Tuesday, September 29, 2009

Proposed changes to HSDD

In my last post, I informed readers that the report of the Sexual and Gender Identity Disorders Workgroup for DSM-V for female HSDD has been published, and I said that I would summarize it and give a little commentary.

First, there are documents that I will be discussing: the report of female HSDD and the report of Female Sexual Arousal Disorder (FSAD). Mostly, I'll talk about the first one, but the current proposal involves merging them, so I'll refer to the other one a few times as well.

Brotto, L.A. (in press) The DSM Diagnostic Criteria for Hypoactive Sexual Desire Disorder in Women. Archives of Sexual Behavior DOI 10.1007/s10508-009-9543-1

Graham, C. A. (in press) The DSM Diagnostic Criteria for Female Sexual Arousal Disorder Archives of Sexual Behavior DOI 10.1007/s10508-009-9535-1

I would strongly encourage readers with sufficient library access to simply read at least these, especially the first (as it deals more with issues of direct concern to the asexual community.) I'll summarize the main issues that I think will be of interest to members of the asexual community.

The part of Brotto's paper where asexuality is directly addressed is the section on whether the distress criterion should be kept. There have been serious proposals to remove it, and she briefly mentions some of these--premature ejaculation and Female Orgasmic Disorder--noting that it seems illogical to say that a woman who cannot orgasm does not have this simply because she is not distressed by it. She notes, however, that according to the New View, labeling this as a disorder in the absence of distress "assumes that orgasm is a normal/natural state and that its absence denotes pathology."

Regarding low desire, she claims, the matter is less clear; to support this, she notes that "there is a small but growing body of literature on the
phenomenon of human asexuality [citations] defined as lifelong lack of
sexual attraction." People have described asexuality as a sexual identity rather than as a sexual dysfunction because of the "finding that the only distress
experienced by asexual persons is in reaction to sociocultural pressures to be sexual, and pathologizing those who do not wish to be sexual."

She continues,
The removal of distress from the criteria for HSDD may lead to the unfortunate labeling of asexuals as having a sexual dysfunction and there is strong opposition to this view among the asexual community [citation]. Although research on asexuality is still in its infancy, there is also insufficient evidence to suggest that asexuality is a sexual dysfunction of low desire. I would forward that the DSM-V consider making this point in the text or adding it to the list of exclusion diagnoses.
She also notes that in studies on the prevalence of low sexual desire and associated distress, there are more who aren't distressed about their low sexual desire than there are who are distressed about it.

Also, of interest is a suggestion that was made by, I think, by L. Tiefer, who is a DSM-V advisor*. The proposal is to replace HSDD, FSAD, and Female Orgamic Disorder with a disorder based on distress about these. (After all, it is distress that causes people see clinicians). A proposed name is "Sexual Response Distress." The idea is only discussed briefly, but Brotto states, "This intriguing idea deserves consideration." I would agree with that judgment.

Proposed changes
The report recommends that the requirement of the absence of fantasies be deleted. It recommends that the "hypoactive" part be deleted from the name, and that the diagnoses HSDD and FSAD be combined into a single diagnosis. Two names are proposed: "Sexual Interest/Arousal Disorder" and "Sexual Arousability Disorder."

I'll quote the language for the proposed diagnostic criteria:
A. Lack of sexual interest/arousal of at least 6 months duration as manifested by at least four of the following indicators:
(1) Absent/reduced interest in sexual activity
(2) Absent/reduced sexual/erotic thoughts or fantasies
(3) No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
(4) Absent/reduced sexual excitement/pleasure during sexual activity (on at least 75% or more of sexual encounters)
(5) Desire is not triggered by any sexual/erotic stimulus (e.g., written, verbal, visual, etc.)
(6) Absent/reduced genital and/or nongenital physical changes during sexual activity (on at least 75% or more of sexual encounters)
B. The disturbance causes clinically significant distress or impairment

(1) Lifelong or acquired
(2) Generalized or situational
(3) Partner factors (partner’s sexual problems, partner’s health status)
(4) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
(5) Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experience)
(6) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
(7) Medical factors (e.g., illness/medications)

Not surprisingly, this proposed diagnosis is almost identical with the diagnosis proposed in Graham's report on FSAD. The differences between them are of interest: there are only two. Graham has one proposed only one name (Sexual Interest/Arousal Disorder), and, in her proposal, criterion A requires 3 out of 5 indicators, rather than 4 out of 6, as in Brotto's proposal. (Graham's does not include Brotto's #5.) There are a number of possible reasons for these differences (e.g. disagreement among the authors, one report being finished some time after the other, wanting to propose multiple versions to stakeholders, etc.) So I will not speculate on the matter.

Thoughts and comments
My guess is that most people in the field will regard these proposed criteria as a considerable improvement over the current diagnosis. It's not clear what comments about asexuality might be made in the text of the DSM-V or how relevant clinicians and researchers would react to such a change. (I assume that no decisions on the matter have been made.)

There are some points in the proposed definition for Sexual Interest/Arousal Disorder (which I'll call SIAD) that seem to lack as much clarity as might be desirable--though these are mostly things that could be dealt with in the supporting text for DSM-V.

There is one issue whose omission seemed to stand out in the Female HSDD report. There is no justification given for including the specifiers "Lifelong or acquired" and "Generalized or situational." The specifiers themselves are nothing new. They were included (under various names) in the original proposals for HSDD/ISD in 1977; they were included in the introduction to the sexual dysfunctions in DSM-III, and they were added as subtypes in the diagnostic criteria for HSDD in DSM-IV.

Brief mention of them is made in Graham's report.
The first two of these subtypes, ‘‘lifelong’’ vs. ‘‘acquired’’ and ‘‘generalized’’ vs. ‘‘situational,’’ seem potentially useful for clinical purposes, although it is worth noting that, in epidemiological research, these distinctions have very rarely been made. The recommendation made here would be to retain these distinctions, although rather than include these as ‘‘subtypes’’ they could instead be incorporated as specifiers.

This strikes me as odd. One of the two subtyping** systems is seen as useful, so both recommended to be included. But they're degraded to the status of specifiers because of lack of empirical evidence. If there is a meaningful difference between generalized and situational low sexual desire in women, it seriously draws into question certain parts of the proposed diagnostic criteria. Namely, indicators (2) and (5):
(2) Absent/reduced sexual/erotic thoughts or fantasies
(5) Desire is not triggered by any sexual/erotic stimulus (e.g., written, verbal, visual, etc.)

Indicator (2) would only be an indicator for "generalized" SIAD, but not for "situational." In (5), it is not clear if "desire" includes solitary desire or is limited to to dyadic desire. If the "generalized" vs. "situational" distinction is meaningful for (at least some?) women, this distinction is crucial. And if it's not, why is the "generalized vs. situational" distinction being retained?

It remains to be seen what commentary will be published in response to this proposed diagnosis, and it remains to be seen what the proposed diagnosis for male HSDD will look like (or whatever might be proposed to replace it.) Personally, I'm a fan of deleting HSDD, FSAD, and Female Orgasmic Disorder and replacing them with Sexual Response Distress.

*In addition to members of each workgroup, the DSM-V Taskforce nominates people to serve in advisory roles. According to the April 2009 report from the Sexual and Gender Identity Disorders Workgroup, "Each sub-work group is providing internal feedback for the literature reviews and the next step will be to obtain feedback from advisors who have been nominated to comment on specific literature/diagnostic reviews." Google didn't provide me with any information on who any of these people are, but names are given in the Acknowledgments of each paper I've cited. Each lists five people, four of whom are on both lists.

**On p. 1 of DSM-IV-TR there is an explanation of the distinction between specifiers and subtypes. Essentially, subtypes should create a partition on the set but specifiers don't have to. The goal is to create more homogeneous sub-populations.

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