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Sexual Interest/Arousal Disorder (SIAD) is a proposed modification/addition to the fifth edition of the diagnostic statistical manual (DSM-V). Currently, in the DSM-IV, women’s sexual desire, arousal, and orgasm disorders are considered separate entities. Recent research, however, has found high comorbidity of desire and arousal disorders in women. This is perhaps due to the fact that the female sexual response cycle is very variable (see Human sexual response cycle and Masters and Johnson for models of sexual response), and that women often have difficulties differentiating between desire and subjective arousal. The high rate of comorbidity between women’s sexual desire and arousal disorders, and the similar etiologies, assessment procedures and treatment options has lead to the proposal to modify the next DSM to include SIAD as an umbrella term merging hypoactive sexual desire disorder (HSDD), Female sexual arousal disorder (FSAD), and Female orgasmic disorder (FOD). It must be noted that SIAD is applicable only to women, as men’s experience of desire, arousal and orgasm are much more distinct. For the rest of this article, the focus will be on female sexual dysfunctions in regards to SIAD and its inclusions.

Hypoactive Sexual Desire Disorder
For full article, see hypoactive sexual desire disorder

Hypoactive sexual desire disorder (HSDD) is defined as “persistently or recurrently deficient (or absent) sexual fantasies and desire for  sexual activity. The disturbance causes marked distress or interpersonal difficulty” (as cited in pg 587).

Criticisms:
One criticism of the current definition of HSDD is that women may not consider fantasies and/or spontaneous desire as a good indicator of their actual level of sexual desire. This is based on recent findings that different women experience a variety of sexual response cycles, and that desire may arise as a response to sexual stimuli, rather than being the initiator (see figure one in word document - was not able to upload to Wikipedia because I don't have permission from the author). It has also been found that many women with low desire still report high levels of sexual satisfaction. This shows the importance of assessing distress in a clinical setting.

Female Sexual Arousal Disorder
For full article, see Female sexual arousal disorder

Female sexual arousal disorder (FSAD) is defined as “persistent or recurrent inability to attain, or maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. The disturbance causes marked distress or interpersonal difficulty” (as cited in pg 587). Additionally, it cannot be better accounted for by another Axis I disorder (other than another sexual dysfunction), and it is not due to the direct effects of a substance or general medical condition.

Criticisms:
One criticism of the current definition of FSAD is that it does not include subjective arousal. This is problematic, because female subjective arousal does not always have a strong correlation with physiological arousal, in that women may experience a lubrication swelling response without experiencing psychological arousal. Furthermore, it is usually a lack of subjective arousal that causes distress, and is presented in clinical settings, rather than a lack of a lubrication/swelling response. An additional note regarding the current definition of FSAD is that women may experience different levels of arousal in different situations. With this in mind, the clinician must assess an adequate amount of sexual stimulation, and what the “normal” arousal response would be based on age, sexual experience, and life circumstances. Recently, the disorder has been divided up into three subtypes; Genital Arousal Disorder, Subjective Sexual Arousal Disorder, and Combined Genital and Subjective Arousal Disorder. The third subtype is the most commonly presented in a clinical setting.

Female Orgasmic Disorder
For full article, see anorgasmia

Female Orgasmic Disorder (FOD) is defined as “persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase” (as cited in pg 587). Additionally, it cannot be better accounted for by another Axis I disorder (other than another sexual dysfunction), and it is not due to the direct effects of a substance or general medical condition.

Criticisms:
One criticism of the current definition of FOD is that it may be hard to differentiate between women experiencing arousal problems and women experiencing orgasm problems. For example, women who cannot achieve orgasm, may be the same population of women who have difficulty perceiving genital arousal, and therefore deciding on the appropriate diagnosis may be challenging. Another criticism of the current definition is that it doesn’t specify whether the “normal sexual excitement phase” is referring to physiological or psychological excitement. Similar to FSAD, it is important that the clinician asses what a normal orgasm response would be based on sexual stimulation received, age, sexual experience, and life circumstances. Recently, it has been proposed to add a subtype of FOD, called reduced orgasmic intensity, and trials are being done to assess the suitability of this proposal.

Gender Differences in Classification Systems of Sexual Dysfunction
For an overview of both men and women’s sexual dysfunctions in the DSM-IV, see sexual dysfunction. The proposed modification of adding SIAD to the DSM is applicable only to women, because men’s experience of desire, arousal and orgasm are much more distinct. For more information on men’s sexual dysfunctions, see erectile dysfunction, premature ejaculation, and anorgasmia. Another important contributing factor the the gender difference in sexual dysfunctions is that men’s sexual response cycle is less variable than women's. For example, men and women initiate sexual activity for different reasons; men usually initiate sex as a result of spontaneous desire, whereas women initiate sex for a wider variety of reasons, such as to achieve intimacy. One of the reasons that the separate entities of desire, arousal and orgasm have been retained in the past was to maintain consistency between male and female diagnostic categories, but in light of recent findings that suggest male and female sexuality is organized differently, this may have been an inaccurate classification system in regards to women. It has been suggested that while men experience desire, arousal and orgasm as distinct entities, women may experience great overlap in these categories. While differences are clear between males and females in regards to sexual response and sexual dysfunction, little research has been done in regards to intersex individuals, transsexuals, hermaphrodites, or individuals with other sexual or gender variations.

Recommendations for DSM-V
One of the largest criticisms of the current definitions of female sexual dysfunctions is the risk of overpathologizing women. It is very important to assess distress before diagnosis, because women’s level of sexual arousal and/or desire is not necessarily related to their sexual satisfaction. Thus, many women experience low desire or arousal, but do not receive a diagnosis, because they are not dissatisfied. Many concepts for a new classification system of women’s sexual dysfunction have been proposed for the DSM-V. Some suggested systems retain the diagnostic categories present in the DSM-IV, while others offer an entirely new classification system. SIAD is part of a new classification system, as it does not include distinct entities of female sexual dysfunctions, and instead offers one diagnosis encompassing many problems that women experience. Perhaps the biggest criticism of the diagnostic categories of sexual dysfunction in women is the comorbidity of desire and arousal disorders. With this in mind, the new classification system of Sexual Interest/Arousal Disorder has been proposed in order to merge the diagnostic categories into one general category, which does not distinguish between types of arousal (subjective or genital), and therefore avoids overpathologizing women who experience variation in their sexual experiences.

Proposed criteria for SIAD
A. Lack of sexual interest/arousal, of at least 6 months duration, as manifested by at least three of the following indicators:

(1) Absent/reduced interest in sexual activity

(2) Absent/reduced sexual/erotic thoughts or fantasies

(3) No initiation of sexual activity and is not receptive to a partner’s attempts to initiate

(4) Absent/reduced sexual excitement/pleasure during sexual activity (on at least 75% or more of sexual encounters)

(5) Absent/reduced genital and/or non-genital physical changes during sexual activity (on at least 75% or more of sexual encounters)

B. The disturbance causes clinically significant distress or impairment

Specifiers:

(1) Lifelong or acquired

(2) Generalized or situational

(3) Partner factors (partner’s sexual problems, partner’s health status)

(4) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)

(5) Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experiences)

(6) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)

(7) Medical factors (e.g., illness/medication)

Additionally, the disorder must not be better accounted for by another Axis I disorder (other than another sexual dysfunction), and it is not due to the direct effects of a substance or general medical condition.

Etiology
The causes of desire and arousal related sexual disorders are very interrelated. They will be presented in this article together, as they will be for SIAD, but it is important to note that most of this research is based on studies done regarding desire and arousal separately.

Neurotransmitters and Hormones:
For a more extensive review, see sexual motivation and hormones main page.

Neurotransmitters are important biological contributors to the cognitive awareness of rewards. In regards to sex, neurotransmitters contribute to the rewarding experience of arousal and orgasm. Through the experience of reward, the neurotransmitters norepinephrine, dopamine, melanocortin, oxytocin, and serotonin (acting through 5HT1A and 5HT2C) all contribute to pro-sexual behaviour. On the other side of things, the neurotransmitters prolactin, GABA, and serotonin (through other serotonin receptors) act to inhibit sexual response.

Hormones influencing sexual functioning are testosterone, progesterone and estrogen. One indication that hormones are important for sexual desire and arousal is that women’s desire fluctuates throughout her menstrual cycle, along with the fluctuating hormone levels (see PSM and Sexuality). Another indication of the importance of hormones in sexual desire is the finding that premenopausal women using hormonal contraceptives have lower levels of testosterone, and thus a lower sex drive, than women who are not using hormonal contraceptives. Related to this finding is the information regarding low hormone levels and low sexual desire in postmenopausal women, and the effects of hormone therapy (see HRT and sexual desire). Estradiol is the most common estrogen, and it is important for maintaining vaginal lubrication in order to avoid painful intercourse. Androgens important in sexual response include testosterone (T), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate DHEAS, androstenedione (A4), and 5 α-dihydrotestosterone (DHT). Androgen levels are highest when women are in their twenties, and drop consistently until about half the level of androgens exist when women are in their forties. Androgen insufficiency can lead to decreased desire, but it is important to note that normative levels are unknown.

Additional Biological Factors:
Certain medications can have an effect on sexual desire and arousal. Additionally, other sexual dysfunctions may contribute to low desire. For example, sexual pain disorders (i.e. vulvodynia, vaginismus) may lead to less desire in the future, as a result of pain during sexual activity.

Age and Menopause
Aging (see sexuality in older age) and menopause both have negative effects on sexual desire and subjective and genital arousal, but the presence of associated distress seems to have an inverse relationship with aging. Low desire is equally prevalent among women with natural and surgical menopause, but the presence of distress is much higher in women who undergo surgical menopause.

Psychological Factors
There are many psychological variables that can contribute to low sexual desire and subjective arousal. First, early experiences such as a history of sexual abuse can lead to negative cognitions regarding sexual activity, and subsequently, low desire. Another example of a psychological variable that is associated with low desire is stress. Stress may be a contributing factor in low sexual desire because it can distract from the situation, and because it has an influence on cortisol levels in the brain, which may decrease motivation to engage in sexual activity. Another psychological contributor to low sexual desire and arousal is depression. It is unclear whether it is depression on its own, anti-depressant medications, or a combination of both that decreases desire. Further negative influences include personality variables, such as low self esteem and body self-consciousness, and current life situations, such as SES, the loss of a job, or a death in the family. Additional psychological contributors are sociocultural, including religious beliefs regarding appropriate sexual behaviour, expectations about the situation (i.e., from the media - see Media and American adolescent sexuality), perceived risk of contracting a sexually transmitted infection, and perceived pregnancy risk (but of course that depends on one’s desire or lack thereof to become pregnant). Clearly, there are many psychological factors that contribute to one’s level of desire. For a more extensive list, and further explanation, see factors affecting sexual desire.

Relationship Factors
Relationship satisfaction is highly correlated with sexual satisfaction, although one is not needed for the other, and it is important to remember that sexual satisfaction is not related to frequency of sexual activity, or level of desire and arousal. To begin, the length of relationship is negatively related to desire (not necessarily predicting distress). Another important factor in heterosexual relationships is that the presence of sexual dysfunction in the male partner (i.e. erectile dysfunction, premature ejaculation) decreases desire and arousal in the female. Perhaps this finding could be extended to homosexual relationships, in that the presence of sexual dysfunction in any partner may lead to decreased desire in the unaffected person. Another important influence in sexual desire and arousal is the context in which sexual activity is taking place, and the adequacy of the sexual stimulation. This could be related to communication between partners, in that poor communication of appropriate location and stimulation can decrease desire.

Emotion Theory states that sexual desire is an adaptive response to an emotionally competent stimulus, similar to the response cycle of other emotions. This theory is also related to the incentive-motivation model proposed by Laan and Both (2008) in that the experience of desire is the conscious awareness of automatic physical responses in the body. The awareness of these responses can be modified by biological factors, psychological factors, and relationship factors.

Dynamical Systems Theory proposed by Diamond (2012) highlights the importance of looking at the contributing factors as bidirectional, and discusses the complicated interplay of biological, psychological and relationship factors. It is also important to look at predisposing, precipitating, and maintaining factors.

Biopsychosocial Interview
The biopsychosocial interview is an intensive interview between the clinician, the patient, and her partner (if available). During this interview, the clinician will asses any predisposing, precipitating, and maintaining factors influencing the patient’s desire and/or arousal complaints. Graham and Bancroft, as cited in Brotto et al. recommend using a “three windows” approach for understanding each patient’s individual circumstance, in order to provide a better personalized diagnosis. The first window describes the patient’s current situation, such as relationship factors, and their partner’s sexual (in)adequacy. The second window explores the woman’s individual vulnerability to developing desire and arousal problems, such as negative attitudes, and early experience of sexual abuse. The third window explores both mental and physical health related factors such as the prevalence of a mental illness, and the use of prescription and/or recreational drugs. Graham and Bancroft reinforce the idea that following the guidance of these three windows when conducting a biopsychosocial interview will lead to great insight into each individual diagnosis.

Self-Report
Self-report questionnaires are a useful tool to use when assessing women’s sexual response, because they assess the individual’s level of distress. Self-reports are most useful when they are used in conjunction with other assessment tools. As cited in Brotto et. al., some examples of self-report questionnaires utilized in the domain of sexual response in women are (among others):

-Golombok-Rust Inventory of Sexual Satisfaction (GRISS)

-Sexual Desire Inventory (SDI)

-Female Sexual Function Index (FSFI)

-Sexual Function Questionnaire (SFQ)

-Female Sexual Distress Scale (FSDS)

-Sexual Interest and Desire Inventory (SIDI)

Physical Examination
The physical examination is used to rule out or identify certain medical factors that can contribute to sexual response problems. Additionally, it is used for educational purposes (i.e., exploring one’s own body), and reassurance (i.e., debunking myths regarding sexual response). Psychophysiological tools are used to measure genital changes (physiological) in response to sexual stimuli (psychological). The most commonly used tool is the vaginal photoplethysmograph. This tool measures the vaginal blood volume and the vaginal pulse amplitude. The vaginal photoplethysmograph is a good tool for measuring arousal, but one criticism is that it does not have an absolute scale, so data can be ranked, but differences between each measure cannot be compared, and studies have shown no significant differences between rankings of women with and without sexual dysfunction. Vaginal photoplethysmography is usually only used in research, rather than clinical settings, because of its invasive nature. As cited in Brotto et al., more alternative, but less common psychophysiological tools include (among others):

-Labial Thermistor

-Labial and Clitoral Photoplethysmograph

-Measurement of Vaginal pH

-Thermal Imaging

Treatment
Below is a look at what is currently known about treatment options for the DSM-IV diagnoses of sexual and arousal disorders as well as recommendations for future investigations should SIAD be the new diagnosis. It should be noted that this is what is known when looking at arousal, desire, and orgasm separately however there is a lot of overlap within treatment options. When SIAD is entered into the DSM-V the treatment research will likely transfer over to treatment options specific to that diagnosis criteria, until then, however, below is a review of the current understanding.

General Treatments Relevant to All Sexual Problems in Women
Also see sexual dysfunction.

There are some general changes to lifestyle that can impact all sexual function and disorders. Improved well being including diet, exercise, possible alcohol and chemical substance abuse, and sleep should be addressed in all women. Prescription and nonprescription medications, vitamins and herbal supplements and recreational drugs can also impact sexual function. Finally, education about basic genital anatomy and physiology, and a discussion of sexual stimulation and sexual activities other than intercourse should be part of early stage treatment as well as learning to use techniques that enhance arousal.

Treatment Issues Specific to Low Desire
For more information specific to desire disorders, see hypoactive sexual desire disorder

Psychosexual Treatments for Low Desire
There are only a few studies looking at treatments that focus specifically on low desire. However, in treatment, when low desire is accounted for by depression, poor body image, sexual assault, or other factors, these factors must be addressed first. Some psychosexual treatments that have shown to impact desire have been group cognitive behavioral therapy treatments, a modified Masters and Johnson sex therapy , and sensate focus and traditional sex therapy techniques. In one non-controlled trial, mindfulness-based cognitive therapy administered in a group format to women with mixed HSDD and FSAD resulted in significant improvements in sexual desire and other domains or sexual response and mood.

Recommendation
Psychological approaches have a long history of being effective immediately after treatment and sustained, as well as not having any adverse side effects. . Newer cognitive-behavioural treatments which integrate mindfulness meditation show excellent promise but require controlled testing  so this may be worth investing in. In general more randomized, controlled testing is required in order to make more conclusive inferences about these treatments.

Hormonal Treatments for Low Desire
Testosterone (T) has been used for hormonal treatment since the 1930s. In more recent controlled studies 300μg/day patch increased sexual desire, , ,. However, in one study 30% of T group experienced androgenic side effects and there were four new cases of breast cancer in the T but not the placebo group. In Europe, Tibolone (an androgenic, progestogenic, and estrogenic synthetic hormone) is available and has shown a significant increase in Female Sexual Function Index (FSFI) after 24 weeks of use. It has also been shown to significantly increase sexual desire, arousability, vaginal lubrication, and the frequency of sexual fantasies compared to a placebo condition.

Recommendation
T therapy is effective for estrogen-replete, naturally menopausal women and marginally effective for pre-menopausal women however there is conflicting data showing no effect among cancer survivors with HSDD. The long-term risks are unknown for breast cancer, insulin resistance, and metabolic syndromes so careful discussion of risks is necessary before using this treatment method.

Nonhormonal Medications for Low Desire
In non-depressed women with HSDD, the anti-depressant Bupropion was found to significantly improve sexual arousal and orgasm but not sexual desire. . As well it is seen to benefit both males and females. Flibanserin is a centrally acting agent for HSDD however the method of action is not fully understood. It is suggested to act on a 5-HT2A serotonin receptor agonist and 5-HT1A serotonin receptor antagonist. . A pooled analysis of 1378 premenopausal US women showed a statistically significant increase in the frequency of sexually satisfying events in women taking Flibanserin. However, in 2010 the FDA did not approve of the drug stating that the results were not robust enough to justify the risks.

Recommendation
These medications do show promise but randomized controlled trials are required.

Treatment Issues Specific to Low Arousal
For more information specific to arousal disorders, see female sexual arousal disorder

Psychological Treatments
Generally sensate focus and masturbation training are used as psychological treatment for low arousal, and tends to emphasize self-focus and assertiveness. However, there have not been any randomized control trial studies for psychological treatment of FSAD.

Recommendation
Psychological treatment should be recommended for FSAD because the majority of sexual arousal problems in healthy women are not due to impaired genital responsiveness.

Hormonal Pharmacotherapy for FSAD
In a placebo controlled study with hypogonadotropic hypogonadal women or those suffering from hypogonadism, treatment with testosterone undecanoate enhanced genital arousal. Local and systemic estrogen treatment benefits vulvo-vagnial atrophy and relieves vaginal dryness and dyspareunia. . As well Tibolone has been used as treatment in postmenopausal women in a randomized, double-blind, cross-over study and showed a significant increase in vaginal blood flow in response to erotic fantasy. This is associated with a significant increase in sexual desire, frequency of arousability and of sexual fantasies compared with those taking a placebo. Vaginal lubrication was significantly improved as well.

A randomized controlled trial studying the effect of vaginal application of dehydroepiandrosterone (DHEA) on vaginal atrophy in postmenopausal women showed rapid beneficial change to vaginal epithelial cell maturation and vaginal pH as well as increase sexual desire/interest, sexual arousal, orgasm, and pain.

Nonhormonal Pharmacotherapy for FSAD
For men, there has been the development of many pharmacological treatments in order to treat arousal disorders and many pharmacological treatments have been tested in women, however none have been approved for use for women.

Treatment Issues Specific to Difficulties with Orgasm
For more information specific to orgasmic disorders, see female orgasmic disorder (FOD). There is some evidence that shows significant heritability in orgasmic function both alone or with a partner. Directed masturbation, sex education, anxiety reduction techniques, and CBT remain the main therapeutic tools for anorgasmia. However, sildenafil used for women with SSRI-induced FOD showed to have significantly fewer negative sexual side effects.

The Placebo Response
For more information specific to placebo response, see placebo. With all of these treatments, there is significant placebo response among women randomized to the placebo group of a drug trial, , ,. Bradford and Meston reviewed 16 placebo-controlled pharmacological trials in women’s sexual dysfunction and found that placebo response is stronger in retrospective studies, those studies using postmenopausal women, and those focusing on sexual desire. .

Overall Recommendations For SIAD Treatment
Some of the issues with the current research on treatment for female desire and arousal disorders are that few studies have looked at arousal and sexuality from a cultural perspective and thus these disorders are observed through an ethnocentric lens, sexual stimulation must be assessed, studies with better methodological trials on psychological treatments are needed, and subjective excitement, pleasure, and relationship satisfaction should be targeted end points in all future randomized control trials. What’s more, looking at arousal disorders while controlling for sexuality variation has not been taken into consideration.