Thursday, May 13, 2010

Sex DSM-5--and the Apocalypse: A commentary

Earlier today, Daniel B. Block MD had an editorial published in the Psychiatric Times: Sex, DSM-5— and the Apocalypse: A Commentary, one of the few that I've seen recently dealing with HSDD.

I find his commentary interesting because there is a certain naivety and insight. From reading it, it seems that he has not read the proposed changes to this diagnosis and hasn't read up as much as he might on some of the debates surrounding these issues, yet his commentary also shows a very healthy dose of common sense and clinical insight. (And a healthy skepticism when a pharmaceutical representative tried to "inform" him about Female Hypoactive Sexual Desire Disorder.)

Commenting on the DSM-IV-TR criteria for HSDD, he writes:
From these criteria, “I’m not in the mood” (and not happy about not being in the mood) is a disorder. There really is no room for not being in the mood. How about if someone is not in the mood because her husband only pays attention to her when he wants sex and then when he does typically considers grabbing his wife’s breast and making a joke as foreplay? Or the man whose wife, girlfriend, or significant other only seems to want sex on her own terms and has had a chronic pattern of using sex in a manipulative fashion throughout their relationship? (I have had various patients complain of just these things.) Do I diagnose these patients with an illness—a disorder? Or are they simply unhappy and perhaps desiring of sex but with someone else or in a setting where their current relationships are on better ground? How about if someone is simply just too tired because he/she worked hard all week?

I remember fondly one of my favorite teachers in medical school and residency – Dr Jack Benson. He told the following story of a 90-year-old man who once presented to him for consultation because he was experiencing trouble maintaining an erection as well as getting one as often as he would have liked. (There was no sildenafil back then.) Dr Benson was making a teaching point that would echo the words of Sir William Osler: “Listen to the patient: He is telling you the diagnosis.” Or, he is telling you what the problem or issue is. It turned out that this healthy 90-year-old widower had 3 healthy girlfriends, all about 20 years younger than he and all demanding sex from him (no HSDD there!). He was simply too tired to keep up and had very little knowledge of human sexuality beyond the basics. Dr Benson helped to reframe his situation for him and the man went away relieved there was nothing wrong with him.

The currently proposed criteria for this diagnosis actually make relationship problems a specificier (meaning lack of interest in sex because one's partner is a jerk is a disorder if it causes distress or "impairment.") I understand that the goal is to help facilitate treatment in such cases, but, as Dr. Block points out, this really makes no sense.

(From my reading of the relevant reports of the Sexual Dysfunctions Workgroup, I detect a certain ambivalence regarding these issues.)

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