The New Avatar of Female Sexual Dysfunction in ICD-11—Will It Herald a Better Future?

Abstract

Abstract

Female sexual dysfunction has always had challenges related to nosological issues due to inadequate research and understanding in this area. The ICD-11 has proposed substantial changes to the classification of conditions related to sexual health. In this review, we have discussed the proposed changes, compared with other classificatory systems and discussed its implications on clinical practice and research in this field. While there have been several progressive moves in the taxonomy of sexual dysfunctions, we have expressed our views on possible changes which can help with better diagnosis and management of sexual problems in women.

Moving on From the Linear Model

Research in the field of psychosexual medicine and taxonomy of sexual dysfunction has developed only in the past 50 years, both progressing alongside of one another. ¹

The original classification of sexual dysfunction, from the consensus panel meeting in 1998, was in accordance with the linear model of sexual response, which did not account for differences between men and women in their sexual response models. Both International Classification of Diseases, Tenth Revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) used this linear model to classify sexual dysfunction as problems in desire, erection, orgasm, and ejaculation.

Some of the challenges in classifying sexual dysfunction include defining the threshold for the disorder, using a categorical approach over a dimensional approach, and distinguishing between organic and psychological factors. In addition to this, sexual dysfunction in women is under-recognized due to lack of understanding of sexual functioning among women and problems in measurement of sexual functions. The revision process of ICD-10 required to address these complex and potentially controversial issues. ¹

Female sexual dysfunction (FSD) is multifaceted and complex, and numerous biopsychosocial factors such as family and cultural beliefs, early sexual experiences, partner relationship, and external stressors impact sexual functioning in women. These factors have now been recognized as important components of FSD and have gradually been incorporated into the classificatory systems. ²

FSD in ICD-11—a New Location and New Criteria

Among the proposed changes for ICD-11, substantial changes have been proposed to the classification of conditions related to sexual health. A major change was to move sexual dysfunctions from “Mental and behavioural disorders” to a separate section on “Conditions related to sexual health,” while in the ICD-10, they were included under “Behavioural syndromes associated with physiological disturbances and physical factors.” This section includes sexual dysfunctions, sexual pain disorders, paraphilic disorders, and gender incongruence along with conditions which are diseases of the genitourinary system.^{3, 4}

The classification of sexual dysfunctions (F52), in ICD-10, is based on Cartesian dualism of dividing disorders into “organic” or “non-organic” conditions. Sexual dysfunctions are considered as “non-organic” conditions and are classified in the ICD-10 chapter on mental and behavioral disorders, while most of the “organic” sexual dysfunctions are placed in the chapter on diseases of the genitourinary system. ⁵

The current available evidence points towards an interaction between physical and psychological factors in the origin and maintenance of sexual dysfunctions, and the rationale for this change in ICD-11 is consistent with the current, more integrative clinical approaches in sexual health. While this move may attenuate the boundary between mental and physical disorders, thus reducing stigma and encouraging more women to seek treatment for these conditions, there is a risk of medicalizing sexual dysfunctions by moving this category away from mental and behavioral disorders. The outcome of this major move in the ICD-11 remains to be seen. ⁶

In ICD-11 draft, sexual dysfunctions have been subgrouped into hypoactive sexual desire dysfunctions, sexual arousal dysfunctions, orgasmic dysfunction, ejaculatory dysfunctions, sexual dysfunctions associated with pelvic organ prolapse, and sexual anhedonia. ⁴

The proposed ICD-11 diagnostic guidelines continue to organize sexual dysfunction as per the traditional linear progression model of the female sexual response cycle having four distinct physiologic phases. Unfortunately, the linear progression model for women’s sexuality did not prove useful in conceptualizing the complexities of women’s sexual functioning and satisfaction which is often linked to physiological factors as well as to factors such as intimacy and relationship.

In contrast, Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) has eliminated hypoactive sexual desire disorder and merged “desire” and “arousal” disorders in women into one entity to form a new category called the sexual interest/arousal disorder (SIAD), thus emphasizing on a nonlinear approach. ⁷

ICD-11 has retained the diagnosis of hypoactive sexual desire dysfunction, which can be applied to both men and women, while the sexual arousal dysfunctions have been classified separately for men and women.

Male and female sexual arousal dysfunctions have been separated in ICD-11. This is a progressive change as female sexual experience is influenced and measured by a multitude of factors related to emotional, physical, and relational aspects as compared to male sexual problems which are more physiological and easily measurable.

In ICD-11, separate categories are provided for men and women (female sexual arousal dysfunction and male erectile dysfunction) to replace ICD-10 category of “failure of genital response,” because of anatomical and physiological differences underlying the distinct clinical presentations between men and women.

The ICD-11 category, of orgasmic dysfunction, is gender-neutral and can be applied to both men and women.

The proposed criteria indicate that sexual dysfunction must be present frequently for several months and cause significant distress in order to be considered sexual dysfunction. ICD-11 also uses specifiers for life-long and acquired, situational, and generalized sexual dysfunctions. This is a good move that is more in harmony with the DSM-5 and will avoid overdiagnosis. However, in cases where there is an immediate acute cause of the sexual dysfunction (such as injury or medications), an exception to the duration criteria must be taken into consideration and it may be appropriate to assign the diagnosis even though the duration requirement has not been met, in order to initiate treatment. ⁸

Sexual aversion and excessive sexual drive have been eliminated with the rationale that the diagnosis had very little empirical support. Sexual aversion disorder shares numerous similarities with anxiety and phobic disorders with respect to symptomatology and management, and this move may help better identification. Excessive sexual disorder, particularly among women, has always been viewed with skepticism. Social constructs of female sexuality have changed with time and this category deserved to be put to rest.

Dyspareunia and vaginismus have been now classified under sexual pain disorders. This decision was based on the conclusion that the two disorders could not be reliably differentiated, for two main reasons. First, there is inadequate empirical evidence to diagnose vaginismus on the basis of “vaginal muscle spasm” and second, fear of pain or fear of penetration is often used in clinical descriptions of vaginismus, leading to phobic avoidance. Vaginismus and dyspareunia also overlap to a great degree. ⁹

In ICD-11, the ICD-10 category sexual aversion would be categorized either under sexual pain-penetration disorder or under specific phobia, depending on the specific nature of symptoms.

How Will These Changes Influence Practice?

The changes in the newer classificatory systems are an attempt to move away from the traditional linear model of sexual response cycle and are a progressive move in classifying FSD which comprises of overlapping phases in a variable sequence, influenced by various psychological and physical factors during the process. Having a gender-specific criteria for the subgroup is another positive step.

ICD-10 primarily focused on objective measures to look at sexual satisfaction and define normal sexual functioning in women; however, our current knowledge suggests that sexual satisfaction in women is an interplay between physical excitement, subjective emotions, and psychosocial factors, which needs to figure in the newer classificatory systems.

DSM-5 has incorporated relationship distress and psychosocial stress as an exclusion factor for sexual dysfunction but ICD-11 misses an opportunity to include cultural and psychosocial factors in the current version.

While there have been several positive changes in the taxonomy of sexual dysfunctions, further incorporating the physiological, psychological, and interpersonal factors in the classificatory system can help with correct diagnosis and treatment of women with sexual problems.