The experimental evidence and theoretical notions presented earlier strongly suggest that for women, sexual dysfunction is not about genital response. The women in our study who were diagnosed with FSAD according to strict DSM-IV criteria (42) turned out not to be sexually dysfunctional according to these same criteria because their genital response was not impaired. This study demonstrated that it is difficult to be sure that sexual arousal problems are not caused by a lack of adequate sexual stimulation, and that impaired genital response cannot be assessed on the basis of an anamnestic interview. This implies that the current DSM-IV criteria for sexual arousal disorder, which states that genital (lubrication/swelling) response is strongly impaired or absent, is unworkable. For most women, even those without sexual problems, it is difficult to accurately assess genital cues of sexual arousal, but this is exactly what the DSM-IV definition of sexual arousal disorder requires. The group of women the DSM-IV refers to may even be virtually nonexistent. Medically healthy women who have complaints of absent or low arousal but are genitally responsive, given adequate sexual stimulation, do not qualify for a sexual arousal diagnosis according to DSM-IV. Women with a somatic condition explaining the sexual arousal difficulties do not qualify for one of the four primary diagnoses, including FSAD, either, even though, as we have argued, the presence of a somatic condition that affects sexual response may be the most important predictor for impaired genital responsiveness. In medically healthy women impaired genital responsiveness is not a valid diagnostic criterion. Consequently, we believe that the DSM-IV criteria for sexual arousal disorder are in need of revision.
A first consensus meeting on the definitions and classifications of female sexual problems in 1998 did not generate a significantly different classification system but did propose to replace the "marked distress and interpersonal difficulty" criterion of DSM-IV with a "personal sexual distress" criterion (95). Bancroft, Loftus and Long subsequently investigated which sexual problems predicted sexual distress in a randomly selected sample of 815 North American heterosexual women aged 20-65, who were sexually active (16). The best predictors were markers of general emotional and physical well being and the emotional relationship with their partner during sexual activity. Sexual distress was not related to physical aspects of sexual response, including arousal, vaginal lubrication, and orgasm. The study provided data supporting the possibility that relationship disharmony may cause impaired sexual response rather than the opposite. The authors concluded that the predictors of sexual distress do not fit well with the DSM-IV criteria for the diagnosis of sexual dysfunction in women. These findings are in line with the problems with DSM-IV that were discussed in this chapter. When one believes, as we do, that the problems that generate most sexual distress deserve most of our research and clinical attention, the current focus of DSM-IV on genital response is unjustified. The choice of DSM-IV to exclude women with a somatic condition from the four primary diagnoses of sexual disfunction seems unwarranted as well, because women with such a condition reported highest levels of sexual distress. On the other hand, a high sexual distress score does not automatically implicate sexual dysfunction.
When should we consider a sexual problem to be a sexual dysfunction? The objective and medical connotation of the word "dysfunction" has probably promoted the choice for impaired genital responsiveness as the criterion for an arousal disorder in DSM-IV. In this chapter, we have argued that many women with a medical condition have sexual problems that may or may not be caused by the disease directly, but that the sexual problems of healthy women are better explained by lack of adequate sexual stimulation and sexual and emotional closeness to their partner. Similarly, Tiefer (96) has presented a "New View of Women's Sexual Problems" that strives to de-emphasize the more medicalized aspects of sexual problems that currently prevail, and that looks at "problems" rather than at dysfunctions [see also Refs. (19,97)]. Bancroft (98) argues that a substantial part of the sexual problems of women are a logical, adaptive response to life circumstances, and should not be considered as a sign of a dysfunctional sexual response system, which would explain why prevalence figures based on frequencies yield much higher dysfunction rates (19) than actual distress figures.
The latest classification proposal also embraces the personal distress criterion and has reintroduced a subjective criterion, but avoids an answer to the question of when a sexual problem is a dysfunction. In this proposal the word "dysfunction" is used to mean simply lack of healthy/expected/"normal" response/interest, and is not meant to imply any pathology within the woman (15). This does again suggest, however, that we have clear criteria for healthy and normal response.
The answer to the question of what is not a sexual dysfunction is more easy than generating clear cut criteria for sexual dysfunction. As long as lack of adequate sexual stimulation—whether this is the result of absence of sexual stimulation or of lack of knowledge about, bad technique of, a lack of attention for, or negative emotions to sexual stimuli—explains the absence of sexual feelings and genital response, the label "dysfunction" is inappropriate. Problems that are situational do not deserve the label dysfunctional, as is now possible in DSM-IV.
The study of Bancroft and colleagues might be taken to imply that only medical and somatic problems that generate sexual unresponsiveness, which cannot be understood as adaptations to life circumstances and which cause sexual distress, should be considered a dysfunction. This is a view that we can endorse. Without completely resolving this issue, we might at best suggest that a differentiation between genital and subjective unresponsiveness in all circumstances ("dysfunction") and not being able to create the right conditions for sexual arousal ("problem") is the most theoretically and clinically meaningful.
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