¹Both revised titles reflect the common empirical finding that desire and (at least subjective) arousal highly overlap. Women express difficulties differentiating desire from subjective arousal (Brotto et al., 2009; Graham, Sanders, Milhausen, & McBride, 2004; Hartmann et al., 2002). Also, in some women desire precedes arousal whereas in other women, it follows (Graham et al., 2004). There are inconsistencies in how desire is defined, with some focusing on sexual behavior as an indicator of desire, some definitions focusing on spontaneous sexual thoughts/fantasies, and others emphasizing the responsive nature of women’s desire. The DSM-IV-TR uses a definition of desire (i.e., sexual fantasies and desire for sexual activity) that is highly problematic for some women, given that women report sexual experiences that are concordant with different models of sexual response (Sand & Fisher, 2007), and therefore loss of anticipatory desire for sex may be relevant only to some women. In other words, many women report only infrequent sexual fantasies.

²It connotes a deficiency of activity and, therefore, unnecessarily emphasizes sexual activity as the central focus of the loss of desire. Some interpret the “hypo” in HSDD to infer a biological deficiency of testosterone.

³Women report sexual experiences that are concordant with different models of sexual response.  Also, research indicates that many women do not report (frequent) sexual fantasies. The requirement of absent/reduced fantasies and desire for sex for a diagnosis of HSDD may pathologize women with other (normal) indicators of desire/arousal and it does not capture individual variability.

⁴(1) The word “desire” is changed to “interest”. Desire connotes a deficiency and often implies a biological urge.

(2) Preservation of “fantasies” but with the addition of erotic thoughts. Women may not describe “sexual fantasies” in their experiences of desire and there is a low base rate of spontaneous sexual fantasies (i.e., fantasies that are not deliberately evoked as a means of boosting arousal).

(3) Research evidence that these reflect lack of desire for some women.

(4) Evidence that arousal and desire overlap and women do not differentiate desire from arousal when sexually excited.

(5) Increasing evidence from Incentive Motivation Theory that sexual arousal and desire are responsive to “sexually competent stimuli”.  There is no such thing as “spontaneous” sexual desire.

(6) Previously in the diagnosis of Female Sexual Arousal Disorder, the wording was changed to emphasize the importance of other genital and non-genital changes.

⁵Persistent and recurrent were not clearly operationalized in DSM-IV. By not including specific cut-off criteria for duration and frequency of symptoms, there is a danger of pathologizing normal variations in sexual desire. This time duration was chosen given the finding of the NATSAL survey (Mercer et al., 2003) that lack of interest in sex for the past one month was significantly more common (40.6%) than lack of interest lasting for six months (10.2%). Balon et al. also recommended that the symptom of low desire be present in 75% or more of sexual encounters (Balon, 2008; Balon et al., 2007; Segraves et al., 2007). This frequency corresponds to the “usually always/always” criteria in the study by Oberg et al. (2004), who labeled  sexual problems occurring at this level as  “manifest dysfunctions” and found them to be less common (29%) than “mild dysfunction” (i.e., rarely or sometimes present; 60%).

⁶The DSM-IV-TR had no way to document or quantify the extent of the relational influence on sexual dysfunction in the DSM-IV-TR. Numerous studies associate sexual distress with partner-related factors.

⁷Recognition of the important influence of mood and increasing data showing cross-cultural differences in the expression of desire. Also, there is abundant data showing the importance of partner and relationship factors in sexual difficulties.

⁸Recognition of the fact that, in many cases, the causes of sexual disorders are multifactorial and that medical factors may partially contribute to the etiology of a disorder. This specifier captures the clinician’s impression as to whether medical factors play a role in the etiology.

³¹ This specifier presumes knowledge of etiology, which often does not exist.