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.8Suggested 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.