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

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.

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.

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.

ARGUMENTS for or against removal of distress from the diagnostic criteria of sexual dysfunctions by former and current members of the DSM Task Force and Work Group on Sexual Disorders, as well as by other authors in the field of sex research, are reviewed and critically assessed.

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.

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.