There may be absent or reduced frequency or intensity of interest in sexual activity (Crite- rion A1), which was previously termed hypoactive sexual desire disorder. The frequency or inten— sity of sexual and erotic thoughts or fantasies may be absent or reduced (Criterion A2). The expression of fantasies varies widely across women and may include memories of past sexual experiences. The normative decline in sexual thoughts with age should be taken into account when this criterion is being assessed. Absence or reduced frequency of initiating sexual activ- ity and of receptivity to a partner’s sexual invitations (Criterion A3) is a behaviorally focused criterion. A couple’s beliefs and preferences for sexual initiation patterns are highly relevant to the assessment of this criterion. There may be absent or reduced sexual excitement or pleasure terion A4). Lack of pleasure is a common presenting clinical complaint in women with low de- sire. Among women who report low sexual desire, there are fewer sexual or erotic cues that elicit sexual interest or arousal (i.e., there is a lack of ”responsive desire”). Assessment of the adequacy of sexual stimuli will assist in determining if there is a difficulty with responsive sex- ual desire (Criterion A5). Frequency or intensity of genital or nongenital sensations during sex- ual activity may be reduced or absent (Criterion A6). This may include reduced vaginal lubrication/vasocongestion, but because physiological measures of genital sexual response do not differentiate women who report sexual arousal concerns from those who do not, the self- report of reduced or absent genital or nongenital sensations is sufficient.
For a diagnosis of female sexual interest/arousal disorder to be made, clinically signif- icant distress must accompany the symptoms in Criterion A. Distress may be experienced as a result of the lack of sexual interest/arousal or as a result of significant interference in a woman's life and well-being. If a lifelong lack of sexual desire is better explained by one’s self—identification as ”asexual,” then a diagnosis of female sexual interest/arousal disor- der would not be made.
Female sexual interest/ arousal disorder is frequently associated with problems in experi- encing orgasm, pain experienced during sexual activity, infrequent sexual activity, and couple-level discrepancies in desire. Relationship difficulties and mood disorders are also frequently associated features of female sexual interest/ arousal disorder. Unrealistic ex- pectations and norms regarding the ”appropriate" level of sexual interest or arousal, along with poor sexual techniques and lack of information about sexuality, may also be evident in women diagnosed with female sexual interest/arousal disorder. The latter, as well as normative beliefs about gender roles, are important factors to consider.
In addition to the subtypes ”lifelong/acquired” and "generalized/situational,” the follow- ing five factors must be considered during assessment and diagnosis of female sexual interest/ arousal disorder given that they may be relevant to etiology and / or treatment: 1) partner fac- tors (e.g., partner’s sexual problems, partner’s health status); 2) relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); 3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., de- pression, anxiety), or stressors (e.g., job loss, bereavement); 4) cultural/ religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment. Note that each of these factors may contribute (fifferently to the presenting symptoms of different women with this disorder.