FSAD refers to inhibition of the “vasocongestionlubrication response” to sexual stimulation. In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), FSAD is defined as the pervasive or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubricationswelling response of sexual excitement, coupled with marked distress or interpersonal difficulty. The DSM classification of sexual disorders has been derived from phases of the sexual response cycle, on the basis of the work of Masters and Johnson and Kaplan. This model depicts a sexual desire phase and a subsequent sexual arousal phase, characterized by genital vasocongestion, followed by a plateau phase of higher arousal, resulting in orgasm and subsequent resolution. It is assumed in this model that womens sexual response is similar to mens, such that womens sexual dysfunction in DSM-IV mirrors categories of mens sexual dysfunction. In contrast to the third edition of the DSM manual, subjective sexual experience is no longer part of the definition, possibly in a further attempt to match norms and criteria for mens and womens sexual dysfunctions.
There are a number of serious problems with the current DSM-IV classification criteria. Firstly, although the DSM-IV explicitly requires the clinician to assess the adequacy of sexual stimulation only when considering the diagnosis of FOD, adequacy of sexual stimulation is a critical variable in evaluating each of the female sexual dysfunctions, and FSAD in particular. Exactly what is adequate sexual stimulation? Some sort of physical (genital) stimulation is a necessary, but not necessarily sufficient, prerequisite for arousal. For many women, adequate sexual arousal involves physical as well as “psychological” and “situational” stimulation, such as intimacy with a partner, the exchange of confidences, the sharing of hopes and dreams and fears, and not only directly prior to the sexual event. What if certain types of sexual stimulation have been adequate in the past, but not anymore? Is it evidence of FSAD, or could it be explained in terms of habituation or an adaptation to changing life circumstances? And what is meant by “completion of the sexual activity?” Is it masturbation to orgasm, sexual contact with a partner, sexual contact including coitus? These are very different activities that are known to differ in their sexually arousing qualities.
Secondly, the description of the first problem demonstrates that clinical judgements are required about sexual stimulation and the severity of the problem, the validity of which is questionable. The clinician has to evaluate what is normal, based on age, life circumstances, and sexual experience. Research on the basis of which clear criteria can be formulated, is lacking. There is a great variety in the ease with which women can become sexually aroused and which types of stimulation are required.