Sexual dysfunctions: what's distress got to do with it? A study on sexual difficulties, sexual dysfunctions and sexual distress: prevalence and associated factors

Sexual difficulties, i.e., impairments in one or more aspects of the sexual response cycle, i.e., sexual desire, sexual arousal, orgasm or pain, are common in men and women. Epidemiological studies suggest that about 40-50% of adult women and about 20-30% of adult men have at least one sexual difficulty (Fugl-Meyer et al., 2010; Hayes & Dennerstein, 2005; Lewis et al., 2010). For a sexual difficulty to become a sexual dysfunction , the sexual difficulty has to cause marked distress or interpersonal difficulty (American Psychiatric Association (APA), 1994; 2000; 2013). Research focusing on sexual difficulties and sexual dysfunctions is characterized by two major limitations (see Chapter 1). First, most epidemiological studies were based on the traditional model of the human sexual response cycle (Masters & Johnson, 1966; Kaplan, 1979) which was also the main framework for the conceptualization of sexual dysfunctions in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association). This traditional model has, however, progressively received more and more critiques during the last two decades (for reviews, Levin, 2005; Pfaus et al., 2014; Tiefer, 1991; 2012). Nevertheless, alternative diagnostic categories such as hyperactive sexual desire, a lack of responsive sexual desire, a lack of subjective arousal have not yet been empirically assessed. Second, although since the fourth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV; APA, 1994), stipulated that distress is a necessary criterion for a diagnosis of a sexual dysfunction, empirical studies have typically not included a measurement of sexual distress when assessing sexual difficulties. As a consequence, epidemiological data on sexual dysfunctions as well as studies assessing factors associated with sexual distress are still relatively scarce. The fact that sexual distress has consistently been neglected in empirical studies on sexual difficulties could be partly due to the fact that the inclusion of a distress-criterion in the diagnostic criteria to define sexual dysfunctions in DSM has been disputed ever since its first inclusion in DSM-IV. Therefore, our first aim was to critically review the meaning, importance and role of distress as a criterion for a diagnosis of a sexual dysfunction according to the DSM (Chapter 2). Secondly, the present dissertation was initiated to gain empirical insight into sexual difficulties, sexual dysfunctions, and sexual distress (Chapters 3 7). Therefore, (age-related) prevalence rates of sexual difficulties (including uncommonly assessed difficulties), sexual dysfunctions, and sexual distress were generated from a representative population-based study in Flanders (Sexpert-study, N = 1,832) and from an online survey with Flemish men and women (OGOM-study, N = 30,378). Furthermore, we aimed at enhancing our understanding about factors associated with sexual distress in women with a sexual difficulty (Sexpert-study). In Chapter 2, we provided a historical review and evaluation of the arguments used in the debate about the necessity to in- or exclude sexual distress as a diagnostic criterion for a diagnosis of sexual dysfunction in the DSM. We concluded that the protagonists in the debate do not agree on the necessity of the distress criterion because they differ in their view on the essence and utility of a diagnosis. While according to the proponents of an objective approach a diagnosis should be neutral and based on objectively measurably criteria, the proponents of a functional approach stress that a diagnosis should enable us to detect clinically meaningful sexual dysfunctions and that the experience of distress is just what is helping to separate those with and without a need for treatment. We concluded that this debate cannot be solved based on empirical data only, but that it is first and foremost a philosophical matter about what a diagnosis exactly is. The debate has become and will remain probably endless, until the American Psychiatric Association will be more explicit as to what meaning they ascribe to a diagnosis of a sexual dysfunction in DSM. In Chapters 3 and 4, prevalence estimates of commonly and uncommonly assessed sexual difficulties and sexual dysfunctions were presented. In the Sexpert-study (Chapter 3), 44% of women and 35% of men had at least one sexual difficulty, while 22% of women and 12% of men were classified with at least one sexual dysfunction. In the OGOM-study (Chapter 4), 49% of women and 48% of men were classified with a sexual difficulty, and 24% of women and 21% of men were classified with a sexual dysfunction. In both studies, the most prevalent sexual difficulties/dysfunctions in women were lack of spontaneous sexual desire (16-21% for the sexual difficulty; 9-10% for the sexual dysfunction) responsive sexual desire (11-14% for the sexual difficulty, 8-9% for the sexual dysfunction), absent or delayed orgasm (17-19% and 6-7%), lubrication difficulties (13-15% for the sexual difficulty, 8-9% for the sexual dysfunction), and lack of subjective arousal (7-11% for the sexual difficulty, 5-7% for the sexual dysfunction). In men, most common sexual difficulties/dysfunctions were hyperactive sexual desire (13-27% for the sexual difficulty, 3-10% for the sexual dysfunction), erectile difficulties (8-9% for the sexual difficulty, 4-5% for the sexual dysfunction), and premature ejaculation (9-12% for the sexual difficulty, 4-6% for the sexual dysfunction). Overall, the present study revealed that prevalence estimates of sexual difficulties and sexual dysfunctions seemed to vary extensively depending on the criteria used to define them. That is also why prevalence rates vary extensively across studies and why comparison of prevalence estimates from different studies is a hazardous undertaking. Our studies revealed that especially using more stringent severity criteria to define sexual difficulties (i.e., not including mild impairment in sexual difficulties ) and including an assessment of sexual distress seemed to have a pronounced impact on prevalence rates. Since it is unknown which criteria and cut-offs in questionnaire research are useful to identify real (diagnoses and clinically relevant) sexual dysfunctions, we cannot be sure whether the prevalence estimates we found here approximate real prevalence rates of real sexual dysfunctions. Future research should further explore this weakness.In Chapter 3, besides prevalence rates, also co-occurrence rates between lack of sexual desire and lack of sexual arousal in men and women were analyzed (OGOM-study). In women, co-occurrence between lack of desire and lack of arousal was generally quite high (mostly between 45% to 53% for sexual difficulties, and 29% to 49% for sexual dysfunctions). However, despite high co-occurrence rates, more women had a desire dysfunction without an arousal dysfunction than a combined desire/arousal dysfunction. In men, co-occurrence rates were somewhat lower than in women though co-occurrence between lack of subjective arousal and lack of desire was relatively high (between 30.4% to 49.5% for sexual difficulties, and 26.6% to 43.0% for sexual dysfunctions). Especially erectile difficulties/dysfunctions displayed lower co-occurrence with lack of sexual desire (between 18.5% and 19.2% for sexual difficulties and between 13.4% and 17.9% for sexual dysfunctions). Taken together, although prevalence rates suggest that desire dysfunctions and arousal dysfunctions are commonly occurring independent, the high co-occurrence rates also suggest that desire and arousal difficulties/dysfunctions in men and women are closely related. These findings challenge the traditional ideas about the differences between men´s and women´s sexuality.Chapters 5 and 6 presented an overview of the age-related prevalence rates of commonly and uncommonly assessed sexual difficulties, sexual dysfunctions and sexual distress in men and women (OGOM-study). For women, our findings indicated that while most sexual difficulties increased with age or displayed a U-shaped pattern with age, for most sexual difficulties it was found that older women were less likely to report sexual distress. For men, our findings also indicated that sexual difficulties and sexual distress could be differently related to age (e.g., erectile difficulties increased with age, while distress associated with erectile difficulties decreased with age). As demonstrated by the curvilinear associations of sexual difficulties and sexual dysfunctions with age found in the current study, it becomes clear that the link between age and sexual difficulties, sexual dysfunctions and distress is complex and yet not well-understood.The focus of chapter 7 was on the association of sexual distress with the propensity for sexual inhibition and sexual excitation in women (based on data of the Sexpert-survey). The findings suggest that sexual inhibition due to threat of performance failure is an important predictor of sexual distress in low sexual desire and arousal (apart from lubrication difficulties) above and beyond age, mental health, relationship adjustment, dyadic sexual communication, and the severity of the sexual impairment. Since this study was exploratory in nature, the present results need to be replicated in future research. Furthermore, establishing more knowledge on factors related to sexual distress due to impairments in sexual functioning is important because it might have important implications for clinical work.Finally, in Chapter 8 we concluded that the results of the current dissertation have increased our awareness of importance of a correct interpretation of prevalence rates of sexual dysfunctions. The current findings clearly indicate that prevalence rates of sexual difficulties in which distress is not taken into account should be interpreted with caution, as these will inflate our idea about the number of people for whom sexual difficulties are possibly a health concern. We also conclude that the results in the current dissertation have increased our preliminary insight into factors associated with sexual distress in women, though it is clear that research on sexual distress is in need of a theoretical framework that could guide and inspire studies focusing on possible predisposing and precipitating risk factors of sexual distress due to sexual difficulties in both men and women. In this final chapter, we further discussed several implications of the results of our studies, described the strengths and limitations of our studies and made a number of suggestions to inspire future research in this interesting but understudied and unresolved field. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.Fugl-Meyer,K. S., Lewis, R. W.,Corona, G.,Hayes,R.D., Laumann, E. O.,Moreira,E.D., . . . Segraves,T. (2010). Definitions, classification, and epidemiology of sexual dysfunction. In F.Montorsi, R. Basson, G. Adaikan, E. Becher, A. Clayton, F. Giuliano, S. Khoury, & F. Sharlip (Eds.), Sexual medicine: Sexual dysfunctions in men and women (pp. 41 117). Paris, France: Health Publications.Hayes, R.D, & Dennerstein, L. (2005). The Impact of Aging on Sexual Function and Sexual Dysfunction in Women: A Review of Population‐Based Studies. The Journal of Sexual Medicine, 2, 317 330.Kaplan, H. S. (1979). Disorders of sexual desire. The new sex therapy. Volume II. New York: Brunner/Mazel.Levin, R. J. (2005). Sexual arousal: Its physiological role in human production. Annual Review of Sex Research, 16, 154 189.Lewis, R. W., Fugl‐Meyer, K. S., Corona, G., Hayes, R. D., Laumann, E. O., Moreira Jr, E. D., ... & Segraves, T. (2010). Original articles: definitions/epidemiology/risk factors for sexual dysfunction. The Journal of Sexual Medicine, 7, 1598-1607.Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown.Pfaus, J. G., Scepkowski, L. A., Marson, L., & Georgiadis, J. R. (2014). Biology of the sexual response. In: D. L. Tolman, & L. M. Diamond (Eds.). APA Handbook of sexuality and psychology. Volume 1: Person-based approaches (pp.145-203). Washington: American Psychological Association.Tiefer, L. (1991). Historical, scientific, clinical and feminist criticisms of the human sexual response cycle model. Annual Review of Sex Research, 2, 1 23.Tiefer, L. (2012).The New View campaign: A feminist critique of sex therapy and an alternative vision. In: P. K. Kleinplatz (Ed.). New directions in sex therapy (2nd ed., pp.21-35). London: Routledge.nrpages: 279status: publishe

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Distress, sexual dysfunctions, and DSM: Dialogue at cross purposes?

Introduction. A distress criterion was added to the diagnostic criteria of sexual dysfunctions in Diagnostic and Statistical Manual of Mental Disorders, 4th Edition DSM-IV; 1994). This decision was neither based on empirical evidence, nor on an open, academic, or public debate about its necessity. As a result, this decision has been disputed ever since the publication of DSM-IV. Aim. In this article, the necessity to include or exclude the distress criterion from the diagnostic criteria of sexual dysfunctions is critically evaluated, illustrating its consequences for both sex research and clinical practice. Methods. Apart from careful reading of relevant sections in DSM-II, DSM-III, DSM-IV, DSM-IV Text Revision, and articles about and online proposals for DSM-5, an extensive PubMed literature search was performed including words as “sexual dysfunction”/“sexual difficulty”/“sexual disorder,” “distress”/“clinical significance,” “diagnostic criteria,” and “DSM”/“Diagnostic and statistical manual of mental disorders.” Based on analysis of the references of the retrieved works, more relevant articles were also found. Main Outcome Measures. Arguments for or against removal of distress from the diagnostic criteria of sexual dysfunctions by former and current members of the DSM Task Force andWork Group on Sexual Disorders, as well as by other authors in the field of sex research, are reviewed and critically assessed. Results. Proponents and opponents of including the distress criterion in the diagnostic criteria of sexual dysfunctions appear to be unresponsive to each others’ arguments. To prevent the debate from becoming an endlessly repetitive discussion, it is first necessary to acknowledge that this is a philosophical debate about the nature, function, and goals of the diagnosis of a sexual dysfunction. Conclusions. Given the current lack of data supporting either the retention or removal of the distress criterion, distress should always be taken into account in future research on sexual dysfunctions. Such forthcoming data should increase our understanding of the association between distress and sexual difficulties. Hendrickx L, Gijs L, and Enzlin P. Distress, sexual dysfunctions, and DSM: Dialogue at cross purposes? J Sex Med 2013;10:630–641. Key Words. Diagnostic Criteria; Sexual Dysfunction; Distress; Clinical Significance; DSMstatus: publishe

Predictors of Sexual Distress in Women With Desire and Arousal Difficulties: Distinguishing Between Personal, Partner, and Interpersonal Distress

Although impaired sexual function is relatively common, not all sexual impairments are associated with distress. To date, most studies on protective and risk factors for sexual distress have asked about distress in a more general manner and have failed to distinguish different dimensions of sexual distress.publisher: Elsevier articletitle: Predictors of Sexual Distress in Women With Desire and Arousal Difficulties: Distinguishing Between Personal, Partner, and Interpersonal Distress journaltitle: The Journal of Sexual Medicine articlelink: http://dx.doi.org/10.1016/j.jsxm.2016.09.016 content_type: article copyright: Copyright © 2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.status: publishe

The Early Old Kingdom at Nuwayrat in the 16th Upper Egyptian Nome

The cemetery of Nuwayrat was discovered over a century ago by Garstang, who attributed it to the Third Dynasty. Kessler 1981 however proposed a date in the late Old Kingdom. An analysis of surface pottery and the occurrence of rock circle tombs here, which strongly resemble those from Dayr al-Barsha, prove that Garstang was right. This is important, as the cemetery can now be shown to feature the oldest known roch tombs in all Egypt. In the conclusions some demographic aspects of the community buried in Nuwarat are dealt with.edition: 1ststatus: publishe