Classification of Female Sexual Disorders

The classification of female sexual disorders has undergone several revisions and continues to evolve as knowledge expands. Several useful classification systems have been created, but no one system stands as the hard-and-fast rule or gold standard. The following section discusses two of the most widely known and used classifications.

DSM-IV Classification

The American Psychiatric Association's DSM-IV: Diagnostic and Statistical Manual, 4th edition, published in 1994, as well as the World Health Organization's International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10), published in 1992, contains a classification system for female sexual disorders that is based on the Masters and Johnson and Kaplan linear model of the female sexual response.^(1,2) The DSM-IV, which focuses on psychiatric disorders, defines a female sexual disorder as a "disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty." This classification system has increasingly come under scrutiny and criticism, not the least of which is because it focuses only on the psychiatric component of sexual disorders. ^(3,4)

The DSM-IV categorizes female sexual disorders as follows:

• Sexual desire disorders
  a. Hypoactive sexual desire
  b. Sexual aversion disorder

• Sexual arousal disorders - Orgasmic disorders

• Sexual pain disorders
  a. Dyspareunia
  b. Vaginismus

• Sexual dysfunction due to a general medical condition

• Substance-induced sexual dysfunction

• Sexual dysfunction not otherwise specified

The psychiatric diagnostic manual also provides subtypes to assist in diagnosis and treatment of sexual disorders: whether the disorder is lifelong or acquired, generalized or situational, and due to psychological factors or combined psychological/medical factors.

American Foundation for Urologic Disease Consensus-Based Classification of Female Sexual Dysfunction (CCFSD)

In 1, an international multidisciplinary panel of 19 experts in female sexual disorders was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to evaluate and revise the existing definitions for female sexual disorders from the DSM-IV and the ICD-10 in an attempt to provide a well-defined, broadly accepted diagnostic framework for clinical research and the treatment of female sexual problems.⁽⁵⁾ The conference was supported by educational grants from several pharmaceutical companies. ( Affiliated Research Centers, Eli Lilly/ICOS Pharmaceuticals, Pentech Pharmaceuticals, Pfizer Inc., Procter & Gamble Pharmaceuticals, Inc., Schering-Plough, Solvay Pharmaceuticals, TAP Pharmaceuticals, and Zonagen.)

Like previous classifications, the Consensus-Based Classification of Female Sexual Dysfunction (CCFSD) is based on the Masters and Johnson and Kaplan linear model of the female sexual response, which is problematic. However, the CCFSD classification represents an advance over the older systems because it incorporates both psychogenic and organic causes of desire, arousal, orgasm, and sexual pain disorders (see Table 7). The diagnostic system also has a "personal distress"  criterion, indicating that a condition is considered a disorder only if a woman is distressed by it.

The four general categories from the DSM-IV and ICD-10 classifications were used to structure the CCFSD system, with definitions for diagnoses as described as follows.

• Sexual desire disorders are divided into two types. Hypoactive sexual desire disorder is the persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress. Sexual aversion disorder is the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.

• Sexual arousal disorder is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses.

• Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.

• Sexual pain disorders are also divided into three categories: Dyspareunia is the recurrent or persistent genital pain associated with sexual intercourse. Vaginismus is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress. Non-coital sexual pain disorder is recurrent or persistent genital pain induced by non-coital sexual stimulation.

Disorders are further subtyped according to medical history, laboratory tests, and physical examination as lifelong versus acquired, generalized versus situational, and of organic, psychogenic, mixed, or unknown origin.

RESOURCES:

1. American Psychiatric Association. DSM IV: Diagnostic and Statistical Manual for Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press; 1994.
2. World Health Organization. ICD 10: International Statistical Classification of Diseases and Related Health Problems. Geneva: World Health Organization; 1992.
3. Sugrue DP, Whipple B. The consensus-based classification of female sexual dysfunction: barriers to universal acceptance. J Sex Marital Ther 2001;27:221-226.
4. Working Group on A New View of Women's Sexual Problems. A new view of women's sexual problems. Electronic Journal of Human Sexuality 2000;3. Available at www.ejhs.org/volume 3/newview.htm. Accessed 3/21/05.
5. Basson R, Berman J, Burnett A, et al. Report of the International Consensus Development Conference on female sexual dysfunction: definitions and classifications. J Urol 2000;163:888-893.