Sex, DSM-5- and the Apocalypse: A Commentary


I just finished reading Dr Zucker’s retort to Dr Frances’ critique of proposed categories for paraphilias in DSM5, as well as Dr Frances’ reply.

I just finished reading Dr Zucker’s retort to Dr Frances’ critique of proposed categories for paraphilias in DSM5, as well as Dr Frances’ reply. I wholeheartedly agree with Dr Frances and his approach. I fail to understand why as a profession we seem to have this ongoing drive to pathologize anything and everything. Furthermore, I agree with Dr Frances' implication that some of the new categories proposed will inadvertently create a slippery slope that will be readily manipulated and exploited by defense attorneys all over the country.
Dr Frances writes: “I continue to find no reason to label as mental disorders sexual urges, fantasies or behaviors that are harmless to others and cause no distress or impairment to the individual.” In other words, leave well enough alone, but from Dr Zucker’s rather defensive reply and angry overtones, it is hard for him and his group to do so. Perhaps the countless hours spent on this particular subcommittee helped to create an entity with a momentum all its own. Allow me to add to this argument by describing a very brief but bothersome meeting in my office a few days ago.

I am a board certified adult psychiatrist in private solo practice in a small town in southeastern Pennsylvania. I cannot escape having to go through the waiting room to get to my small kitchen area, so I am obliged to make contact with whatever pharmaceutical representative might be waiting there. Imagine my surprise the other day when a woman introduced herself as an employee of an educational division of Boehringer Ingelheim Pharmaceuticals. I asked what product she was representing; she told me that it was not a product but an opportunity to educate me about “Female Hypoactive Sexual Desire Disorder (HSDD).” She did not (or perhaps she did not have corporate permission to) inform me that her company is developing a chemical named flibanserin, which – you guessed it – is for this “disorder.” My first thought was:  “You’re kidding me?” My next thought was: “Well, what about us men? Can’t we be disordered too?” I politely declined her offer to educate me or leave propaganda for me to peruse in my all too scant leisure time.  

DSM-IV criteria for HSDD are as follows:
Diagnostic criteria for 302.71 Hypoactive Sexual Desire Disorder

A. 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.
B. The disturbance causes marked distress or interpersonal difficulty.
C. 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 (eg, a drug of abuse, a medication) or a general medical condition.

Specify type:
Lifelong Type
Acquired Type

Specify type:
Generalized Type
Situational Type

Due to Psychological Factors
Due to Combined Factors

I want to pay specific attention to Criterion C. There is a call to account for another Axis I condition, a direct physiological effect of a substance (drug of abuse or medication) or a general medical condition. From these criteria, “I’m not in the mood” (and not happy about not being in the mood) is a disorder. There really is no room for not being in the mood.  How about if someone is not in the mood because her husband only pays attention to her when he wants sex and then when he does typically considers grabbing his wife’s breast and making a joke as foreplay? Or the man whose wife, girlfriend, or significant other only seems to want sex on her own terms and has had a chronic pattern of using sex in a manipulative fashion throughout their relationship? (I have had various patients complain of just these things.) Do I diagnose these patients with an illness-a disorder? Or are they simply unhappy and perhaps desiring of sex but with someone else or in a setting where their current relationships are on better ground?  How about if someone is simply just too tired because he/she worked hard all week? 

I remember fondly one of my favorite teachers in medical school and residency – Dr Jack Benson. He told the following story of a 90-year-old man who once presented to him for consultation because he was experiencing trouble maintaining an erection as well as getting one as often as he would have liked. (There was no sildenafil back then.) Dr Benson was making a teaching point that would echo the words of Sir William Osler: “Listen to the patient: He is telling you the diagnosis.” Or, he is telling you what the problem or issue is. It turned out that this healthy 90-year-old widower had 3 healthy girlfriends, all about 20 years younger than he and all demanding sex from him (no HSDD there!). He was simply too tired to keep up and had very little knowledge of human sexuality beyond the basics. Dr Benson helped to reframe his situation for him and the man went away relieved there was nothing wrong with him.

I gather Dr Zucker and his subcommittee would have suggested a major evaluation for this patient; they would have started psychotherapy with a sexual disorders focus and sent the patient to a urologist for sildenafil or a psychiatrist to be evaluated for the need for psychotropic medications. Some doctor working in a Medicare HMO would have performed a perfunctory screening and evaluation, and perhaps would have diagnosed depression and prescribed an SSRI. The patient would have been back within a week or two with a new “diagnosis”-anorgasmia.  Ah, the brutality of iatrogenesis!

I can appreciate the vital importance of maintaining intellectual curiosity and trying out new ideas and new approaches. It’s how we learn. Everyone is entitled to an opinion about something, but let’s remember that no matter how informed the opinion, there is almost invariably going to be an unconsciously motivated and emotional element interjected into that rendering. So what indeed is truly and purely objective? This is especially the case in our field, where we deal with the subjective, the irrational, and the unconscious on a daily basis. I think far greater care needs to be taken before ANY new disorder is introduced as a disorder, lest we create a whole new group of “patients.” On the other hand, maybe if we did . . . nah, nevermind!

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