Female Sexual Dysfunction.

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

Sexual disorders beyond DSM-5: the unfinished affaire.

PURPOSE OF REVIEW: To provide an overview of post-The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. classifications related to human sexuality. After reviewing the literature on classification and clinical practice of sexual disorders, some of the most important contributions on main sexological classifications and frameworks were selected, especially from January 2016 till June 2017. RECENT FINDINGS: New relevant contributions on psychiatric and sexological classifications and frameworks have been proposed, such as the international classification of diseases 11th revision (ICD-11), research domain criteria, the third edition of the Diagnostic Manual in Sexology and the person-centered psychiatry perspective. SUMMARY: ICD-11 proposals regarding conditions related to sexual health including sexual dysfunctions and gender incongruence as well as vaginismus, such as sexual pain disorder, paraphilic disorders as mental Disorders. The disorders associated with sexual development and orientation, are proposed for deletion. The other perspectives aforementioned are also presented.

Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women.

BACKGROUND: In the professional literature and among our professional societies, female sexual dysfunction nomenclature and diagnostic criterion sets have been the source of considerable controversy. Recently, a consensus group, supported by the International Society for Women's Sexual Health, published its recommendations for nosology and nomenclature, which included only one type of arousal dysfunction, female genital arousal disorder, in its classification system. Subjective arousal was considered an aspect of sexual desire and not part of the arousal phase. AIM: To advocate for the importance of including subjective arousal disorder in the diagnostic nomenclature in addition to the genital arousal subtype. METHODS: We reviewed how the construct of subjective arousal was included in or eliminated from the iterations of various diagnostic and statistical manuals. The Female Sexual Function Index (FSFI) was used to examine the relations among subjective arousal, genital arousal, and desire in women with and without sexual arousal concerns. MAIN OUTCOME MEASURES: Sexual arousal through a self-report Film Scale, physiologic sexual arousal through vaginal photoplethysmography in response to an erotic film, and the FSFI. RESULTS: The clinical literature and experience support differentiating subjective arousal from desire and genital arousal. Correlations between the FSFI domains representing desire and subjective arousal, although sufficient to suggest relatedness, share approximately 58% of the variance between constructs-a lower shared variance than FSFI domains representing subjective arousal and orgasm. Similarly, when looking at FSFI individual items best representative of sexual desire and subjective arousal, the large majority of the variance in subjective arousal was unexplained by desire. A third line of evidence showed no significant difference in levels of subjective arousal to erotic films between sexually functional women and women with desire problems. If desire and subjective arousal were the same construct, then one would expect to see evidence of low subjective arousal in women with low sexual desire. CLINICAL IMPLICATIONS: Optimized treatment efficacy requires differentiating mental and physical factors that contribute to female sexual dysfunction. STRENGTHS AND LIMITATIONS: Support for our conclusion is based on clinical qualitative evidence and quantitative evidence. However, the quantitative support is from only one laboratory at this time. CONCLUSION: These findings strongly support the view that female sexual arousal disorder includes a subjective arousal subtype and that subjective arousal and desire are related but not similar constructs. We advocate for the relevance of maintaining subjective arousal disorder in the diagnostic nomenclature and present several lines of evidence to support this contention. Althof SE, Meston CM, Perelman M, et al. Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women. J Sex Med 2017;14:1365-1371.

[Sexual dysfunction: Changing conceptions and criteria of classification]. / Sexuelle Funktionsstörungen: Wandel der Sichtweisen und Klassifikationskriterien.

BACKGROUND: Sexual response is the result of a complex interaction of psychological, physiological, interpersonal, social and cultural factors. Those factors - as well as sexual behavior - are subject to permanent change. OBJECTIVES: In this study, we investigated how the growth of basic knowledge and constantly changing social-cultural conditions impact the scientific definition of sexual dysfunctions, which controversies exist and to what degree these changes counteract the common tendencies of medicalization and stigmatization of sexual difficulties. MATERIALS AND METHODS: With reference to the leading international classification systems of mental disorders and on the basis of the current scientific literature, we comment and reflect the changed criteria of sexual dysfunctions in women and men. RESULTS AND CONCLUSIONS: The new revised criteria for sexual dysfunctions are more objective, which provides an enhanced basis for valid diagnoses. The concept of sexual aversion is considered obsolete and no longer being pursued. Nevertheless, there are obvious differences between the revised classification systems, especially regarding the dualistic perspective of sexual problems as either caused by psychological versus organic factors. Further change is predetermined.

Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria.

The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.

Toward a More Evidence-Based Nosology and Nomenclature for Female Sexual Dysfunctions-Part I.

INTRODUCTION: A nomenclature is defined as a classification system for assigning names or terms in a scientific discipline. A nosology more specifically provides a scientific classification system for diseases or disorders. Historically, the nosologic system informing female sexual dysfunction (FSD) has been the system developed by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders (DSM-III through DSM-5). Experts have recognized limitations of its use in clinical practice, including concerns that the DSM-5 system does not adequately reflect the spectrum and presentation of FSD. AIM: To review the central considerations and issues that underlie the development of a new evidence-based nomenclature that reliably and validly defines the categories of FSD and will effectively function in clinical and research settings, serve as a basis for International Classification of Diseases (ICD) codes, and provide regulatory guidance for interventions designed as FSD treatments. METHODS: The International Society for the Study of Women's Sexual Health conducted a 2-day conference on nomenclature for FSD in December 2013. Key opinion leaders representing diverse areas of expertise discussed ideal characteristics, existing DSM definitions, and current and future ICD coding to develop consensus for this new nomenclature. MAIN OUTCOME MEASURE: A comprehensive appreciation of the parameters and characteristics essential to a new FSD nomenclature and terminology that will serve as the principal nosology for the description and diagnosis of FSD. RESULTS: A critical appraisal of the essential elements of a classification system for diagnosing FSD was accomplished. The applicability of DSM-5 FSD definitions was challenged; and the considerations for developing a new nomenclature were discussed, including comorbidities, clinical thresholds, alternative etiologies, and validity. CONCLUSION: The essential elements for developing a valid, reliable, credible, and clinically applicable nosology for FSD were enumerated as a preamble to constructing the actual nosologic system (Part II).

Abnormal sexuality in Parkinson's disease: fact or fancy?

PURPOSE: Patients with Parkinson's disease (PD) variably report sexual dysfunctions. We assessed sexuality in PD by comparing sexual function between a large group of patients with idiopathic PD and a group of subjects without PD. METHODS: We recruited 121 patients with mild-to-moderate PD (aged 40-80years) from four Italian Movement Disorder Clinics and 123 non-Parkinsonian controls (NPC) (aged 40-80years). Sexual function was assessed with four scales: the Brief Index of Sexual Functioning (BISF-M for men; BISF-W for women), the International Index of Erectile Function (IIEF), and the Female Sexual Function Index (FSFI). Both groups also underwent assessment with the Beck Depression Inventory (BDI) and the Mini Mental State Examination (MMSE), and patients were assessed with the Parkinson's Disease Questionnaire-8 (PDQ-8). RESULTS: No differences in total score were found between PD and NPC for any sexual function scale (BISF-M, BISF-W, IIEF, FSFI: p>0.05). However, the Orgasm/Pleasure Domain (BISF, D5) was significantly lower in male patients than in controls. CONCLUSION: Our findings fail to confirm previous findings that PD is associated with a significant sexual impairment. NPC and patients with PD have comparable sexual function in both sexes. Thus, rather than dismissing sexual dysfunction as a normal parkinsonian symptom, physicians should refer patients to sexual medicine specialists who can investigate and discuss problems fully, diagnose possible comorbidities, and suggest appropriate treatments.

Definitions of Sexual Dysfunctions in Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015.

INTRODUCTION: Definitions of sexual dysfunctions in women and men are critical in facilitating research and enabling clinicians to communicate accurately. AIMS: To present the new set of definitions of all forms of sexual dysfunction in women and men adopted by the Fourth International Consultation on Sexual Medicine (ICSM) held in 2015. METHODS: Classification systems, including the International Classification of Diseases, 10th Edition and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and systems that focus on only specific types of sexual dysfunctions (e.g., the International Society for Sexual Medicine definition for premature ejaculation) were reviewed. MAIN OUTCOME MEASURES: Evidence-based definitions were retained, gaps in definitions were identified, and outdated definitions were updated or discarded. Where evidence was insufficient or absent, expert opinion was used. Some definitions were self-evident and termed clinical principles. RESULTS: The evidence to support the various classification systems was carefully evaluated. A more comprehensive analysis of this evidence can be found in two other articles in this journal that consider the incidence and prevalence and the risk factors for sexual dysfunction in men and women. These data were used to shape the definitions for sexual dysfunction that have been recommended by the 2015 ICSM. CONCLUSION: The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions. As more research and clinical studies are conducted, there likely will be modifications of at least some definitions.

A Streetcar Named "Derousal"? A Psychophysiological Examination of the Desire-Arousal Distinction in Sexually Functional and Dysfunctional Women.

Research indicates that desire and arousal problems are highly interrelated in women. Therefore, hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD) were removed from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and a new diagnostic category, female sexual interest/arousal disorder (FSIAD), was created to include both arousal and desire difficulties. However, no research has tried to distinguish these problems based on psychosocial-physiological patterns to identify whether unique profiles exist. This study compared psychosocial-physiological patterns in a community sample of 84 women meeting DSM-IV (American Psychiatric Association, 2000 ) criteria for HSDD (n = 22), FSAD (n = 18), both disorders (FSAD/HSDD; n = 25), and healthy controls (n = 19). Women completed self-report measures and watched neutral and erotic films while genital arousal (GA) and subjective arousal (SA) were measured. Results indicated that GA increased equally for all groups during the erotic condition, whereas women with HSDD and FSAD/HSDD reported less SA than controls or FSAD women. Women in the clinical groups also showed lower concordance and greater impairment on psychosocial variables as compared to controls, with women with FSAD/HSDD showing lowest functioning. Results have important implications for the classification and treatment of these difficulties.

Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases.

Hypersexuality remains an increasingly common but poorly understood patient complaint. Despite diversity in clinical presentations of patients referred for hypersexuality, the literature has maintained treatment approaches that are assumed to apply to the entire phenomenon. This approach has proven ineffective, despite its application over several decades. The present study used quantitative methods to examine demographic, mental health, and sexological correlates of common clinical subtypes of hypersexuality referrals. Findings support the existence of subtypes, each with distinct clusters of features. Paraphilic hypersexuals reported greater numbers of sexual partners, more substance abuse, initiation to sexual activity at an earlier age, and novelty as a driving force behind their sexual behavior. Avoidant masturbators reported greater levels of anxiety, delayed ejaculation, and use of sex as an avoidance strategy. Chronic adulterers reported premature ejaculation and later onset of puberty. Designated patients were less likely to report substance abuse, employment, or finance problems. Although quantitative, this article nonetheless presents a descriptive study in which the underlying typology emerged from features most salient in routine sexological assessment. Future studies might apply purely empirical statistical techniques, such as cluster analyses, to ascertain to what extent similar typologies emerge when examined prospectively.

A systematic review of instruments to measure sexual functioning in patients using antipsychotics.

Sexual dysfunction is a frequent side effect of antipsychotics, but information is scant regarding the psychometric properties and clinical usefulness of currently existing questionnaires. This systematic review compares the psychometric properties and content of questionnaires for assessment of sexual functioning in patients using antipsychotics. A systematic literature search was performed using three electronic databases (PubMed, Embase, and PsycINFO) with predefined search terms. We identified six validated instruments for assessment of sexual functioning in patients using antipsychotics: the Antipsychotic Non-Neurological Side Effects Rating Scale (ANNSERS), the Arizona Sexual Experience Scale (ASEX), the Antipsychotics and Sexual Functioning Questionnaire (ASFQ), the Changes in Sexual Function Questionnaire-14 (CSFQ-14), the Nagoya Sexual Function Questionnaire (NSFQ), and the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ). The ASFQ, CSFQ-14, and PRSexDQ cover all stages of sexual functioning, which makes these questionnaires preferable to the other three questionnaires described. The ASFQ and PRSexDQ are clinician-administered and ask for a change in sexual functioning related to medication. The ASFQ assesses improvement as well as deterioration of sexual functioning, and includes items about hyperprolactinemia. The CSFQ-14 is useful when self-report is desired but contains more items.

Arriving at the diagnosis of female sexual dysfunction.

Female sexual dysfunctions include a group of sexual complaints and disorders affecting women of all ages, and stemming from a heterogeneous array of etiologies and contributing factors. The classification system for sexual dysfunctions in the woman has evolved from a linear categorization of sexual desire, arousal, orgasm, and pain disorders to one that is more complex and overlapping. Personal distress is a key factor in defining a sexual problem as a dysfunction. The recently released Diagnostic and Statistical Manual of Mental Disorders, edition 5, collapses former definitions of female sexual disorders and moves away from the older linear model of diagnostic categories. Physicians should be open to discussing sexual problems with women, and may make use of validated questionnaires in the office setting. Evaluation tools available for assessing sexual function in the woman are in use in the research setting, as are physiological measures of assessment.

Female sexual dysfunction: definition, classification, and debates.

Sexual dysfunction refers to difficulties that occur during the sexual response cycle that prevent the individual from experiencing satisfaction from sexual activity. It is relatively difficult to estimate the prevalence of female sexual dysfunction (FSD), because the definition and diagnostic criteria are still controversial and under development. These difficulties reveal our insufficient understanding of the basis of FSD. This review was conducted in an effort to deal with this complicated clinical issue, by examining the most updated clinical criteria of FSD under the context of a redefined female sexual response model.

[Discussion regarding classification of sexual disorders in DSM-5 and research trends within the area of sexual disorders in Poland]. / Dyskusja nad klasyfikacja zaburzen seksualnych w DSM-5 a trendy badawcze w obszarze seksuologii w Polsce.

The fifth version of the American Psychiatric Association's classification, DSM, was released in May 2013. Its completion was preceded by years of intensive discussions, clinical trials and secondary data analysis, which were aimed at as best as possible reflecting of clinical reality. In the present article review of literature was presented, showing the range of work connected with the area of widely understood sexual disorders as well as the most important changes regarding it that are included in DSM-5. Review of Polish literature published in the last three years (2011-2013) regarding sexual issues in selected scientific journals: Seksuologia Polska, Ginekologia Polska, Psychiatria Polska, Psychoterapia was also conducted. It was aimed at analysis of basic research trends within the area of sexual disorders in Poland. The review shows that there were relatively not many articles, they were concentrated on interdisciplinary issues and clinical populations of patients suffering from disorders different than sexual. It was noticed that there were no articles on paraphilias, and at the same time publications regarding forensic sexology were present. It would be advisable to publish reports form scientific congresses of sexology on a more regular basis, that would perhaps inspire further research in the field of sexology in our country.

Distress, sexual dysfunctions, and DSM: dialogue at cross purposes?

INTRODUCTION: A distress criterion was added to the diagnostic criteria of sexual dysfunctions in Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; 1994). This decision was neither based on empirical evidence, nor on an open, academic, or public debate about its necessity. As a result, this decision has been disputed ever since the publication of DSM-IV. AIM: In this article, the necessity to include or exclude the distress criterion from the diagnostic criteria of sexual dysfunctions is critically evaluated, illustrating its consequences for both sex research and clinical practice. METHODS: Apart from careful reading of relevant sections in DSM-II, DSM-III, DSM-IV, DSM-IV Text Revision, and articles about and online proposals for DSM-5, an extensive PubMed literature search was performed including words as "sexual dysfunction"/"sexual difficulty"/"sexual disorder,""distress"/"clinical significance,""diagnostic criteria," and "DSM"/"Diagnostic and statistical manual of mental disorders." Based on analysis of the references of the retrieved works, more relevant articles were also found. MAIN OUTCOME MEASURES: ARGUMENTS for or against removal of distress from the diagnostic criteria of sexual dysfunctions by former and current members of the DSM Task Force and Work Group on Sexual Disorders, as well as by other authors in the field of sex research, are reviewed and critically assessed. RESULTS: Proponents and opponents of including the distress criterion in the diagnostic criteria of sexual dysfunctions appear to be unresponsive to each others' arguments. To prevent the debate from becoming an endlessly repetitive discussion, it is first necessary to acknowledge that this is a philosophical debate about the nature, function, and goals of the diagnosis of a sexual dysfunction. CONCLUSIONS: Given the current lack of data supporting either the retention or removal of the distress criterion, distress should always be taken into account in future research on sexual dysfunctions. Such forthcoming data should increase our understanding of the association between distress and sexual difficulties.

Minding the body: situating gender identity diagnoses in the ICD-11.

The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.