S16 From whence comes HSDD? - The Journal of Family Practice

Supplement toFrom whence comes HSDD?Sharon J. Parish, MDAssociate Professor ofClinical MedicineDepartment of MedicineAlbert Einstein Collegeof MedicineDirector of PsychosocialTrainingDepartment of MedicineMontefiore Medical CenterBronx, New YorkFemale sexual dysfunction (FSD) encompasses a group of highly prevalentdisorders characterized by problems related to sexual desire, arousal, orgasm,or pain. 1,2 Among these is hypoactive sexual desire disorder (HSDD),a condition that causes marked distress and interpersonal difficulties. 1 In viewof the complexity of factors contributing to the various types of FSD, the identificationof HSDD requires that it be carefully differentiated from other forms ofsexual dysfunction. An understanding of the definitions of FSD and HSDD, theirprevalence in various subpopulations of women, and their impact on quality oflife can increase awareness of the importance of these disorders. Such knowledgewill also help family physicians appreciate the place of HSDD within thespectrum of FSD and become better equipped to recognize this disorder in clinicalpractice.Definitions of FSD and HSDDThe definition of FSD in the American Psychiatric Association’s Diagnostic andStatistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) isbased on a traditional linear model of human sexual response. 1 Sexual dysfunctionis classified as disorders of desire, arousal, orgasm, and pain (Table 1). 1 Aninterdisciplinary consensus panel convened by the American Foundation forUrological Disease (AFUD) developed a classification system that retained theframework of the DSM-IV-TR categories but expanded them to include organiccauses of sexual dysfunction (Table 2). 2 This system is also based on the linearmodel of sexual response. In both the DSM-IV-TR and AFUD classifications,HSDD is placed under the general category of sexual desire disorders. The definitionsrequire that HSDD be marked by persistent or recurrent deficient (or absent)sexual fantasies and desire for sexual activity that causes marked distressor interpersonal difficulty. 1,2 The category of HSDD can be further divided intosubtypes: general (a general lack of sexual desire) vs situational (a woman previouslyhad sexual desire for her current partner but now lacks sexual interestin that individual, although she still has desire for sexual stimulation alone orwith someone other than her present partner), and acquired (beginning after aperiod of normal sexual function) vs lifelong (in a woman who has always hadlow or no sexual desire). 1Definitions of FSD derived from a linear model have been criticized as beingmore characteristic of men than women. 3 Newer models depict the sexual responsein women as a circular sequence of events that may involve overlappingphases in a variable order. 4,5 Women may not have a sense of desire at the initiationof a sexual encounter. 5 Nonetheless, the absence of desire does not precludea satisfactory sexual experience. 6,7 The model shown in the Figure (page S20)demonstrates that desire can be triggeredlater during a sexual experienceonce the woman has become subjectivelyaroused. 4,5The DSM-IV-TR definition ofHSDD has also been criticized becauseit considers sexual fantasies aprimary trigger for sexual behavior.Research has shown that spontaneoussexual thoughts or fantasies maybe characteristic of women in newrelationships but occur much lessfrequently among sexually healthywomen in longer-term relationships. 8Moreover, a woman’s desire for sexualactivity may be prompted by factorsnot addressed by current definitions,such as wanting to experience tendernessand appreciation by her partnerand feeling desirable. 9Since lack of sexual desire at thebeginning of a sexual encounter doesnot necessarily indicate HSDD, expertshave suggested that the definitionbe refined to indicate a recurrent,consistent lack of ability to experienceany desire or arousal. 5 Such criteriawould reflect the fact that desireproblems are usually associated withdifficulties in all phases of the sexualresponse cycle. For instance, orgasmcannot occur without arousal, and alack of arousal often results in a lackof desire because sexual activity isnot enjoyable. Sexual pain disordersand lack of sexual arousal may also belinked, as intercourse without arousaland associated lubrication can bepainful and lead to the avoidance ofsexual activity.EpidemiologyTable 1FSDPrevalence estimates of FSD vary based on the patientpopulation and methodology employed. For example,age and age-group categorizations have differed amongmany studies, and inclusion criteria are often limited toDSM-IV-TR classification of female sexual dysfunction 1ClassificationSexual desire disordersHypoactive sexual desire disorderSexual aversion disorderSEXUAL AROUSAL DISORDERSFemale sexual arousal disorderORGASMIC DISORDERSFemale orgasmic disorderPAIN DISORDERSDyspareuniaVaginismusSymptomsAbsence or deficiency of sexual interest and/or desireAversion to and avoidance of genital contact witha sexual partnerInability to attain or maintain adequate lubricationswellingresponse of sexual excitementDelay in or absence of orgasm after a normal sexualexcitement phaseGenital pain associated with sexual intercourseInvoluntary contraction of the perineal muscles, preventingvaginal penetrationDSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders 4th edition, text revision.Table 2AFUD classification of female sexual dysfunction 2ClassificationSexual desire disordersHypoactive sexual desire disorderSexual aversion disorderSEXUAL AROUSAL DISORDERSFemale sexual arousal disorderORGASMIC DISORDERSFemale orgasmic disorderPAIN DISORDERSDyspareuniaVaginismusNoncoital painAFUD, American Foundation for Urological Disease.SymptomsAbsence of sexual fantasies, thoughts, and/or desire for,or receptivity to, sexual activity, which causes personaldistressPhobic aversion to and avoidance of sexual contact witha sexual partner, which causes personal distressInability to attain or maintain sufficient sexual excitement,causing personal distress, which may be expressed as a lackof subjective excitement, or genital (lubrication-swelling) orother somatic responsesDelay in or absence of attaining orgasm following sufficientsexual stimulation and arousal, which causes personaldistressGenital pain associated with sexual intercourseInvoluntary spasm of the musculature of the outer thirdof the vagina that interferes with vaginal penetration,which causes personal distressGenital pain induced by noncoital sexual stimulationwomen in sexual or stable relationships, omitting significantnumbers of women. Cultural differences, avoidanceof a dialogue surrounding sexual complaints, and spanof recall also may confound epidemiologic studies. 10 TheS16 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S17