Limitations of the DSM Diagnostic Categories
Although the DSM-5 provides the information necessary to assign a diagnosis that meets insurance or other third-party payer needs, it may not provide a full enough understanding of the factors that precipitate, maintain, contribute to, or follow from a sexual problem. The DSM-5 assumes normal sexual functioning to include the facility to experience desire and satisfaction (that is, receptivity to sexual activity), with the experiencing of orgasm under suitable circumstances (Sugrue 8c Whipple, 2001). This has led to what some believe is sexology’s preoccupation with coitus and orgasm (Tiefer, 2001; 2002). This section reviews some of the limitations of the current DSM-5 categories and definitions in order to provide clinicians with a better understanding of how sexual problems arise and impact other areas of functioning. Such information is presented to help with a more accurate diagnosis and treatment plan.
Disorder versus Problem
Many of our clients, especially women, report a lack of sexual pleasure, enjoyment, and satisfaction, despite being able to respond sexually in terms of having an adequate sex drive, becoming aroused, and being able to achieve orgasm. In these situations, sexual dissatisfaction is not a diagnosable disorder. In addition, many clients will report dissatisfaction with the amount of foreplay and afterplay; the partner choosing an inconvenient time or location to have sex; and a difference in preferred sexual practices, including positions. The sex therapist will likely see many cases involving individual or dyadic sexual issues that may or may not qualify as diagnosable sexual disorders by the DSM-5 standards. “Sexual disorder” implies that normal functioning is impaired and that this impairment causes personal and/or interpersonal distress. Nonetheless, many sexual problems do not qualify as sexual disorders yet produce similar, if not greater, levels of distress for clients. We encourage clinicians to consider those sexual problems as well. For example, a woman may present for treatment because she commonly experiences a high level of sexual desire that troubles her. This could be understood in several ways, none of which the DSM-5 addresses with a specific diagnostic category, yet it is vital that the therapist take the woman’s distress seriously (American Psychiatric Association (APA), 2013).
Another more common sexual problem, which does not fit within the DSM-5 qualification of sexual disorder, is differing levels of sexual desire between sexual partners; this very common presentation is called desire discrepancy. It can occur in same gender or heterosexual couples. It is often difficult to determine whether the problem is based on perception or lack of knowledge, or if it stems from other, more serious issues, either individual or relational. One interesting case involved a woman who expressed that she had low sexual interest and low physiological arousal. On further examination, the therapist learned that her female partner wanted to have sex three or four times a week while she only desired sex one or two times a week. Her level of desire was within normal limits, but she pathologized herself rather than considering that her distress was related to a desire discrepancy.
Etiology: Physiology versus Psychology
From the Intersystem perspective, there is a problematic dichotomy between physiological and psychological causes of a disorder. This dichotomy suggests that treatment should be binary: some problems should be treated from a strictly medical perspective and others from a psychotherapeutic perspective. Typically, the etiology of a sexual disorder can be both physical and psychological, such as the aging man presenting with ED or a perimenopausal woman with sexual pain due to lack of lubrication.
Regardless of the source of the cause or the combination of etiologic factors, sexual symptoms will always have psychological/relational consequences. Sexual problems are embedded in relationship dynamics and vice versa. Treatment from just one perspective is simplistic. For example, a man may have ED stemming from a medical problem and will require medical treatment. Additionally, the ED will have psychological consequences for the man and for the couple that need to be recognized and become part of the overall treatment program. Sexual problems, even those with a purely physiological basis, are best treated with an approach that combines medical and psychotherapeutic approaches (Gambescia 8c Weeks, 2020). In cases where clinicians have conducted a thorough Intersystem assessment and suspect a physiological component of sexual disorder, a good clinical practice requires consultation/collaboration with a physician who has expertise in the area of sexual disorders and a working knowledge of the wide range of normal physical sexual responses.
