13. Sexual Dysfunctions
13.1. Delayed Ejaculation
13.2. Erectile Disorder
13.3. Female Orgasmic Disorder
13.4. Female Sexual Interest/Arousal Disorder
13.5. Genito-Pelvic Pain/Penetration Disorder
13.6. Male Hypoactive Sexual Desire Disorder
13.7. Premature (Early) Ejaculation
13.8. Substance/Medication-Induced Sexual Dysfunction
Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic
disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder,
male hypoactive sexual desire disorder, premature (early) ejaculation, substance/medicationinduced
sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction.
Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized
by a clinically significant disturbance in a person's ability to respond sexually or to
experience sexual pleasure. An individual may have several sexual dysfunctions at the same
time. In such cases, all of the dysfunctions should be diagnosed.
Clinical judgment should be used to determine if the sexual difficulties are the result of
inadequate sexual stimulation; in these cases, there may still be a need for care, but a diagnosis
of a sexual dysfimction would not be made. These cases may include, but are not
limited to, conditions in which lack of knowledge about effective stimulation prevents the
experience of arousal or orgasm.
Subtypes are used to designate the onset of the difficulty. In many individuals with
sexual dysfunctions, the time of onset may indicate different etiologies and interventions.
Lifelong refers to a sexual problem that has been present from first sexual experiences, and
acquired applies to sexual disorders that develop after a period of relatively normal sexual
function. Generalized refers to sexual difficulties that are not limited to certain types of
stimulation, situations, or partners, and situational refers to sexual difficulties that only occur
with certain types of stimulation, situations, or partners.
In addition to the lifelong/ acquired and generalized/situational subtypes, a number
of factors must be considered during the assessment of sexual dysfunction, given that they
may be relevant to etiology and/or treatment, and that may contribute, to varying degrees,
across individuals: 1) partner factors (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., depression, anxiety), or stressors (e.g., job loss,
bereavement); 4) cultural or religious factors (e.g., inhibitions related to prohibitions against
sexual activity or pleasure; attitudes toward sexuality); and 5) medical factors relevant to
prognosis, course, or treatment.
Clinical judgment about the diagnosis of sexual dysfunction should take into consideration
cultural factors that may influence expectations or engender prohibitions about the experience
of sexual pleasure. Aging may be associated with a normative decrease in sexual response.
Sexual response has a requisite biological undeφinning, yet is usually experienced in
an intrapersonal, interpersonal, and cultural context. Thus, sexual function involves a complex
interaction among biological, sociocultural, and psychological factors. In many clinical
contexts, a precise understanding of the etiology of a sexual problem is unknown. Nonetheless,
a sexual dysfunction diagnosis requires ruling out problems that are better explained
by a nonsexual mental disorder, by the effects of a substance (e.g., drug or medication), by
a medical condition (e.g., due to pelvic nerve damage), or by severe relationship distress,
partner violence, or other stressors.
If the sexual dysfunction is mostly explainable by another nonsexual mental disorder (e.g.,
depressive or bipolar disorder, anxiety disorder, posttraumatic stress disorder, psychotic disorder),
then only the other mental disorder diagnosis should be made. If the problem is
thought to be better explained by the use/misuse or discontinuation of a drug or substance, it
should be diagnosed accordingly as a substance/medication-induced sexual dysfunction. If
the sexual dysfunction is attributable to another medical condition (e.g., peripheral neuropathy),
the individual would not receive a psychiatric diagnosis. If severe relationship distress,
partner violence, or significant stressors better explain the sexual difficulties, then a sexual dysfunction
diagnosis is not made, but an appropriate V or Z code for the relationship problem or
stressor may be listed. In many cases, a precise etiological relationship between another condition
(e.g., a medical condition) and a sexual dysfunction cannot be established.
The distinguishing feature of delayed ejaculation is a marked delay in or inability to achieve ejaculation (Criterion A). The man reports difficulty or inability to ejaculate despite the presence of adequate sexual stimulation and the desire to ejaculate. The presenting complaint usually involves partnered sexual activity. In most cases, the diagnosis will be made by self-report of the individual. The definition of "delay" does not have precise boundaries, as there is noconsensus as to what constitutes a reasonable time to reach orgasm or what is unacceptably long for most men and their sexual partners.
The man and his partner may report prolonged thrusting to achieve orgasm to the point of exhaustion or genital discomfort and then ceasing efforts. Some men may report avoiding sexual activity because of a repetitive pattern of difficulty ejaculating. Some sexual partners may report feeliAg less sexually attractive because their partner cannot ejaculate easily. In addition to the subtypes "lifelong/acquired" and "generalized/situational," the following five factors must be considered during assessment and diagnosis of delayed ejaculation, given that they may be relevant to etiology and/or treatment: 1) partner factors (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., depression, 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. Each of these factors may contribute differently to the presenting symptoms of different men with this disorder.
Prevalence is unclear because of the lack of a precise definition of this syndrome. It is the least common male sexual complaint. Only 75% of men report always ejaculating during sexual activity, and less than 1% of men will complain of problems with reaching ejaculation that last more than 6 months.
Complaints of ejaculatory delay vary across countries and cultures. Such complaints are more common among men in Asian populations than in men living in Europe, Australia, or the United States. This variation may be attributable to cultural or genetic differences between cultures.
Difficulty with ejaculation may contribute to difficulties in conception. Delayed ejaculation is often associated with considerable psychological distress in one or both partners.
The essential feature of erectile disorder is the repeated failure to obtain or maintain erections during partnered sexual activities (Criterion A). A careful sexual history is necessary to ascertain that the problem has been present for a significant duration of time (i.e., at least approximately 6 months) and occurs on the majority of sexual occasions (i.e., at least 75% of the time). Symptoms may occur only in specific situations involving certain types of stimulation or partners, or they may occur in a generalized manner in all types of situations, stimulation, or partners.
Many men with erectile disorder may have low self-esteem, low self-confidence, and a decreased
sense of masculinity, and may experience depressed affect. Fear and/or avoidance
of future sexual encounters may occur. Decreased sexual satisfaction and reduced
sexual desire in the individual's partner are common.
In addition to the subtypes "lifelong/acquired" and "generalized/situational," the following
five factors must be considered during assessment and diagnosis of erectile disorder
given that they may be relevant to etiology and/or treatment: 1) partner factors (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., depression,
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. Each of these factors may contribute
differentiy to the presenting symptoms of different men with this disorder.
The prevalence of lifelong versus acquired erectile disorder is unknown. There is a strong age-related increase in both prevalence and incidence of problems with erection, particularly after age 50 years. Approximately 13%-21% of men ages 40-80 years complain of occasional problems with erections. Approximately 2% of men younger than age 40-50 years complain of frequent problems with erections, whereas 40%-50% of men older than 60-70 years may have significant problems with erections. About 20% of men fear erectile problems on their first sexual experience, whereas approximately 8% experienced erectile problems that hindered penetration during their first sexual experience.
Complaints of erectile disorder have been found to vary across countries. It is unclear to what extent these differences represent differences in cultural expectations as opposed to genuine differences in the frequency of erectile failure.
Erectile disorder can interfere with fertility and produce both individual and interpersonal distress. Fear and/or avoidance of sexual encounters may interfere with the ability to develop intimate relationships.
Female orgasmic disorder is characterized by difficulty experiencing orgasm and/or
markedly reduced intensity of orgasmic sensations (Criterion A). Women show wide variability
in the type or intensity of stimulation that elicits orgasm. Similarly, subjective descriptions
of orgasm are extremely varied, suggesting that it is experienced in very different
ways, both across women and on different occasions by the same woman. For a diagnosis
of female orgasmic disorder, symptoms must be experienced on almost all or all (approximately
75%-100%) occasions of sexual activity (in identified situational contexts or, if
generalized, in all contexts) and have a minimum duration of approximately 6 months.
The use of the minimum severity and duration criteria is intended to distinguish transient
orgasm difficulties from more persistent orgasmic dysfunction. The inclusion of "approximately"
in Criterion B allows for clinician judgment in cases in which symptom duration
does not meet the recommended 6-month threshold.
For a woman to have a diagnosis of female orgasmic disorder, clinically significant distress
must accompany the symptoms (Criterion C). In many cases of orgasm problems, the
causes are multifactorial or cannot be determined. If female orgasmic disorder is deemed
to be better explained by another mental disorder, the effects of a substance/medication,
or a medical condition, then a diagnosis of female orgasmic disorder would not be made.
Finally, if interpersonal or significant contextual factors, such as severe relationship distress,
intimate partner violence, or other significant stressors, are present, then a diagnosis
of female orgasmic disorder would not be made.
Many women require clitoral stimulation to reach orgasm, and a relatively small proportion
of women report that they always experience orgasm during penile-vaginal intercourse.
Thus, a woman's experiencing orgasm through clitoral stimulation but not during
intercourse does not meet criteria for a clinical diagnosis of female orgasmic disorder. It is
also important to consider whether orgasmic difficulties are the result of inadequate sexual
stimulation; in these cases, there may still be a need for care, but a diagnosis of female
orgasmic disorder would not be made.
Associations between specific patterns of personality traits or psychopathology and orgasmic
dysfunction have generally not been supported. Compared with women without the
disorder, some women with female orgasmic disorder may have greater difficulty communicating
about sexual issues. Overall sexual satisfaction, however, is not strongly correlated
with orgasmic experience. Many women report high levels of sexual satisfaction
despite rarely or never experiencing orgasm. Orgasmic difficulties in women often cooccur
with problems related to sexual interest and arousal.
In addition to the subtypes "lifelong/acquired" and "generalized/situational/' the following
five factors must be considered during assessment and diagnosis of female orgasmic
disorder given that they may be relevant to etiology and/or treatment: 1) partner
factors (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., depression, 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.
Each of these factors may contribute differently to the presenting symptoms of different
women with this disorder.
Reported prevalence rates for female orgasmic problems in women vary widely, from 10% to 42%, depending on multiple factors (e.g., age, culture, duration, and severity of symptoms); however, these estimates do not take into account the presence of distress. Only a proportion of women experiencing orgasm difficulties also report associated distress. Variation in how symptoms are assessed (e.g., the duration of symptoms and the recall period) also influence prevalence rates. Approximately 10% of women do not experience orgasm throughout their lifetime.
The degree to which lack of orgasm in women is regarded as a problem that requires treatment may vary depending on cultural context. In addition, women differ in how important orgasm is to their sexual satisfaction. There may be marked sociocultural and generational differences in women's orgasmic ability. For example, the prevalence of inability to reach orgasm has ranged from 17.7% (in Northern Europe) to 42.2% (in Southeast Asia).
The functional consequences of female orgasmic disorder are unclear. Although there is a strong association between relationship problems and orgasmic difficulties in women, it is unclear whether relationship factors are risk factors for orgasmic difficulties or are consequences of those difficulties.
In assessing female sexual interest/arousal disorder, interpersonal context must be taken
into account. A "desire discrepancy," in which a woman has lower desire for sexual activity
than her partner, is not sufficient to diagnose female sexual interest/arousal disorder.
In order for the criteria for the disorder to be met, there must be absence or reduced frequency
or intensity of at least three of six indicators (Criterion A) for a minimum duration
of approximately 6 months (Criterion B). There may be different symptom profiles across
women, as well as variability in how sexual interest and arousal are expressed. For example,
in one woman, sexual interest/arousal disorder may be expressed as a lack of interest
in sexual activity, an absence of erotic or sexual thoughts, and reluctance to initiate sexual
activity and respond to a partner's sexual invitations. In another woman, an inability to become
sexually excited, to respond to sexual stimuli with sexual desire, and a corresponding
lack of signs of physical sexual arousal may be the primary features. Because sexual
desire and arousal frequently coexist and are elicited in response to adequate sexual cues,
the criteria for female sexual interest/arousal disorder take into account that difficulties in
desire and arousal often simultaneously characterize the complaints of women with this
disorder. Short-term changes in sexual interest or arousal are common and may be adaptive
responses to events in a woman's life and do not represent a sexual dysfunction. Diagnosis
of female sexual interest/arousal disorder requires a minimum duration of symptoms of
approximately 6 months as a reflection that the symptoms must be a persistent problem.
The estimation of persistence may be determined by clinical judgment when a duration of
6 months cannot be ascertained precisely.
There may be absent or reduced frequency or intensity of interest in sexual activity (Criterion
Al), which was previously termed hypoactive sexual desire disorder. The frequency or intensity
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 activity
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
during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (Criterion
A4). Lack of pleasure is a common presenting clinical complaint in women with low desire.
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 sexual
desire (Criterion A5). Frequency or intensity of genital or nongenital sensations during sexual
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 selfreport
of reduced or absent genital or nongenital sensations is sufficient.
For a diagnosis of female sexual interest/arousal disorder to be made, clinically significant
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 disorder
would not be made.
Female sexual interest/arousal disorder is frequently associated with problems in experiencing 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 expectations 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 following 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 factors (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., depression, 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 differently to the presenting symptoms of different women with this disorder.
The prevalence of female sexual interest/arousal disorder, as defined in this manual, is unknown. The prevalence of low sexual desire and of problems with sexual arousal (with and without associated distress), as defined by DSM-IV or ICD-10, may vary markedly in relation to age, cultural setting, duration of symptoms, and presence of distress. Regarding duration of symptoms, there are striking differences in prevalence estimates between short-term and persistent problems related to lack of sexual interest. When distress about sexual functioning is required, prevalence estimates are markedly lower. Some older women report less distress about low sexual desire than younger women, although sexual desire may decrease with age.
There is marked variability in prevalence rates of low desire across cultures. Lower rates of sexual desire may be more common among East Asian women compared with Euro- Canadian women. Although the lower levels of sexual desire and arousal found in men and women from East Asian countries compared with Euro-American groups may reflect less interest in sex in those cultures, the possibility remains that such group differences are an artifact of the measures used to quantify desire. A judgment about whether low sexual desire reported by a woman from a certain ethnocultural group meets criteria for female sexual interest/arousal disorder must take into account the fact that different cultures may pathologize some behaviors and not others.
By definition, the diagnosis of female sexual interest/arousal disorder is only given to women. Distressing difficulties with sexual desire in men would be considered under male hypoactive sexual desire disorder.
Difficulties in sexual interest/arousal are often associated with decreased relationship satisfaction.
Genito-pelvic pain/penetration disorder refers to four commonly comorbid symptom dimensions:
1) difficulty having intercourse, 2) genito-pelvic pain, 3) fear of pain or vaginal
penetration, and 4) tension of the pelvic floor muscles (Criterion A). Because major difficulty
in any one of these symptom dimensions is often sufficient to cause clinically significant
distress, a diagnosis can be made on the basis of marked difficulty in only one
symptom dimension. However, all four symptom dimensions should be assessed even if a
diagnosis can be made on the basis of only one symptom dimension.
Marked dijficulty having vaginal intercourse/penetration (Criterion Al) can vary from a total inability
to experience vaginal penetration in any situation (e.g., intercourse, gynecological examinations,
tampon insertion) to the ability to easily experience penetration in one situation
and but not in another. Although the most common clinical situation is when a woman is unable
to experience intercourse or penetration with a partner, difficulties in undergoing required
gynecological examinations may also be present. Marked vulvovaginal or pelvic pain
during vaginal intercourse or penetration attempts (Criterion A2) refers to pain occurring in different
locations in the genito-pelvic area. Location of pain as well as intensity should be assessed.
Typically, pain can be characterized as superficial (vulvovaginal or occurring during penetration)
or deep (pelvic; i.e., not felt until deeper penetration). The intensity of the pain is often not
linearly related to distress or interference with sexual intercourse or other sexual activities.
Some genito-pelvic pain only occurs when provoked (i.e., by intercourse or mechanical stimIllation);
other genito-pelvic pain may be spontaneous as well as provoked. Genito-pelvic pain
can also be usefully characterized qualitatively (e.g., "burning," "cutting," "shooting," "throbbing").
The pain may persist for a period after intercourse is completed and may also occur
during urination. Typically, the pain experienced during sexual intercourse can be reproduced
during a gynecological examination.
Marked fear or anxiety about vulvovaginal or pelvic pain either in anticipation of, or during, or
as a result of vaginal penetration (Criterion A3) is commonly reported by women who have
regularly experienced pain during sexual intercourse. This "normal" reaction may lead to
avoidance of sexual/intimate situations. In other cases, this marked fear does not appear
to be closely related to the experience of pain but nonetheless leads to avoidance of intercourse
and vaginal penetration situations. Some have described this as similar to a phobic
reaction except that the phobic object may be vaginal penetration or the fear of pain.
Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration
(Criterion A4) can vary from reflexive-like spasm of the pelvic floor in response to attempted
vaginal entry to "normal/voluntary" muscle guarding in response to the anticipated
or the repeated experience of pain or to fear or anxiety. In the case of "normal/
guarding" reactions, penetration may be possible under circumstances of relaxation. The
characterization and assessment of pelvic floor dysfunction is often best undertaken by a
specialist gynecologist or by a pelvic floor physical therapist.
Genito-pelvic pain/penetration disorder is frequently associated with other sexual dysfunctions, particularly reduced sexual desire and interest (female sexual interest/arousal disorder). a)metimes desire and interest are preserved in sexual situations that are not painful or do not require penetration. Even when individuals with genito-pelvic pain/penetration disorder report sexual interest/motivation, there is often behavioral avoidance of sexual situations and opportunities. Avoidance of gynecological examinations despite medical recommendations is also frequent. The pattern of avoidance is similar to that seen in phobic disorders. It is common for women who have not succeeded in having sexual intercourse to come for treatment only when they wish to conceive. Many women with genito-pelvic pain/ penetration disorder will experience associated relationship/marital problems; they also often report that the sjnnptoms significantly diminish their feelings of femininity. In addition to the subtype "lifelong/acquired," five factors should be considered during assessment and diagnosis of genito-pelvic pain/penetration disorder because they may be relevant to etiology and/or treatment: 1) partner factors (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., depression, 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. Each of these factors may contribute differently to the presenting symptoms of different women with this disorder. There are no valid physiological measures of any of the component symptom dimensions of genito-pelvic pain/penetration disorder. Validated psychometric inventories may be used to formally assess the pain and anxiety components related to genito-pelvic pain/ penetration disorder.
The prevalence of genito-pelvic pain/penetration disorder is unknown. However, approximately 15% of women in North America report recurrent pain during intercourse. Difficulties having intercourse appear to be a frequent referral to sexual dysfunction clinics and to specialist clinicians.
In the past, inadequate sexual education and religious orthodoxy have often been considered to be culturally related predisposing factors to the DSM-IV diagnosis of vaginismus. This perception appears to be confirmed by recent reports from Turkey, a primarily Muslim country, indicating a strikingly high prevalence for the disorder. However, most available research, although limited in scope, does not support this notion (Lahaie et al. 2010).
By definition, the diagnosis of genito-pelvic pain/penetration disorder is only given to women. There is relatively new research concerning urological chronic pelvic pain syndrome in men, suggesting that men may experience some similar problems. The research and clinical experience are not sufficiently developed yet to justify the application of this diagnosis to men. Other specified sexual dysfunction or unspecified sexual dysfunction may be diagnosed in men appearing to fit this pattern.
Functional difficulties in genito-pelvic pain/penetration disorder are often associated with interference in relationship satisfaction and sometimes with the ability to conceive via penile/vaginal intercourse.
When an assessment for male hypoactive sexual desire disorder is being made, interpersonal
context must be taken into account. A "desire discrepancy," in which a man has
lower desire for sexual activity than his partner, is not sufficient to diagnose male hypoactive
sexual desire disorder. Both low/absent desire for sex and deficient/absent sexual
thoughts or fantasies are required for a diagnosis of the disorder. There may be variation
across men in how sexual desire is expressed.
The lack of desire for sex and deficient/absent erotic thoughts or fantasies must be persistent
or recurrent and must occur for a minimum duration of approximately 6 months.
The inclusion of this duration criterion is meant to safeguard against making a diagnosis in
cases in which a man's low sexual desire may represent an adaptive response to adverse
life conditions (e.g., concern about a partner's pregnancy when the man is considering terminating
the relationship). The introduction of "approximately" in Criterion B allows for
clinician judgment in cases in which symptom duration does not meet the recommended
6-month threshold.
Male hypoactive sexual desire disorder is sometimes associated with erectile and/or ejaculatory
concerns. For example, persistent difficulties obtaining an erection may lead a man
to lose interest in sexual activity. Men with hypoactive sexual desire disorder often report
that they no longer initiate sexual activity and that they are minimally receptive to a partner's
attempt to initiate. Sexual activities (e.g., masturbation or partnered sexual activity)
may sometimes occur even in the presence of low sexual desire. Relationship-specific preferences
regarding patterns of sexual initiation must be taken into account when making a
diagnosis of male hypoactive sexual desire disorder. Although men are more likely to initiate
sexual activity, and thus low desire may be characterized by a pattern of non-initiation,
many men may prefer to have their partner initiate sexual activity. In such situations, the
man's lack of receptivity to a partner's initiation should be considered when evaluating low
desire.
In addition to the subtypes "lifelong/acquired" and "generalized/situational," the following
five factors must be considered during assessment and diagnosis of male hypoactive
sexual desire disorder given that they may be relevant to etiology and/or treatment:
1) partner factors (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., depression, 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.
Each of these factors may contribute differently to the presenting symptoms of different
men with this disorder.
The prevalence of male hypoactive sexual desire disorder varies depending on country of origin and method of assessment. Approximately 6% of younger men (ages 18-24 years) and 41% of older men (ages 66-74 years) have problems with sexual desire. However, a persistent lack of interest in sex, lasting 6 months or more, affects only a small proportion of men ages 16-44 (1.8%).
There is marked variability in prevalence rates of low desire across cultures, ranging from 12.5% in Northern European men to 28% in Southeast Asian men ages 40-80 years. Just as there are higher rates of low desire among East Asian subgroups of women, men of East Asian ancestry also have higher rates of low desire. Guilt about sex may mediate this association between East Asian ethnicity and sexual desire in men.
In contrast to the classification of sexual disorders in women, desire and arousal disorders have been retained as separate constructs in men. Despite some similarities in the experience of desire across men and women, and the fact that desire fluctuates over time and is dependent on contextual factors, men do report a significantly higher intensity and frequency of sexual desire compared with women.
Premature (early) ejaculation is manifested by ejaculation that occurs prior to or shortly after vaginal penetration, operationalized by an individual's estimate of ejaculatory latency (i.e., elapsed time before ejaculation) after vaginal penetration. Estimated and measured intravaginal ejaculatory latencies are highly correlated as long as the ejaculatory latency is of short duration; therefore, self-reported estimates of ejaculatory latency are sufficient for diagnostic puφoses. A 60-second intravaginal ejaculatory latency time is an appropriate cutoff for the diagnosis of lifelong premature (early) ejaculation in heterosexual men. There are insufficient data to determine if this duration criterion can be applied to acquired premature (early) ejaculation. The durational definition may apply to males of varying sexual orientations, since ejaculatory latencies appear to be similar across men of different sexual orientations and across different sexual activities.
Many males with premature (early) ejaculation complain of a sense of lack of control over
ejaculation and report apprehension about their anticipated inability to delay ejaculation
on future sexual encounters.
The following factors may be relevant in the evaluation of any sexual dysfunction:
1) partner factors (e.g., partner's sexual problems, partner's health status); 2) relationship factors
(e.g., poor conrmiunication, 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., depression, anxiety), and 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.
Estimates of the prevalence of premature (early) ejaculation vary widely depending on the definition utilized. Internationally, more than 20%-30% of men ages 18-70 years report concern about how rapidly they ejaculate. With the new definition of premature (early) ejaculation (i.e., ejaculation occurring within approximately 1 minute of vaginal penetration), only l%-3% of men would be diagnosed with the disorder. Prevalence of premature (early) ejaculation may increase with age.
Perception of what constitutes a normal ejaculatory latency is different in many cultures. Measured ejaculatory latencies may differ in some countries. Such differences may be explained by cultural or religious factors as well as genetic differences between populations.
Premature (early) ejaculation is a sexual disorder in males. Males and their sexual partners may differ in their perception of what constitutes an acceptable ejaculatory latency. There may be increasing concerns in females about early ejaculation in their sexual partners, which may be a reflection of changing societal attitudes concerning female sexual activity.
A pattern of premature (early) ejaculation may be associated with decreased self-esteem, a sense of lack of control, and adverse consequences for partner relationships. It may also cause personal distress in the sexual partner and decreased sexual satisfaction in the sexual partner. Ejaculation prior to penetration may be associated with difficulties in conception.
The major feature is a disturbance in sexual function that has a temporal relationship with substance/medication initiation, dose increase, or substance/medication discontinuation.
Sexual dysfunctions can occur in association with intoxication with the following classes of
substances: alcohol; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including cocaine);
and other (or unknown) substances. Sexual dysfunctions can occur in association
with withdrawal from the following classes of substances: alcohol; opioids; sedatives, hypnotics,
or anxiolytics; and other (or unknown) substances. Medications that can induce sexual
dysfunctions include antidepressants, antipsychotics, and hormonal contraceptives.
The most commonly reported side effect of antidepressant drugs is difficulty with orgasm
or ejaculation. Problems with desire and erection are less frequent. Approximately
30% of sexual complaints are clinically significant. Certain agents, such as bupropion and
mirtazapine, appear not to be associated with sexual side effects.
The sexual problems associated with antipsychotic drugs, including problems with
sexual desire, erection, lubrication, ejaculation, or orgasm, have occurred with typical as
well as atypical agents. However, problems are less common with prolactin-sparing antipsychotics
than with agents that cause significant prolactin elevation.
Although the effects of mood stabilizers on sexual function are unclear, it is possible
that lithium and anticonvulsants, with the possible exception of lamotrigine, have adverse
effects on sexual desire. Problems with orgasm may occur with gabapentin. Similarly, there
may be a higher prevalence of erectile and orgasmic problems associated with benzodiazepines.
There have not been such reports with buspirone.
Many nonpsychiatric medications, such as cardiovascular, cytotoxic, gastrointestinal,
and hormonal agents, are associated with disturbances in sexual function. Illicit substance
use is associated with decreased sexual desire, erectile dysfunction, and difficulty reaching
orgasm. Sexual dysfunctions are also seen in individuals receiving methadone but are
seldom reported by patients receiving buprenoφhine. Chronic alcohol abuse and chronic
nicotine abuse are associated with erectile problems.
The prevalence and the incidence of substance/medication-induced sexual dysfunction
are unclear, likely because of underreporting of treatment-emergent sexual side effects.
Data on substance/medication-induced sexual dysfunction typically concern the effects of
antidepressant drugs. The prevalence of antidepressant-induced sexual dysfunction varies
in part depending on the specific agent. Approximately 25%-80% of individuals taking
monoamine oxidase inhibitors, tricyclic antidepressants, serotonergic antidepressants,
and combined serotonergic-adrenergic antidepressants report sexual side effects. There
are differences in the incidence of sexual side effects between some serotonergic and combined
adrenergic-serotonergic antidepressants, although it is unclear if these differences
are clinically significant.
Approximately 50% of individuals taking antipsychotic medications will experience
adverse sexual side effects, including problems with sexual desire, erection, lubrication,
ejaculation, or orgasm. The incidence of these side effects among different antipsychotic
agents is unclear.
Exact prevalence and incidence of sexual dysfunctions among users of nonpsychiatric
medications such as cardiovascular, cytotoxic, gastrointestinal, and hormonal agents are
unknown. Elevated rates of sexual dysfunction have been reported with methadone or
high-dose opioid drugs for pain. There are increased rates of decreased sexual desire, erectile
dysfunction, and difficulty reaching orgasm associated with illicit substance use. The
prevalence of sexual problems appears related to chronic drug abuse and appears higher
in individuals who abuse heroin (approximately 60%-70%) than in individuals who abuse
amphetamines or 3,4-methylenedioxymethamphetamine (i.e., MDMA, ecstasy). Elevated
rates of sexual dysfunction are also seen in individuals receiving methadone but are seldom
reported by patients receiving buprenorphine. Chronic alcohol abuse and chronic
nicotine abuse are related to higher rates of erectile problems.
There may be an interaction among cultural factors, the influence of medications on sexual functioning, and the response of the individual to those changes.
Some gender differences in sexual side effects may exist.
Medication-induced sexual dysfunction may result in medication noncompliance.