Sexual dysfunctions and paraphilias are disorders of either disturbance of processes in sexual functioning (sexual dysfunctions) or sexual behavior(s) (paraphilias). Human sexuality presents a very complex interaction of biology and psychology, which is reflected in complex physiological responses. A seemingly very simple event, such as erection, is regulated on the central nervous system and peripheral nervous system level, modified by various hormones, impacted by vascular changes, and influenced by various expectations, interpersonal issues, intrapsychic processes, not to mention the influences of medications and substances of abuse, the aging processes, diseases and personal habits. While there is a substantial body of literature on human sexuality in general and sexual dysfunctions and paraphilias in particular, there is mostly a lack of good evidence-based literature on most aspects of these disorders. The focus has definitely moved from psychology to biology and medicalization of human sexuality. The biological sciences, such as pharmacology, have contributed enormously to the developments in this area. However, an exclusive focus on biology and medical aspects of human sexuality is unwarranted and may trivialize a very complex area of human behavior. Even the clearly “biological” treatment approaches to sexual dysfunction may fail in certain situations due to various psychological factors. Thus, we caution the reader to always consider all factors, biological and psychological, in making the diagnosis and in planning treatment. In most cases, the judicious combination of biological and psychological treatment approaches will yield the most satisfactory results.
The diagnoses of sexual dysfunctions and paraphilias are mostly descriptive, no diagnosis specific tests or examinations are usually available. The classification of sexual dysfunctions is based on the notion of connected yet separate and clearly defined phases of the sexual response cycle—desire, arousal/excitement, orgasm, and resolution. Thus, sexual dysfunctions are classified according to impairments of one of the first three “phases” (no impairment of the resolution phase has been identified). However, clinically these disturbances are not so clearly separated and frequently overlap or coexist (e.g., lack of libido with impaired orgasm). Interestingly, the present classification defines and uses only one end of the sexual functioning spectrum, the “lack” of functioning (e.g., lack of libido), though imprecisely and vaguely. Hypersexuality is not well-defined and not conceptualized as a dysfunction, but rather at times (if at all) as related to addiction, compulsivity, or impulsivity. Another important point in classifying and diagnosing sexual dysfunctions and paraphilias is the use of clinically significant distress or impairment as one of the defining criteria of these disorders. Thus, if the lack of sexual desire does not cause any distress or impairment, one should not qualify it as a dysfunction. There seem to be some individuals who have no interest in sex and are not distressed by it, thus they do not suffer from any sexual disorder according to the currently used diagnostic systems (they may present just one end of the spectrum of certain behavior, similar to rapid vs. absent ejaculation, discussed later).
The current diagnostic system employs similar specifiers through the entire system, and thus sexual dysfunctions (not paraphilias, though) may be further subclassified as lifelong or acquired, generalized or situational, and due to psychological factors or due to combined factors. The diagnostic system also uses categories of sexual dysfunctions due to general medical condition (e.g., diabetes mellitus) or substance-induced sexual dysfunction, which may be useful to consider in formulating the diagnosis and treatment plan.
Hypoactive Sexual Desire Disorder
The DSM-IV-TR criteria for the diagnosis of hypoactive sexual desire disorder (HSDD) are:
Persistently or recurrently deficient (or absent) sexual fantasies or 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 physiological effect of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
HSDD should also be diagnosed according to subtypes: Generalized vs. situational; lifelong vs. acquired; due to psychological factors vs. due to combined factors.
(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000, p. 541.)
There are no specific duration or severity criteria for the diagnosis of HSDD. The clinician should take into consideration such factors as the patient's age and life circumstance and use clinical judgment whether a problem should be diagnosed as a psychiatric disorder. If the individual is not stressed by the absence of libido and it does not cause interpersonal distress, a disorder cannot be diagnosed. The report of a high frequency of coital activity does not rule out the presence of HSDD in one member of a couple. The patient may agree to sexual activity in the absence of desire in order to stabilize a relationship. In the past HSDD has been labeled inhibited sexual desire, generalized sexual dysfunction, and frigidity. Lifelong HSDD is usually due to psychological factors. Situational HSDD is suggestive of interpersonal discord.
Epidemiological studies in Europe, the United States, South America and Asia have found that the prevalence of complaints of low sexual desire is approximately 25–30% in females and approximately 12–25% in males. The number meeting the diagnostic criteria of this causing marked distress is probably less.
HSDD may due to a general medical condition such as hypothyroidism, hyperprolactinemia, or hypogonadism. In males, hypogonadism may be responsible for decreased libido. It is suspected, but unproven, that decreased androgenic activity in females is responsible for decreased libido in women who are post oophorectomy. ...