Proposed Revisions and Additions in the DSM-V for Sexual and Gender Identity Disorders

Some disorders included in the DSM-V are Hypersexual Disorder, Paraphilic Coercive Disorder, Sexual Interest/Arousal Disorder in Women, Sexual Interest/Arousal Disorder in Men, and Genito-Pelvic Pain/Penetration Disorder. These are not in the DSM-IV-TR.

1. Hypersexual Disorder (14)

  • In the DSM-V, Symptom Clusters A, B, and C must be met for a diagnosis of Hypersexual Disorder

A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

  • A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.
  • Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states such as anxiety, depression, boredom, and irritability.
  • Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.
  • Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.
  • Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.

B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior

C. These sexual fantasies, urges, and behaviors are not due to the direct physiological effect of an exogenous substance such as an abused drug or medication.

  • Specify if
    • Masturbation
    • Pornography
    • Sexual behavior with consenting adults
    • Cybersex
    • Telephone Sex
    • Strip Clubs
    • Other
  • See here for the DSM-V proposed changes DSM-V – Hypersexual Disorder

Hypersexual Disorder has been proposed as a new sexual disorder diagnostic category. The evidence in support of this is explained in a review by Martin Kafka (see **Hypersexual Disorder: A Proposed Diagnosis for DSM-V**). There is empirical evidence that supports each A Criterion in the report. There are several other available reports and literature that support this.

Rationale

Clinical need

There is a compelling clinical need for mental health professionals to pinpoint and diagnose men and women of a distinct group who are seeking and receiving mental health care. These people are seeing psychological clinicians because they have sexual behaviors that are out of control but that are not intrinsically socially unorthodox. People that have these conditions are, at the moment, diagnosed with Sexual Disorder Not Otherwise Specified. This has been called a diagnostic wastebasket and DSM-V editors would like to see it diminished. This affliction is ranked as one of the more serious disorders but it is still a neglected contemporary psychiatric disorder. Men and women who have Hypersexual Disorder have the tendency to be sexual risk takers. There are at a higher risk to catch and propagate sexually transmitted diseases, including HIV.

Research Need

There is a need for research to cement an operational definition for this condition. This is needed so that research from diversified theoretical perspectives can unite with a common set of criteria. Specific empirically supported criteria has not been validated.

Hypersexual Disorder and its diagnostic neighbors

Paraphilic disorders are the closest diagnostic neighbors of this disorder but they have core differences. Pharaphilias are characterized by constant, deviant sexual arousal (e.g., Exhibitionistic Disorder) whereas Hypersexual Disorder is represented by normophilic sexual behaviors that are repetitive, excessive, or disinhibited (e.g., sexual behavior with consenting adults). It is clinically plausible without paraphilias or independently co-associated with paraphilias (e.g., Voyeuristic Disorder and Hypersexual Disorder; telephone sex and masturbation) or conveyed with Hypersexual Disorder (e.g., Pedohebephilic Disorder and Hypersexual Disorder; [child] pornography and masturbation). The Hypersexual Disorder in all these examples has a continuous sexualy behavior that is not paraphilic

Hypersexual Disorder and polythetic criteria

The operational criteria “A” suggested for Hypersexual Disorder are gathered from items included in published validated instruments noted that support each criterion. 4 out of 5 “A criteria” are required for a diagnosis. This is based on items specifically included in published validated instruments although none of these scales contain all of the specific diagnostic A criteria that is proposed for Hypersexual Disorder. The requirement of 4 out of 5 criterion items was chosen as a threshold for the disorder because it is based on clinical grounds and is intended to reduce false-positive diagnoses of Hypersexual Disorder. The threshold need a large amount of field testing.

Significant gaps in basic knowledge remain

There are gaps in the current knowledge regarding extra former, present, and predictive validators for Hypersexual Disorder. Developmental risk factors, for example, are not presently known. Additional empirically-based knowledge of the disorder in women is also needed.

2. Paraphilic Coercive Disorder

* The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occations

  • Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges are focused on sexual coercion
  • The diagnosis of Paraphilic Coercive Disorder is not made if the patien meets the criteria for a diagnosis of Sexual Sadism Disorder
  • See here for the DSM-V proposed changes DSM-V – Paraphilic Coercive Disorder

Rationale

  • The Paraphilias Subworkgroup is currently proposing two changes that affect the paraphilia diagnoses. The first change comes from the general agreement that paraphilias are not ipso facto psychiatric disorders. It is proposed that the DSM-V make a distinction between paraphilias and paraphilic disorder. By itself, a paraphilia would not require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress, impairment, and harm to the individual as well as others. This approach leaves the distinction between normative and non-normative sexual behavior intact. This could be important for researchers, but without automatically labeling non-normative sexual behavior as psychopathological.
  • The second change applies to paraphilias where nonconsenting persons are involved. Some examples of this are Exhibitionistic Disorder and Voyeuristic Disorder. It is proposed that Criteria B suggest a minimum number of separate victims for the diagnosis of paraphilia in uncooperative patients. This reflects the fact that for a large number of patients referred for assessment of paraphilias is referred after committing a sexual offense. These patients are usually not candid about their urges and sexual fantasies and are also not reliable historians. The criteria have been modified so that the dependence of self-reports is lessened. The word “recurrent” in the DSM-IV TR A criteria only says “more than once.” This is too vague to be clinically useful. The minimum number of separate victims varies for different paraphilias. This is an attempt to gather similar rates of false positive and false negative diagnoses for all the paraphilias. The logic is that paraphilias differ in the extent they resemble behavior in the usual adult’s sexual repertoire. Sexual arousal from seeing unsuspecting people naked seems more probably, in the usual adult, than arousal from harming terrified strangers. It follows that the closer a behavior resembles a potentially normophilic behavior, the more evidence should be required to decide the behavior is motivated paraphilically. Therefore three victims have been suggested for Voyeuristic Disorder and only two for Sexual Sadism Disorder.
  • Coercive sexual fantasy is not uncommonly reported by rapists participating in treatment. Convicted rapists who have more persistently engage in rape are more likely to show preferential arousal to saliently-coercive rape in laboratory tests than those who have less persistently engaged in rape.
  • There has been a tendency in the past to over-diagnose Paraphilic Coercive Disorder on the bases of repeated coercive sexual behavior. The diagnostic criteria that is proposed here should lead to more appropriate diagnosis. The reliance on “forcing sex on three or more nonconsenting persons on a separate occasion” in the indication that the paraphilia is a disorder, will probably have the effect of increasing the accuracy of the ascertainment of this paraphilic interest.

3. Sexual Interest/Arousal Disorder in Women

Sexual Interest/Arousal Disorder in Women includes a previous diagnosis of Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder.

A. Lack of sexual interest/arousal for at least six months duration as manifested by at least four of the following indicators. Their durations must last at least six months

  • Absent/reduced interest in sexual activity
  • Absent/reduced sexual/erotic thoughts or fantasies
  • No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
  • Absent/reduced sexual excitement/pleasure during sexual activity. This would be on at least 75% or more of sexual encounters
  • Desire is not triggered by any sexual/erotic stimulus
  • Absent/reduced genital and/or nongenital physical changes during sexual activity. This has to be on at least 75% or more of sexual encounters

B. The problem causes clinically significant distress or impairment.

C. The sexual dysfunction is not better accounted for by another Axis 1 disorder, except another sexual dysfunction, and is not due exclusively to the direct physiological effects of a substance or a general medical condition.

  • Addition of the following specifiers:
  • Lifelong (since the onset of sexual activity) or acquired
  • Generalized or situational
  • Partner Factors (sexual problems of the partner, the health status of the partner)
  • Relationship factors like poor communication, relationship discord, and discrepancies in desire for sexual activity for example
  • Individual vulnerability factors like depression, anxiety, poor body image, and history of abuse experience for example
  • Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity
  • Medical factors like illness or medication

See here for the DSM-V proposed changes – DSM-V – Sexual Interest/Desire in Women

Rationale

  • Women show problems in the differentiation between desire and arousal. For some women, desire follows arousal and for others it precedes it. The was desire is defined is inconsistent. Some definitions focus on sexual behavior as an indication of desire, and some focus on spontaneous sexual thoughts, and others emphasize the responsive nature of women’s desire. The DSM-IV-TR uses a definition of desire that is problematic for some women. Many women report infrequent sexual fantasies. It emphasizes sexual activity as the central focus of the loss of desire. Research indicates that a lot of women do not report frequent sexual fantasies.
  • Woman may possibly not describe “sexual fantasies” in their experiences of desire and there is a low base rate of fantasies that are not deliberately evoked to boot arousal.
  • There is evidence that desire and arousal overlap and women do not differentiate between them when sexually excited.
  • There is evidence that there is no such thing as spontaneous sexual desire
  • The words “persistent” and “recurrent” were not operationalized clearly in the DSM-IV.
  • There is increasing data showing cross-cultural differences in the expression of sexual desire
  • The causes of sexual disorders are multifactorial.
  • Etiology does not always exist

4. Sexual Interest/Desire Disorder in Men

The subworkgrop for Sexual Dysfunction is exploring three options for the diagnostic criteria in men. The first option is to preserve the DSM-IV-TR criteria and title for Hypoactive Sexual Desire Disorder but add “in Men” to the title. The second option is a parallel proposal to what is presented for women with Sexual/Desire Disorder. If this is the option that is selected Sexuak Interest/Arousal Disorder will be a gender-neutral category. The third option would be to require five symptoms instead of six. This would involve the removal of the criterion ” Absent/reduced genital and/or nongenital physical changes during sexual activity on at least 75% or more of sexual encounters” from the list.

The workgroup to come to a conclusion based on field trial results. The results of the field trials will also be used to determine the required number of symptoms necessary to meet criteria for a disorder if Option 2 or Option 3 are chosen.

A. Lack of sexual interest/arousal for a duration of at least six months by at least X (either 5 or 6 indicators will be required depending on which option the workgroup chooses) of the following indicators:

  • Absent/reduced interest in sexual activity
  • Absent/reduced sexual/erotic thoughts or fantasies
  • No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
  • Absent/reduced sexual excitement/pleasure during sexual activity on at least 75% or more of the sexual encounters)
  • Desire is not triggered by any sexual/erotic stimulus
  • Absent/reduced genital and/or nongenital physical changes during sexual activity on at lease 75% or more of sexual encounters.

B. The problem causes clinically significant distress or impairment

C. The sexual dysfunction is not better accounted for by another Axis 1 disorder except another sexual dysfunction and is not due exclusively to the direct physiological effects of a substance or a general medical condition.

Specifiers:

  • Lifelong (since the onset of sexual activity) or acquired
  • Generalized or situational
  • Partner factors (partner’s sexual problems, partner’s health status)
  • Relationship factors like poor communication, relationship discord, and discrepancies in desire for sexual activity
  • Individual vulnerability factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
  • Medical factors like illness or medications

See here for DSM-V proposed changes – DSM-V – Sexual Interest/Arousal Disorder in Men

Rationale

Moat literature has focused primarily on low desire in hypogonadal men or men with Erectile Dysfunction. Three possible options have been proposed for the DSM-V.

  • Option 1 is to retain the DSM-IV-TR criteris for HSDD and to rename it “HSDD in men”.
  • Option 2 is to adopt the proposed criteris for Sexual Interest/Arousal Disorder for men and women both.
  • Option 3 is to adopt the proposed Sexual Interest/Arousal Disorder criteria and require that a different number of the symptoms of low desire/sunjective arousal be met.

5. Genito-Pelvis Pain/Penetration Disorder

Genito-Pelvic Pain Penetration Disorder includes a previous diagnoses of Vaginismes and Dyspareunia which are not do to a general medical contition

A. Persistent or recurrent difficulties for six months or more with at least one of the following:

  • Inability to have vaginal intercourse/penetration on at leadt 50% of attempts
  • Marked vulvovaginal or pelvic pain during at least 50% of vaginal intercourse/penetration attempts
  • Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration on at least 50% of vaginal penetration attempts
  • Marked tensing or tightening of the pelvic floor muscles during attempte vaginal penetration on at least 50% of occasions

B. The problem causes clinically significant distress or impairment

C. The sexual dysfunction is not better accounted for by another Axis 1 disorder, except another sexual dysfunction, and is not to exclusively to the direct physiological effects of a substance.

Specify

  • With a General Medical Condition
  • Existing data suggests that there is a lack of reliability for the dignoses of Vaginismus and Dysparenia in the DSM-IV-TR. It also suggests an inability fo differentially diagnose these two disorders. The category that is currently proposed is descriptive and is intended to reflect the situation and also provide a framework to facilitate clinician diagnosis and assessment as well as to allow the inclusion of women suffering from pain and penetration problems into the DSM-V.
  • See here for DSM-V proposed changes –DSM-V – Genito-Pelvis Pain/Penetration Disorder