A “dysfunction” is literally defined as an abnormality or disturbance of function. (Colman, 2009, p. 232) It may also be defined as abnormal or unhealthy interpersonal behavior or interactions. (Merriam-Webster Online Dictionary [MWOD], 2010) Specifically, sexual dysfunctions are defined as “conditions that impair the desire or ability to achieve sexual satisfaction.” (Blaney & Millon, 2009, p. 399) With and within the DSM-IV-TR, the term sexual dysfunction is conceptualized as an umbrella category that encompasses a wide variety of sex related conditions, some of which may or may not “belong” in a manual that is intended to cover and contain “mental disorders.” This essay will give a brief overview of what are currently considered under the broad title of Sexual Dysfunctions, and provide some subjective thought on efficacy of continued inclusion as we move toward the newest revision of the “psychiatric bible,” the DSM-V.
Under the rubric set forth by the current DSM, the DSM-IV-TR, the following disorders are considered under the broader category of Sexual Dysfunctions: Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder), Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder), and Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation), Sexual Pain Disorders (i.e., Dyspareunia, Vaginismus), Sexual Dysfunction Due to a General Medical Condition, Substance-Induced Sexual Dysfunction, and Sexual Dysfunction Not Otherwise Specified (NOS). (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 535) Comparatively speaking, a “disorder” is literally defined as an abnormal physical or mental condition. (MWOD, 2010) In the DSM-IV-TR, sexual dysfunctions are differentiated from Paraphilias and Gender Identity Disorders (GIDs). The essential features of a Paraphilia are arousing fantasies, sexual urges, or behaviors generally involving non-hum, the suffering or humiliation of oneself or one’s partner, or children or other non-consenting persons. (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 566) Paraphilias include Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Sadism, Transvestic Fetishism, Voyeurism, and Paraphilia NOS. Conversely, GID is characterized by strong and persistent cross-gender identification coupled with a persistent discomfort about one’s assigned sex and/or gender role. (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 576)
Among those disorders, there are some that appear to fit better than others. Take the Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder) for example… what is considered normal libido? Is there any objective way to quantify or qualify the need or desire to have sexual relations? Honestly, I don’t think there is. What is normal sexual activity to me and my partner may be too much or too little for another. Like most disorders, one of the key diagnostic criterions of the DSM-IV-TR sexual dysfunctions is “marked distress or interpersonal difficulty.” As a result, it’s not a problem unless the potential client makes it one, regardless of the presence of desire to engage in sexual activity. Furthermore, it’s not a disorder unless a deficiency is detected and deemed appropriate by the clinician, thereby inserting another level of subjectivity. It should come as no surprise that inter-rater reliability is lacking, and epidemiological data is mixed based on the definition of the disorder.
Another example is Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder). Although at the core, there may be some genetic or psychological factors at play, I am not sure I could consider it a disorder if someone simply isn’t attracted to their potential partner? There are so many variables at play in Female Sexual Arousal Disorder that it may be increasing difficult to identify specific etiology. Perhaps her partner is less than skilled. Perhaps there is a developmental basis for the lack of lubrication (menopause). Perhaps there are underlying biological causes in the form of circulatory problems that contribute to an inability to attain sufficient swelling response during periods of sexual arousal. All of these situations are in fact treatable, but should we consider them “mental disorders?” In some cases yes, where psychological factors are at play… however, there are an abundance of situations where psychological factors have little relevance in the diagnosis and treatment of Sexual Arousal Disorders.
Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation) may be propagated by psychological factors, and subsequently appropriate for inclusion in the DSM-V. Conversely, there are a whole host of “combined factors,” including a very wide variability in type or intensity of stimulation that can trigger organism, that are likely less than “psychological” in nature. Take premature ejaculation for example. I think we would be hard pressed to find men who don’t want to last longer… and that inability may be a significant cause of duress for some men. But as currently envisioned, there is no baseline as to what constitutes a threshold between a disorder, and simply being “excitable.”
Paraphilias are a hot topic in the psychological community because the presence of “mental disorders” like pedophilia seems to justify the behavior. It would appear to me that any suggestion that paraphilias are in fact a mental disorder would present the opportunity to present a legal argument that “he or she is mentally ill, and as a result, can’t be considered liable for these actions. In my opinion, simply having a legal option like that is counterintuitive and reprehensible.
We have addressed what is present; however, there is one glaring absence in the current nosology. Where is the diagnostic category of “sexual dysfunction due to mental disorder?” One possible solution is to redefine sexual dysfunction due to substance abuse as a dysfunction due to mental disorder “with onset during intoxication.” (Segraves & Balon, 2007) Including such a category would be intuitive in my opinion, despite the fact that our meanings of the words disorder and dysfunction have become rather convoluted in their practical application. It seems to meet the definition of “abnormal or unhealthy,” more so than some of what we currently consider to be dysfunctions. Without, there is a great deal of work that needs to be done in terms of clarification and codification as we approach the watershed appearance of the latest version of the DSM.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.
Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.
Merriam-Webster Online Dictionary. (2010). disorder. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/disorder
Merriam-Webster Online Dictionary. (2010). dysfunction. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/dysfunction
Segraves, R. T., & Balon, R. (2007, Aug). Toward an improved nosology of sexual dysfunctions in DSM-V. Psychiatric Times, 24(9), 44. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1313390581&Fmt=2&clientId=4683&RQT=309&VName=PQD
Community Chest Counseling, PSC 