What The DSM-5 Means For The Diagnosis And Treatment Of Sexual Issues

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the “bible” that psychiatrists and psychologists in the United States use for diagnosing mental health problems. Just a few days ago, the American Psychiatric Association released the latest version, known as the DSM-5, which represents the first major overhaul of the manual in 13 years. The new version has been met with a good deal of controversy, which has already been covered extensively in the popular media. One thing that has not been particularly well-covered, though, is the DSM-5’s implications for the diagnosis and treatment of sexual issues.

One of the most notable changes in this area is that the psychiatric community is now making an explicit distinction between having a paraphilia and having a paraphilic disorder. In case you are not familiar with the term “paraphilia,” it refers to a persistent pattern of behavior in which sexual arousal is contingent upon an unusual interest, such as touching or kissing another person’s feet (fetishism), rubbing up against unsuspecting people in public (frotteurism), or spying on non-consenting persons who are either undressing or having sex (voyeurism). Historically, paraphilias have simply appeared in the DSM under names such as fetishism, frotteurism, voyeurism, and so on; however, they were not diagnosable as true disorders unless they caused personal distress (e.g., they interfered with one’s ability to establish a desired sexual or romantic relationship) and/or resulted in victimization of others.

In the DSM-5, the diagnostic criteria for most of the paraphilic categories remains unchanged, but they have all been renamed to explicitly include “disorder” in the title, such as fetishistic disorder, frotteuristic disorder, and voyeuristic disorder. The goal is to clarify that paraphilias do not inherently represent problematic behavior and require treatment—instead a paraphilia should only be thought of as a disorder when it causes some type of problem for the individual or for society. Psychologists now recognize that it is entirely possible to have an unusual sexual interest (e.g., a foot fetish) and be perfectly happy, as well as have a healthy sexual and romantic life. This labeling change is a step in the right direction; however, there are some who argue that the continued inclusion of specific paraphilias in the DSM in any capacity only serves to marginalize and stigmatize all persons with unusual sexual interests.

Another important labeling change in the DSM-5 is the replacement of the term gender identity disorder (GID) with gender dysphoria. GID is the diagnosis that was formerly applied to persons who are transsexual (e.g., individuals who feel distressed about a discrepancy between their gender identity and their anatomic sex). Because the “disorder” label was seen as stigmatizing to the transsexual community, it was dropped, which is also a positive move. Again, however, there are some who argue that gender dysphoria should not even appear in DSM at all for a variety of reasons (e.g., some argue that transsexualism is a physical rather than a psychological issue, given that the primary treatments are hormone therapy and surgery).

There were also a few changes to the DSM's list of sexual dysfunctions. For one thing, sexual aversion disorder (the label applied to persons with an intense fear of partnered sexual activity) was dropped entirely because it was rarely used by clinicians. In addition, two female sexual pain disorders (dyspareunia and vaginismus) were combined into one broader category known as genito-pelvic pain/penetration disorder because they frequently co-occurred and were hard to distinguish. Similarly, hypoactive sexual desire disorder and female sexual arousal disorder were combined into a broader diagnosis known as female sexual interest/arousal disorder, given that low interest in sex and difficulties becoming aroused frequently appear together in women.

One notable omission from the DSM-5 is the fact that a listing for hypersexuality (i.e., compulsive sexual behavior) still does not exist. It is odd that extremely low sexual interest can potentially represent a disorder, but not the opposite. I realize that it is difficult to try and define or quantify “excessive” sexual behavior. Also, it is certainly true that far too many male celebrities have cheapened the notion of “sexual addiction” by claiming it every time they get caught with their pants down as a way of absolving themselves from personal responsibility. However, it is unarguably the case that some people feel that their sex drive is out of control and they experience distress and personal impairment as a result of this. Moreover, other medical manuals (e.g., the International Statistical Classification of Diseases and Related Health Problems, or ICD) already include a diagnostic category for “excessive sexual drive,” so why doesn’t the DSM?

As you can see, these changes hardly represent a seismic shift in how the field is going to approach sexual issues in the near future. Although many of the changes (particularly the labeling issues) can be seen as a positive step, it is probably safe to say that the DSM-5 does not go quite far enough to make anyone happy.

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