any one or more of the phases; as discussed above, the DSM-IV classification system is based on this model. The HRSC model has received much criticism, particularly regarding its applicability to women (e.g., Boyle, 1994; Hartmann, Heiser, Ruffer-Hesse, & Kloth, 2002; Levin, 2008; Tiefer, 1991). 8 Focusing on incentive motivation, the model put forward by Laan and Janssen (2007) defines sexual motivation as “the result of the activation of a sensitive sexual response system by sexually competent stimuli that are present in the environment” (p. 329; see also Laan & Everaerd, 1995). Both sexual arousal and sexual desire are viewed as responses to a sexually relevant stimulus. Sexual “desire” may reflect early arousal processes (Everaerd, Laan, Both, & van der Velde, 2000) and it is argued that there is no such thing as spontaneous sexual desire (Laan & Both, 2008). Sexual thoughts or sexual activity act as stimuli, which then trigger the desire-arousal process. Individuals have variable tendencies to respond to sexual stimuli (often referred to as “arousability”) (Laan & Both, 2008). While the drive model assumes that we have sex because we feel desire (Laan & Janssen, 2007), the incentive motivation model instead suggests that we feel sexual desire because we have sex or think about sex (Laan & Both, 2008). In other words, sexual thoughts or sexual activity act as stimuli, which then trigger the desire/arousal process. Everaerd et al. (2000) suggested that, in comparison with men, genital changes might influence subjective experience of sexual arousal in women to a lesser extent than external, contextual cues. There is now a considerable body of evidence that supports this model (Both, Everaerd, & Laan, 2003; Laan & Everaerd, 1995; Laan & Janssen, 2007; for review, see Toates, 2009). Another model of female sexual response, similar in some ways to the incentive motivation model, was put forward by Basson (2000), who suggested that women most frequently engage in sexual activity not because of any intrinsic sexual desire, but from a state of “sexual neutrality” and primarily motivated by non-sexual reasons, such as desire for emotional closeness with a partner. According to this model, a combination of incentives for sexual activity, appropriate sexual stimuli for the woman, and a context conducive to facilitating her arousal (e.g., privacy, lack of distractions, etc.) would encourage the experience of sexual arousal. If this sexual arousal was positive for the woman, this then 9 triggered a “desire” for her to continue the sexual encounter, now for both non-sexual and sexual reasons. This emergent desire (which followed arousal) was termed “responsive sexual desire.” Basson (2000) also argued that sexual arousal in women is “more a mental excitement, very much about the appreciation of the sexual stimulus and less about the awareness of genital changes” (p. 63). A study by Sand and Fisher (2007) challenged the idea that there is one underlying “model” of sexual response that is uniform across women. A group of 111 nurses were asked which of three different models of sexual response–Masters and Johnson‟s (1966), Kaplan‟s (1974), and Basson‟s (2000)–best represented their own experience. Approximately equal proportions of women endorsed each of these three models and, interestingly, those women who endorsed the Basson model had lower scores on the Female Sexual Function Index (FSFI) (Rosen et al., 2000) (indicating worse sexual functioning) than women endorsing one of the other two models. With regard to the endocrinology of sexual arousal, despite considerable research, our understanding of the relevance of hormones in women‟s sexual arousal is still limited. There is minimal evidence of a direct effect of estradiol on sexual arousability in women (Dennerstein, Burrows, Wood, & Hyman, 1980; Sherwin, 1991). Although there has been much interest in the role of testosterone in female sexuality, the evidence is inconsistent, compared to the male data, and there appears to be considerable variability in women‟s response to androgens (Graham, Bancroft, Greco, Tanner, & Doll, 2007). The role of peptides, such as oxytocin and prolactin, is also uncertain (Bancroft, 2005). Assessment of Genital Response Assessment of genital response in women is considered difficult in comparison with that of men (Bartlik & Goldberg, 2000). Levin (2003) pointed out that the relationship between vaginal lubrication and sexual arousal is uncertain. Although lubrication does 10 usually increase during sexual arousal, it may not be maintained, especially after a lengthy period of stimulation. It is also worth noting that although the essential criterion for a DSM diagnosis of FSAD is an inadequate “lubrication-swelling” response, the focus in almost all of the research has been on the lubrication aspect, and not on genital “swelling,” which presents considerable challenges in terms of measurement. Moreover, regarding lubrication difficulties, clinical and epidemiological research has relied almost exclusively on women‟s subjective reports of lubrication, i.e., not on any objective measurement of lubrication. Rather than measuring vaginal lubrication or swelling, studies dating back to the 1970s investigating genital response in women have mainly assessed pulse amplitude in the vaginal wall (VPA), using vaginal photoplethysomography (Laan & Everaerd, 1995; Sintchak & Geer, 1975). There is now a large literature on VPA, although the methodology has a number of limitations (Levin, 2007). Increases in VPA occur quickly, often within a few seconds, in laboratory studies where women are presented with erotic stimuli (Laan & Everaerd, 1995), suggesting an “automatic” response (Laan & Both, 2008). A consistent observation has been that when subjective reports of arousal are correlated with VPA, the correlations are low in women (Chivers, Seto, Lalumière, Laan, & Grimbos, in press). In contrast, in men, the degree of penile erection correlates highly with subjective ratings of arousal and is usually always significant. In women, the most consistent pattern found in laboratory studies is that VPA occurs in response to sexual stimuli, but subjective sexual arousal is low or non-existent (Everaerd et al., 2000). As Everaerd et al. (2000) observed, “hardly ever was desynchrony between genital and subjective sexual arousal found to be the result of subjective sexual arousal without genital responding” (p. 122). There has been an implicit assumption in the literature that VPA is a measure of sexual arousal (Bancroft, 2009). However, there is uncertainty about the relationship of increased vaginal blood flow to sexual arousal in women (Levin, 2003). Although it is well