Should sexual desire and arousal disorders in women be merged?

We are grateful for the opportunity to reply to the Letter to the Editor entitled‘‘Should Sexual Desire and Arousal Disorders in Women Be Merged?’’by DeRogatis, Clayton, Rosen, Sand, and Pyke (2010). Considerable debate has emerged since the publication of our proposed revisions for Hypoactive Sexual Desire Disorder (HSDD) and Female Sexual Arousal Disorder (FSAD) for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Brotto, 2010; Graham, 2010).Published commentariesand our response (Binik, Brotto, Graham, & Segraves, 2010) appeared in a recent issue of the Journal of Sexual Medicine. At the outset, we wish to respond to a statement made by DeRogatis et al. regarding the basis for our proposed revisions. DeRogatis et al. argued that fundamental changes to psychiatric nomenclature ‘‘...should be based on confirmed data— preferably from multiple clinical trials or observational studies—rather than on theoretical speculations or expert opinion, as in the current proposal.’’The published guidelines for making changes to DSM-5 (Kendler, Kupfer, Narrow, Phillips, & Fawcett, 2009) clearly state that recommendations should be guided by research evidence but that, unlike DSM-IV,‘‘there will be no a priori constraints on the degree of change between DSM-IV and DSM-V.’’ There is simply no justification for asserting that the proposal for Sexual Interest/Arousal Disorder was based on‘‘theoretical speculations or expert opinion.’’ Comprehensive and critical reviews of the empirical literature wereundertaken(Brotto,2010;Graham,2010)and these formed the basis for the proposals. It should also be noted that the DSMIV-TR diagnoses of HSDD and FSAD were not based on any systematically collected body of data. The diagnosis of HSDD was the result of the expert opinion of Helen Singer Kaplan and Harold Lief: FSAD appears to have initially resulted from the early theorizing concerning the human sexual response cycle by Masters and Johnson and was probably saved from extinction by the hope that PDE-5 inhibitors would be effective for women. In their letter, DeRogatis et al. reported on data from two nontreatment studies funded by Boehringer Ingelheim (BI). In one study, women with primary HSDD and primary FSAD (n = 143) differed significantly from each other in terms of symptom profile. The women with HSDD had better sexual functioning, as measured by the Female Sexual Function Index (FSFI), compared to women with FSAD (total mean FSFI scores of 23.7 and 20.2, respectively). On the basis of these two groups showing ‘‘different symptom profiles,’’ DeRogatis et al. argued that the diagnostic categories ofHSDDand FSAD should not be merged in DSM-5. We believe that DeRogatis et al.’s findings of distinct symptom patterns among women with HSDD and those with FSAD are due to how the samples were recruited. As women were diagnosed using DSM-IV criteria (which separate deficient or absent desire for sex [HSDD] from impaired lubrication [FSAD], one would expect different symptom profiles in L. A. Brotto (&) Department of Obstetrics and Gynaecology, University of British Columbia, 2775 Laurel Street, 6th Floor, Vancouver, BC V5Z 1M9, Canada e-mail: [email protected]