A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:
1. Absent/reduced interest in sexual activity
2. Absent/reduced sexual/erotic thoughts or fantasies
3. No/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate
4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts)
5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual)
6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts)
B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months
C. The symptoms in Criterion A cause clinically significant distress in the individual
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually active
Acquired: The disturbance began after a period of relatively normal sexual function
Specify whether:
Generalized: Not limited to certain types of stimulation, situations, or partners
Situational: Only occurs with certain types of stimulation, situations, or partners
Specify current severity:
Mild: Evidence of mild distress over the symptoms in Criterion A
Moderate: Evidence of moderate distress over the symptoms in Criterion A
Severe: Evidence of severe or extreme distress over the symptoms in Criterion A
In past editions of the DSM, sexual interest and sexual arousal have been conceptualized as separate, though related, constructs. Most recently, the DSM-IV-TR had separate diagnoses for low or absent interest and arousal, hypoactive sexual desire disorder (HSDD), and female sexual arousal disorder (FSAD), respectively. HSDD was characterized by persistently or recurrently deficient (or absent) sexual desire and fantasies, while FSAD was characterized by continuous or recurrent inability to achieve or maintain sufficient physiological arousal, such as vaginal lubrication or swelling.
During the formulation of the DSM-5, the Sexual Dysfunction Subworkgroup referenced various forms of evidence to suggest that desire and arousal cannot be reliably distinguished in women. Sarin and colleagues [65] reported that differentiating desire and arousal in women has been complicated by four specific types of evidence. First, quantitative data has indicated that there is a high degree of comorbidity of desire and arousal disorders [66]. Second, qualitative data has suggested that women may have trouble discriminating between desire and arousal [64, 67, 68]. Third, researchers have found that women’s sexual response is nonlinear, as desire may precede or follow arousal within any given sexual encounter [64, 69]. Finally, Sarin and colleagues [65] noted that psychophysiological data (such as vaginal pulse amplitude) does not differentiate sexually healthy women from women who report difficulties becoming genitally aroused [70]. It was also suggested that FSAD as a distinct disorder was problematic in that it focused exclusively on the impairment of genital response and did not incorporate women’s subjective perceptions of arousal [71].
The merging of HSDD and FSAD into one diagnosis has led to substantial controversy in the field, as some experts disagree with this new conceptualization [72]. Balon and Clayton [73] reviewed the evidence against the establishment of the new disorder, namely, the lack of field trial testing, and the lack of attention paid to problems with lubrication and other genital sensations that have long been associated with absent or impaired genital sexual arousal. Other evidence cited by Balon and Clayton [73] included unclear symptom distinction (i.e., based on the established six symptoms, a diagnosis of FSIAD can be made without any impairment of physiological arousal) and no proposed underlying pathology. Additionally, recent findings suggest that there is significant genetic sharing between arousal, lubrication, and orgasm, which is independent of desire [74]. Balon and Clayton [73] conclude that the establishment of the new diagnosis risks harm to women who meet DSM-IV-TR diagnostic criteria for FSAD or HSDD, but not for FSIAD, as their insurance companies may not cover treatment for their sexual problems. This controversy has led to a number of debates among experts in the field. Ultimately, some organizations, such as the International Society for the Study of Women’s Sexual Health (ISSWSH) and the US Food and Drug Administration (FDA), chose to maintain the DSM-IV diagnostic criteria for HSDD and FSAD and to preserve the conceptualization of desire and arousal as distinct constructs.
Assessment of Female Sexual Interest/Arousal Disorder
Given that FSIAD is new to DSM-5, there are no assessment tools based on the new diagnostic criteria. Therefore, this section draws on the HSDD and FSAD literature.
Assessment
Comprehensive assessment of women’s sexual dysfunction includes a detailed clinical interview to gather information on the presenting problem, the woman’s sexual and relationship history, her psychosocial history, and her medical history. A gynecological exam may also be warranted.
The assessment of sexual interest in women is difficult due to the subjective and complex nature of sexual desire. Basson’s [69] model of the female sexual response introduced the concept of receptive desire. She explained that many women respond sexually when approached by their partner despite not seeking out sexual activity. Therefore, it may be important to gauge a woman’s level of responsiveness to sexual stimuli for a thorough assessment of her sexual desire.
When assessing for low sexual desire, clinicians may inquire about sexual thoughts, fantasies, and daydreams; examine the degree to which patients seek out sexually suggestive material; question how often patients have the urge to masturbate or engage in sensual self-touching; and determine level of motivation for partnered sexual activity. Clinicians should also focus on identifying situations or cues that may have stimulated the woman’s interest in sex in the past.
If a woman endorses certain “turn-ons,” it is useful to determine whether these cues or fantasies are currently absent from her life, fail to interest her any longer, or have been deemed unacceptable to her for some reason. A candid discussion of the woman’s attraction to and feelings toward her partner is useful as well. The desire for sex is only one of a multitude of factors informing the choice to be sexual; therefore, frequency of sexual activity should not be considered indicative of a sexual desire problem (or lack thereof). Women engage in sexual activity for a variety of reasons unrelated to sexual desire, including fear, duty, and revenge [75]. Overall, assessment of sexual desire needs to be carefully considered within the context of the dyadic relationship (when relevant) and must take into consideration factors known to affect sexual functioning such as the person’s age, religion, culture, the length of the relationship, the partner’s sexual function, and the context of the person’s life.
Given the close relationship between androgens and sexual desire, laboratory testing may be appropriate. To rule out hormonal causes, clinicians should consider performing assays for prolactin, total testosterone, free testosterone, sex hormone binding globulin (SHBG), dehydroepiandrosterone (DHEA), estrogens, and cortisol. Although diagnostic laboratories routinely provide reference values for these hormones, there is some disagreement as to what differentiates “normal” from “low” and “deficient” hormonal states [76]. Hormone deficiencies are therefore defined primarily by symptoms rather than quantitative cutoff points [77].
Assessment of arousal problems should focus on both the mental and genital aspects of the woman’s sexual response. Specifically, the clinician should ascertain the degree of mental excitement the woman experiences in various sexual situations (e.g., when reading erotica alone, when stimulating herself, when her partner stimulates her), the degree and type of genital sensations that are common during her sexual encounters (e.g., pulsing, swelling, tingling, warmth), and the level of genital wetness or lubrication that occurs during sexual activity. Levels of physiological sexual arousal can also be assessed indirectly using a vaginal photoplethysmograph to assess vaginal blood flow , as well as by sonograms (pictures of internal organs derived by sound waves bouncing off organs and other tissues), thermograms (images of radiation in the long-infrared range of the electromagnetic spectrum), and fMRI (imaging techniques that track changes in blood concentration in inner organs) to assess blood engorgement in the genitals. However, these techniques are more commonly used for research purposes than as clinical diagnostic tools.
If it is suspected that vulvovaginal atrophy or compromised pelvic floor muscle function may be contributing to a patient’s sexual interest and/or arousal concerns, patients should receive a gynecological examination. A gynecologist can evaluate a woman’s level of voluntary control of the pelvic floor muscles, her pelvic floor muscle tone, as well as the presence of vaginal tissue atrophy or infection. It is important to rule out these potential contributors to low sexual desire/arousal before commencing treatment.
Diagnostic Tests , Instruments, or Rating Scales
In addition to the clinical interview, there are a number of validated measures that may help elucidate the degree of sexual dysfunction the woman is experiencing and may also be useful for monitoring treatment-related changes. These include the Brief Index of Sexual Functioning for Women [78], the Changes in Sexual Functioning Questionnaire [79], the Derogatis Interview for Sexual Functioning [80], the Female Sexual Function Index [81], and the Sexual Satisfaction Scale [82] (for review of validated measures, see [83]). Questionnaires that specifically address relationship issues include the Dyadic Adjustment Scale [84], the Relationship Beliefs Scale [85], and the Locke-Wallace Marital Adjustment Test [86]. Scales for measuring female sexual desire are currently in development.
In an effort to create a set of high-quality, self-report assessment tools to measure physical, mental, and social health, the US National Institutes of Health established the Patient-Reported Outcomes Measurement Information System (PROMIS) network (http://nihpromis.org). The first PROMIS Sexual Function and Satisfaction measure (SexFs; [87]) was constructed to assess sexual function and satisfaction in both male and female cancer patients. The second version of the SexFs [88], which was published in 2015, improved upon the original scale by expanding its validity beyond patients with cancer, centering scores around norms for sexually active US adults, and establishing new content domains. The domains that are most relevant to FSIAD include interest in sexual activity and vaginal lubrication for sexual activity. This measure offers researchers and clinicians a flexible and reliable tool for assessing self-reported sexual function and satisfaction.
In general, assessment of both sexual desire and sexual arousal should comprise a complete sexual, medical, and psychosocial history, which can be obtained through standardized interviews and validated self-administered questionnaires mentioned above [89]. The clinician should explore the onset of the sexual problem, taking into account the dates of pregnancies (if applicable), surgeries, medication changes, and diagnoses of medical conditions. In addition to ruling out or identifying various medical factors, the exam serves to educate women about their anatomy and what is normal or problematic. It is also important to assess the context of the problem, especially situations or cues that have stimulated sexual desire and arousal in the past. It should be determined if previous cues for sexual desire or specific instances in which she previously felt aroused are now absent from her life or no longer of interest. The clinician may also explore the woman’s feelings about her current sexual partner to look for relationship factors that could be contributing to the sexual difficulties.
Conclusion
Female sexual interest/arousal disorder is associated with a number of biological and psychological factors. The disorder is diagnosed when women are distressed by a persistent absence or notable reduction of mental interest in sexual activity and/or physiological responsiveness to sexual cues for at least six months. Given that the disorder encompasses both sexual desire and sexual arousal concerns, women with FSIAD may have variable symptom profiles. Therefore, a thorough assessment of women who report low sexual desire and/or low sexual arousal is warranted.
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