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Archive for July, 2009

Numerous individuals and groups have criticized the DSM-IV-TR criteria for sexual disorders. Major suggestions for revision have been made by an international consensus group funded by the American Urological Association. This group met on four occasions and has published a number of manuscripts detailing recommended changes. This group specifically suggested that the criteria sets for hypoactive sexual desire disorder be modified.

Data indicating that many sexually responsive women do not report sexual fantasies was cited as well as evidence that some sexually responsive women do not experience desire for sexual activity but respond to sexual stimuli once involved in a sexual situation. It was recommended that lack of responsive desire be substituted for absence of desire for sexual activity. This group also noted evidence that interest in sexual activity appears to lessen both with age and relationship duration for many women. Basson  specifically states that the linear sequencing of desire, arousal, orgasm as outlined in DSM-IV-TR is a model better suited to male than female sexuality. She posits that many women are unaware of desire for sexual activity at the onset of sexual activity and that emotional intimacy may be the most important factor influencing a woman’s initial sexual responsiveness. In this model, responsive desire and sexual arousal clearly overlap.

It should be noted that the DSM-IV-TR criteria and suggested revisions lack precise criteria sets designating severity or duration criteria. Also, the separation of sexual dysfunctions from relationship discord and adjustment disorders is imprecise. Many clinicians would not diagnose a sexual problem as a sexual dysfunction if it is clearly secondary to relationship discord. However, this is not clearly specified in the DSM-IV-TR text. Similarly, the distinction between an adjustment disorder influencing sexual function and a sexual dysfunction is not clearly specified. Precise operational criteria are necessary to define homogenous clinical groups for research and advancement of knowledge in the field.

Modern nomenclature for the sexual disorders can be traced to Masters and Johnson  who delineated premature ejaculation, ejaculatory incompetence, impotence, orgasmic dysfunction, vaginismus and dyspareunia. Except for vaginismus and dyspareunia,
the sexual dysfunctions were linked to the phases of the sexual response cycle (excitement, plateau, orgasm). The sexual response cycle and those disorders of sexual response were considered to be analogous in both sexes. This diagnostic scheme was initially adopted by most mental health clinicians. As more clinicians gained experience in the treatment of sexual disorders, it became increasingly obvious that the major problem of many patients was the absence of desire for sexual activity, a concept not included in the Masters and Johnson diagnostic schema. Harold Lief and Helen Singer Kaplan, both psychoanalysts, introduced this concept of the diagnosis of inhibited sexual desire.

The first official nomenclature for the sexual disorders was published in the DSM in 1980. In this system, inhibited sexual desire was defined as persistent and pervasive inhibition of sexual desire. The text also indicated that the diagnosis would rarely be made unless the lack of desire was a source of distress to either the individual or partner. In DSM-III-R the term inhibited was deleted as this was felt to imply a psychodynamic etiology and the somewhat awkward term, hypoactive sexual desire was substituted for inhibited sexual desire. The definition was also slightly modified. The new definition was persistently, or recurrently deficient or absent sexual fantasies and desire for sexual activity. In this edition, the following subtype modifiers were introduced: psychogenic only or psychogenic and biogenic, lifelong or acquired, generalized or situational. In DSM-IV, the definition of hypoactive sexual desire remained unchanged except for a new provision that the diagnosis could not be made unless the disturbance caused marked distress or interpersonal difficulty. This definition remained unchanged in DSM-IV-TR.

Disorders of sexual desire are frequently encountered in psychiatric practice. These disorders may be part of the presentation of common psychiatric disorders such as depression and anxiety disorders, a drug side effect, secondary to relationship discord or idiopathic. Understanding the etiology of problems of low sexual desire is also complicated because of the interplay of biological, psychological and interpersonal influences. Because these disorders can have a multitude of etiologies, diagnosis is often complicated and most often imprecise. Because sexuality is such an important part of one’s self-identity and plays a significant role in intimate relationships, low sexual desire can have a multitude of unfortunate consequences and obviously should be a focus of psychiatric interventions.

The goal of this chapter is to review current evidence concerning the diagnosis, epidemiology, etiology and treatment of hypoactive sexual desire disorders. Masters and Johnson and the DSM-IV-TR  regard male and female sexual disorders as symmetrical.

However, there appear to be sex differences in the strength of sexual desire, its covariates, its sequencing in the sexual response cycle, and its response to relationship discord. In this chapter, female disorders of desire will be considered separately from male disorders of desire as they may represent different diagnostic entities.

Almost ninety percent of Indiana adults between the ages of 21 and 59 have engaged in some kind of gambling for money in their lifetime. In the past year, over sixty-five percent of this age group has gambled for money, and in the past month, much less thhalf (42.3%) reported some sort of gaming or betting. Our respondents reported having tried, on average, about three different types of gambling in their lifetime.

Males are more likely to gamble for money than females. Over ninety percent of men reported participating in gambling in their lifetime, and almost half of our male respondents reported having gambled in the past month (47.8%). Nearly eighty-five percent of women had gambled in their lifetime and over a third of women had gambled in the past month (36.8%). The largest difference between male and female gamblinparticipation was found when asked if they had gambled in the past year. Nearly fiftepercent more males (74.2%) reported gambling than women (60.3%) in the past year. Men also conveyed that they have tried more types of gambling for money than have women between the ages of 21 and 59.