onset during intoxication, insomnia type; 292. 85 cocaine-induced sleep disorder, with on-
set during intoxication, insomnia type).
ICD-10-CM. The name of the substance/medication-induced sleep disorder begins with the
specific substance (e.g., cocaine,  bupropion) that is presumed to be causing the sleep distur-
bance. The diagnostic code is selected from the ta ble included in the criteria set, which is based
on the drug class and presence or absence of a comorbid substance use disorder. For sub-
stances that do not fit into any of the classes (e.g., bupropion), the code for “other substance”
should be used; and in cases in which a substance is judged to be an etiological factor but the
specific class of substance is unknown, the category “unknown substance” should be used.
When recording the name of the disorder, th e comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced
sleep disorder, followed by the specification of onset (i.e., onset during intoxication, onsetICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.82 F10.182 F10.282 F10.982
Caffeine 292.85 F15.182 F15.282 F15.982
Cannabis 292.85 F12.188 F12.288 F12.988
Opioid 292.85 F11.182 F11.282 F11.982


416 Sleep-Wake Disorders
during discontinuation/withdrawal), followed by the subtype designation (i.e., insomnia
type, daytime sleepiness type, parasomnia type , mixed type). For example, in the case of
insomnia occurring during withdrawal in a ma n with a severe lorazepam use disorder, the
diagnosis is F13.282 severe lorazepam use disorder with lorazepam-induced sleep disor-
der, with onset during withdrawal, insomnia  type. A separate diagnosis of the comorbid
severe lorazepam use disorder is not given. If  the substance-induced sleep disorder occurs
without a comorbid substance use disorder (e.g., with medication use), no accompanying
substance use disorder is noted (e.g., F19.98 2 bupropion-induced sleep disorder, with on-
set during medication use, insomnia type). When more than one substance is judged to
play a significant role in the development of the sleep disturbance, each should be listed
separately (e.g., F10.282 severe  alcohol use disorder with alcohol-induced sleep disorder,
with onset during intoxication, insomnia ty pe; F14.282 severe cocaine use disorder with
cocaine-induced sleep disord er, with onset during into xication, insomnia type).
Diagnostic Features
The essential feature of substance/medication -induced sleep disorder is a prominent sleep
disturbance that is suffi ciently severe to warrant independen t clinical attent ion (Criterion A)
and that is judged to be primarily associated with the pharmacological effects of a substance
(i.e., a drug of abuse, a medication, toxin ex posure) (Criterion B). Depending on the sub-
stance involved, one of four types of sleep di sturbances is reported. Insomnia type and day-


time sleepiness type are most common, while parasomnia type is seen less often. The mixed
type is noted when more than one type of sl eep disturbance–related symptom is present and
none predominates. The disturbance must not be better explained by another sleep disorder
(Criterion C). A substance/medication-induced sleep disorder is distinguished from insom-
nia disorder or a disorder associated with excessive daytime sleepines s by considering onset
and course. For drugs of abuse, there must be evidence of intoxication or withdrawal from
the history, physical examination, or laboratory findings. Substance/medication-induced
sleep disorder arises only in association wi th intoxication or di scontinuation/withdrawal
states, whereas other sleep disorders may preced e the onset of substance use or occur during
times of sustained abstinence. As discontinuation/withdrawal states for some substances
can be protracted, onset of th e sleep disturbance can occur 4 weeks after cessation of sub-
stance use, and the disturbance may have feat ures atypical of other sleep disorders (e.g.,
atypical age at onset or course). The diagnosi s is not made if the sleep disturbance occurs
only during a delirium (Criterion D). The symptoms must cause clinically significant dis-
tress or impairment in social, occupational, or other important areas of functioning (Crite-
rion E). This diagnosis should be made instea d of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when the symptoms warrant  independent clinical attention.
Associated Features Supporting Diagnosis
During periods of substance/medication use, intoxication, or withdrawal, individuals fre-
quently complain of dysphoric mood, includin g depression and anxiety, irritability, cog-
nitive impairment, inability to concentrate, and fatigue.


nitive impairment, inability to concentrate, and fatigue.
Prominent and severe sleep disturbances can occur in association with intoxication
with the following classes of substances: alco hol; caffeine; cannabis; opioids; sedatives,
hypnotics, or anxiolytics; st imulants (including cocaine); and other (or unknown) sub-
stances. Prominent and severe sleep disturbances can occur in association with withdrawal


hypnotics, or anxiolytics; st imulants (including cocaine); and other (or unknown) sub-
stances. Prominent and severe sleep disturbances can occur in association with withdrawal
from the following classes of substances: alcohol; caffeine; cannabis; opioids; sedatives,
hypnotics, or anxiolytics; stimulant (includi ng cocaine); tobacco; and other (or unknown)
substances. Some medications that invoke sl eep disturbances include adrenergic agonists
and antagonists, dopamine agonists and antagonists, cholinergic agonists and antagonists,
serotonergic agonists and antagonists,  antihistamines, and corticosteroids.


Substance/Medication-Induced Sleep Disorder 417
Alcohol. Alcohol-induced sleep disorder typica lly occurs as insomnia type. During
acute intoxication, alcohol produces an immedi ate sedative effect depending on dose, ac-
companied by increased stages 3 and 4 non– rapid eye movement (NREM) sleep and re-
duced rapid eye movement (REM) sleep. Following these initial e ffects, there may be
increased wakefulness, restless sleep, and vivid and anxiety-laden dreams for the remain-
ing sleep period. In parallel, stages 3 and 4 sleep are reduced, and wakefulness and REM
sleep are increased. Alcohol can aggravate br eathing-related sleep disorder. With habitual
use, alcohol continues to show a short-lived sedati ve effect in the first half of the night, fol-
lowed by sleep continuity disruption in the second half. During alcohol withdrawal, there
is extremely disrupted sleep continuity, and an increased amount and intensity of REM
sleep, associated frequently with vivid drea ming, which in extreme form, constitutes part
of alcohol withdrawal delirium. After acut e withdrawal, chronic alcohol users may con-
tinue to complain of light, fragmented sleep for weeks to years associated with a persistent
deficit in slow-wave sleep.
Caffeine. Caffeine-induced sleep disorder produces insomnia in a dose-dependent man-
ner, with some individuals presenting with  daytime sleepiness related to withdrawal.
Cannabis. Acute administration of cannabis may shorten sleep latency, though arous-
ing effects with increments in sleep latenc y also occur. Cannabis enhances slow-wave
sleep and suppresses REM sleep after acute administration. In chronic users, tolerance to
the sleep-inducing and slow-wave sleep–enha ncing effects develops. Upon withdrawal,
sleep difficulties and unpleasant dreams have  been reported lasting for several weeks.


sleep difficulties and unpleasant dreams have  been reported lasting for several weeks.
Polysomnography studies demonstrate reduced slow-wave sleep and increased REM sleep
during this phase.
Opioids. Opioids may produce an increase in sleepiness and in subjective depth of sleep,
and reduced REM sleep, during acute short-te rm use. With continued administration, tol-
erance to the sedative effects of opioids de velops and there are co mplaints of insomnia.
Consistent with their respiratory depressant  effects, opioids exacerbate sleep apnea.
Sedative, hypnotic, or anxiolytic substances. Sedatives, hypnotics, and anxiolytics (e.g.,
barbiturates, benzodiazepines receptor agon ists, meprobamate, glutethimide, methypry-
lon) have similar effects as opioids on sleep. During acute intoxication, sedative-hypnotic
drugs produce the expected incr ease in sleepiness and decrea se in wakefulness. Chronic
use (particularly of barbiturates and the ol der nonbarbiturate, no nbenzodiazepine drugs)
may cause tolerance with subsequent return  of insomnia. Daytime sleepiness may occur.
Sedative-hypnotic drugs can increase the frequency and severity of obstructive sleep ap-
nea events. Parasomnias are associated with us e of benzodiazepine receptor agonists, es-
pecially when these medications are taken at  higher doses and when they are combined
with other sedative drugs. Ab rupt discontinuation of chronic sedative, hypnotic, or anx-
iolytic use can lead to withdrawal but mo re commonly rebound insomnia, a condition of
an exacerbation of insomnia upon drug disc ontinuation for 1–2 days reported to occur


even with short-term use. Sedative, hypnotic, or anxiolytic drugs with short durations of
action are most likely to produce complain ts of rebound insomnia, whereas those with
longer durations of action are more often asso ciated with daytime sl eepiness. Any sedative,
hypnotic, or anxiolytic drug can potentiall y cause daytime sedation, withdrawal, or re-
bound insomnia.
Amphetamines and related substances and other stimulants. Sleep disorders induced
by amphetamine and related substances and other stimulants are characterized by insomnia


bound insomnia.
Amphetamines and related substances and other stimulants. Sleep disorders induced
by amphetamine and related substances and other stimulants are characterized by insomnia
during intoxication and excessi ve sleepiness during withdrawal. During acute intoxication,
stimulants reduce the total amount of sleep, incr ease sleep latency and sleep continuity distur-
bances, and decrease REM sleep. Slow-wave slee p tends to  be reduced. During withdrawal
from chronic stimulant use, there is both pr olonged nocturnal sleep duration and excessive
daytime sleepiness. Multiple sleep latency te sts may show increased daytime sleepiness dur-


418 Sleep-Wake Disorders
ing the withdrawal phase. Drugs like 3,4- methylenedioxymethamphetamine (MDMA; “ec-
stasy”) and related substances lead to restless and disturbed sleep with in 48 hours of intake;
frequent use of these compounds is associated with persisting symptoms  of anxiety, depres-
sion, and sleep disturbances, even  during longer-term abstinence.
Tobacco. Chronic tobacco consumption is associat ed primarily with symptoms of insom-
nia, decreased slow-wave sleep with a reductio n of sleep efficiency, and increased daytime
sleepiness. Withdrawal from tobacco can lead  to impaired sleep. Individuals who smoke
heavily may experience regular nocturnal awakenings caused by tobacco craving.
Other or unknown substances/medications. Other substances/medications may pro-
duce sleep disturbances, particularly medications that affect the central or autonomic
nervous systems (e.g., adrenergic agonists an d antagonists, dopamine agonists and antag-
onists, cholinergic agonists an d antagonists, serotonergic agonists and antagonists, anti-
histamines, corticosteroids).
Development and Course
Insomnia in children can be identified by eith er a parent or the child. Often the child has a
clear sleep disturbance associated with initiation of a medication but may not report
symptoms, although parents observe the slee p disturbances. The use of some illicit sub-
stances (e.g., cannabis, ecstasy) is prevalen t in adolescence and early adulthood. Insomnia
or any other sleep disturbance encountered in  this age group should  prompt careful con-
sideration of whether the sleep disturbance is due to consumption of these substances.
Help-seeking behavior for the sleep disturbance in these age groups is limited, and thus


Help-seeking behavior for the sleep disturbance in these age groups is limited, and thus
corroborative report may be elic ited from a parent, caregiver, or teacher. Older individuals
take more medications and are at increased risk for developing a substance/medication-
induced sleep disorder. They may interpret sleep  disturbance as part of normal aging and
fail to report symptoms. Individuals with ma jor neurocognitive disorder (e.g., dementia)
are at risk for substance/me dication-induced sleep disord ers but may not report symp-
toms, making corroborative report from  caregiver(s) particularly important.
Risk and Prognostic Factors
Risk and prognostic factors involved in subs tance abuse/dependence  or medication use
are normative for certain age groups. They are relevant for, and likely applicable to, the
type of sleep disturbance encountered (see th e chapter “Substance-Related and Addictive
Disorders” for descriptions of resp ective substance use disorders).
Temperamental. Substance use generally precipitates or accompanies insomnia in vul-
nerable individuals. Thus, presence of insomnia in response to stress or change in sleep en-
vironment or timing can represent a risk for developing substance/medication-induced
sleep disorder. A similar risk may be present for individuals with other sleep disorders
(e.g., individuals with hypersomnia who use stimulants).
Culture-Related Diagnostic Issues
The consumption of substances, including pres cribed medications, may depend in part on
cultural background and specif ic local drug regulations.
Gender-Related Diagnostic Issues
Gender-specific prevalences (i.e., females affected more than males at a ratio of about 2:1) exist
for patterns of consumption of some substances  (e.g., alcohol). The same amount and duration
of consumption of a given substance may lead to highly different sleep-related outcomes in


of consumption of a given substance may lead to highly different sleep-related outcomes in
males and females based on, for example, gender -specific differences in hepatic functioning.


Substance/Medication-Induced Sleep Disorder 419
Diagnostic Markers
Each of the substance/medica tion-induced sleep disorders produces electroencephalo-
graphic sleep patterns that are as sociated with, but cannot be considered diagnostic of, other
disorders. The electroencephalo graphic sleep profile for each substance is related to the
stage of use, whether intake/intoxication, chronic use, or wi thdrawal following discontinu-
ation of the substance. All-night polysomnography can help define the severity of insomnia
complaints, while the multiple sleep latency test provides information about the severity of
daytime sleepiness. Monitoring of nocturnal respiration and periodic limb movements with
polysomnography may verify a substance’s im pact on nocturnal breathing and motor be-
havior. Sleep diaries for 2 weeks and actigraphy  are considered helpful in confirming the
presence of substance/medication-induced sleep disorder. Dr ug screening ca n be of use
when the individual is not aware or unwilling to relate information about substance intake.
Functional Consequences of
Substance/Medication-I nduced Sleep Disorder
While there are many functional consequences  associated with sleep disorders, the only
unique consequence for substa nce/medication-induced sleep disorder is increased risk
for relapse. The degree of sleep disturbance during alcohol withdrawal (e.g., REM sleep
rebound predicts risk of relapse of drinking ). Monitoring of sleep quality and daytime
sleepiness during and after withdrawal may provide clinically meaningful information on
whether an individual is at increased risk for relapse.
Differential Diagnosis
Substance intoxication or substance withdrawal. Sleep disturbances are commonly en-
countered in the context of substance intoxi cation or substance discontinuation/with-
drawal. A diagnosis of substance/medication-induced sleep disorder should be made


drawal. A diagnosis of substance/medication-induced sleep disorder should be made
instead of a diagnosis of substance intoxicati on or substance withdrawal only when the
sleep disturbance is predominant in the clinic al picture and is suffi ciently severe to war-
rant independent clinical attention.
Delirium. If the substance/medication-induced sl eep disturbance occurs exclusively dur-
ing the course of a delirium, it is not diagnosed separately.
Other sleep disorders. A substance/medication-induced sl eep disorder is distinguished
from another sleep disorder if a substance/medication is judged to be etiologically related to
the symptoms. A su bstance/medication-induc ed sleep disorder attributed to a prescribed
medication for a mental disorder or medical co ndition must have its onset while the individual
is receiving the medication or during disconti nuation, if there is a discontinuation/with-
drawal syndrome associated with the medication. Once treatment is discontinued, the sleep
disturbance will usually remit within days to  several weeks. If symptoms persist beyond
4 weeks, other causes for the sleep disturbanc e–related symptoms should be considered. Not
infrequently, individuals with another sleep di sorder use medications or drugs of abuse to
self-medicate their symptoms (e.g., alcohol fo r management of insomn ia). If the substance/
medication is judged to play a significant role in the exacerbation of the sleep disturbance, an
additional diagnosis of a substance/medicati on-induced sleep disorder may be warranted.
Sleep disorder due to an other medical condition. Substance/medication-induced sleep
disorder and sleep disorder associated with  another medical condition may produce sim-
ilar symptoms of insomnia, daytime sleepiness, or a parasomnia. Many individuals with
other medical conditions that  cause sleep disturbance are treated with medications that


other medical conditions that  cause sleep disturbance are treated with medications that
may also cause sleep disturbances. The chrono logy of symptoms is the most important fac-
tor in distinguishing between th ese two sources of sleep symptoms. Difficulties with sleep
that clearly preceded the use of any medication for treatment of a medical condition would


420 Sleep-Wake Disorders
suggest a diagnosis of sleep disorder associated with another medical condition. Con-
versely, sleep symptoms that appear only afte r the initiation of a particular medication/
substance suggest a substance/medication-ind uced sleep disorder. If the disturbance is
comorbid with another medical condition and is also exacerbated by substance use, both
diagnoses (i.e., sleep disorder associated with another medical condition and substance/
medication-induced sleep disorder) are given. When there is insuffici ent evidence to de-
termine whether the sleep distur bance is attributable to a substance/medication or to an-
other medical condition or is primary (i.e., not due to either a substance/medication or
another medical condition), a diagnosis of ot her specified sleep-wake disorder or unspec-
ified sleep-wake disorder is indicated.
Comorbidity
See the “Comorbidity” sections for other sleep  disorders in this chapter, including insom-
nia, hypersomnolence, centra l sleep apnea, sleep-related hypoventilation, and circadian
rhythm sleep-wake disorders, shift work type.
Relationship to Internat ional Classification of
Sleep Disorders
The International Classifica tion of Sleep Disorders, 2nd Edition (ICSD-2), lists sleep disorders
“due to drug or substance” under their respective phenotypes (e.g., insomnia, hypersomnia).
Other Specified Insomnia Disorder
780.52 (G47.09)
This category applies to presentations in which symptoms characteristic of insomnia disorder
that cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning predominate but do not meet th e full criteria for insomnia disorder or any
of the disorders in the sleep-wake disorders diagnostic class. The other specified insomnia dis-


of the disorders in the sleep-wake disorders diagnostic class. The other specified insomnia dis-
order category is used in situations in which the clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for insomnia disorder or any specific
sleep-wake disorder. This is done by recording “other specified insomnia disorder” followed by
the specific reason (e.g., “brief insomnia disorder”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Brief insomnia disorder:  Duration is less than 3 months.
2.Restricted to no nrestorative sleep:  Predominant complaint is nonrestorative sleep
unaccompanied by other sleep symptoms such as difficulty falling asleep or remaining
asleep.
Unspecified Insomnia Disorder
780.52 (G47.00)
This category applies to presentations in which symptoms characteristic of insomnia disor-
der that cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet the full criteria for insomnia dis-
order or any of the disorders in the sleep-wake disorders diagnostic class. The unspecified


Other Specified Hypersomnolence Disorder 421
insomnia disorder category is used in situations in which the clinician chooses not to specify
the reason that the criteria are not met for insomnia disorder or a specific sleep-wake dis-
order, and includes presentations in which there is insufficient information to make a more
specific diagnosis.
Other Specified Hypersomnolence Disorder
780.54 (G47.19)
This category applies to presentations in which symptoms characteristic of hypersomno-
lence disorder that cause clinically signific ant distress or impairment in social, occupation-
al, or other important areas of functioning predominate but do not meet the full criteria for
hypersomnolence disorder or any of the disorders in the sleep-wake disorders diagnostic
class. The other specified hypersomnolence disorder category is used in situations in
which the clinician chooses to communicate the specific reason that the presentation does
not meet the criteria for hypersomnolence diso rder or any specific sleep-wake disorder.
This is done by recording “other specified hypersomnolence disorder” followed by the spe-
cific reason (e.g., “brief-duration hyperso mnolence,” as in Kleine-Levin syndrome).
Unspecified Hypersomnolence Disorder
780.54 (G47.10)
This category applies to presentations in which symptoms characteristic of hypersomno-
lence disorder that cause clinically signific ant distress or impairment in social, occupation-
al, or other important areas of functioning predominate but do not meet the full criteria for
hypersomnolence disorder or any of the disorders in the sleep-wake disorders diagnostic
class. The unspecified hypersomnolence disorder category is used in situations in which
the clinician chooses not to specify the reason that the criteria are not met for hypersom-


the clinician chooses not to specify the reason that the criteria are not met for hypersom-
nolence disorder or a specific sleep-wake disorder, and includes presentations in which
there is insufficient information to make a more specific diagnosis.
Other Specified Sleep-Wake Disorder
780.59 (G47.8)
This category applies to presentations in which symptoms characteristic of a sleep-wake
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the sleep-wake disorders diagnostic class and do not qualify for a diagno-
sis of other specified insomnia disorder or  other specified hypersomnolence disorder. The
other specified sleep-wake disorder category is used in situations in which the clinician
chooses to communicate the specific reason that the presentation does not meet the
criteria for any specific sleep-wake disorder . This is done by recording “other specified
sleep-wake disorder” followed by the specific reason (e.g., “repeated arousals during rapid
eye movement sleep without polysomnography or history of Parkinson’s disease or other
synucleinopathy”).


422 Sleep-Wake Disorders
Unspecified Sleep-Wake Disorder
780.59 (G47.9)
This category applies to presentations in which symptoms characteristic of a sleep-wake
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the sleep-wake disorders di agnostic class and do not qualify for a diagno-
sis of unspecified insomnia disorder or unspecified hypersomnolence disorder. The un-
specified sleep-wake disorder category is used in situations in which the clinician chooses
not to specify the reason that the criteria are not met for a specific sleep-wake disorder,
and includes presentations in which there is insufficient information to make a more spe-
cific diagnosis.


423Sexual
 Dysfunctions
Sexual dysfunctions  include delayed ejaculation, er ectile disorder, female orgasmic
disorder, female sexual intere st/arousal disorder, genito-pelvic pain/penetration disorder,
male hypoactive sexual desire disorder, premature (early) ejac ulation, substance/medication-
induced sexual dysfunction, other specified se xual dysfunction, and unspecified sexual dys-
function. Sexual dysfunctions ar e a heterogeneous group of disorders that are typically char-
acterized 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 determin e if the sexual difficulties are the result of
inadequate sexual stimulation; in these cases,  there may still be a need for care, but a di-
agnosis of a sexual dysfunctio n would not be made. These cases may include, but are not
limited to, conditions in which lack of know ledge 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 in dicate different etiolo gies and interventions.
Lifelong  refers to a sexual problem that has been present from first sexu al 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, situatio ns, or partners, and situational  refers to sexual difficulties that only oc-
cur with certain types of stimul ation, situations, or partners.
In addition to the lifelong/ acquired and generalized/situational subtypes, a number


In addition to the lifelong/ acquired and generalized/situational subtypes, a number
of factors must be considered during the asse ssment 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., pa rtner’s sexual problems; partner’s health sta-
tus); 2) relationship factors (e.g., poor communication; disc repancies in desire for sexual
activity); 3) individual vulnerability factors (e .g., poor body image; history of sexual or emo-
tional abuse), psychiatric comorbidity (e.g., depr ession, anxiety), or stre ssors (e.g., job loss,
bereavement); 4) cultural or religious factors (e.g., inhibitions re lated to prohibitions against
sexual activity or pleasure; attitudes toward sexuality); and 5) medical factors relevant to
prognosis, course, or treatment.
Clinical judgment about the di agnosis of sexual dysfunction should take into consideration
cultural factors that may influe nce expectations or engender pr ohibitions about the experience
of sexual pleasure. Aging may be associated wi th a normative decrease in sexual response.
Sexual response has a requisite biological underpinning, yet is usually experienced in
an intrapersonal, interpersonal, and cultural context. Thus, sexual fu nction involves a com-
plex interaction among biological, sociocultural, and psychological factors. In many clinical
contexts, a precise understanding of the etiolo gy of a sexual problem is unknown. Nonethe-
less, 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 explainabl e by another nonsexual mental disorder (e.g.,
depressive or bipolar disorder, anxiety disord er, posttraumatic stress disorder, psychotic dis-


424 Sexual Dysfunctions
order), 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 anot her medical condition (e.g., peripheral neuropa-
thy), the individual would not receive a psychiatric diagnosis. If severe relationship distress,
partner violence, or significant stressors better ex plain the sexual difficulties, then a sexual dys-
function diagnosis is not made, but an appropriat e V or Z code for the relationship problem or
stressor may be listed. In many cases, a precise etiological relationship between another con-
dition (e.g., a medical condition) and a sexual dysfunction cannot be established.
Delayed Ejaculation
Diagnostic Criteria 302.74 (F52.32)
A. Either of the following symptoms must be experienced on almost all or all occasions
(approximately 75%–100%) of partnered sexual activity (in identified situational con-
texts or, if generalized, in all contexts), and without the individual desiring delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress or other significant stressors and is not at-
tributable to the effects of a substance/medication or another medical condition.
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually active.


Lifelong:  The disturbance has been present since the individual became sexually active.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify whether:
Generalized:  Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
The distinguishing feature of delayed ejaculation is a marked delay in or inability to
achieve ejaculation (Cri terion A). The man reports difficulty or inability to ejaculate de-
spite the presence of adequate sexual stimul ation and the desire to ejaculate. The present-
ing complaint usually involves partnered sexual  activity. In most cases, the diagnosis will
be made by self-report of the individual. The defini tion of “delay” does not have precise
boundaries, as there is noconsensus as to what  constitutes a reasonable time to reach or-
gasm or what is unacceptably long fo r most men and their sexual partners.
Associated Features Supporting Diagnosis
The man and his partner may report prolonged thrusting to achieve or gasm to the point of
exhaustion or genital discomfo rt and then ceasing efforts. Some men may report avoiding


Delayed Ejaculation 425
sexual activity because of a re petitive pattern of difficulty ejaculating. Some sexual partners
may report feeling less sexually attractive because their partner ca nnot ejaculate easily.
In addition to the subtypes “lifelong/acqu ired” and “generalized/situational,” the fol-
lowing five factors must be considered during assessment and diagnosis of delayed ejacu-
lation, given that they may be relevant to etiology and/or  treatment: 1) partner factors (e.g.,
partner’s sexual pr oblems, partner’s health status); 2) relationship factors (e.g., poor com-
munication, 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 stressor s (e.g., job loss, bereavement); 4) cultural/religious factors
(e.g., inhibitions related to prohibitions agains t 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
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 ejacula-
tion that last more than 6 months.
Development and Course
Lifelong delayed ejaculation begins with ea rly sexual experiences and continues through-
out life. By definition, acquired  delayed ejaculation begins after a period of normal sexual
function. There is minimal evidence concerni ng the course of acquired delayed ejacula-


function. There is minimal evidence concerni ng the course of acquired delayed ejacula-
tion. The prevalence of delaye d ejaculation appears to remain relatively constant until
around age 50 years, when the incidence begins  to increase significantly. Men in their 80s
report twice as much difficulty ejac ulating as men younger than 59 years.
Risk and Prognostic Factors
Genetic and physiological. Age-related loss of the fast-conducting peripheral sensory
nerves and age-related decreased sex steroid secretion may be associated with the increase
in delayed ejaculation in men older than 50 years.
Culture-Related Diagnostic Issues
Complaints of ejaculatory delay vary across countries and cultures. Such complaints are
more common among men in Asian population s than in men living in Europe, Australia,
or the United States. This variation may be attributable to cultural or genetic differences
between cultures.
Functional Consequences  of Delayed Ejaculation
Difficulty with ejaculation may contribute to  difficulties in conception. Delayed ejacula-
tion is often associated with considerable psychological distre ss in one or both partners.
Differential Diagnosis
Another medical condition. The major differential diagnosis  is between delayed ejacu-
lation fully explained by another medical illness or injury and delayed ejaculation with a
psychogenic, idiopathic, or combined psycho logical and medical etiology. A situational
aspect to the complaint is suggestive of a psychological basis for the problem (e.g., men
who can ejaculate during sexual activity with one sex but not the other; men who can ejac-
ulate with one partner but not another of the same sex; men with paraphilic arousal pat-


426 Sexual Dysfunctions
terns; men who require highly ritualized ac tivity to ejaculate during partnered sexual
activity). Another medical illness or injury ma y produce delays in ejaculation independent
of psychological issues. For example, inability to ejaculate can be caused by interruption of
the nerve supply to the genitals , such as can occur after traumatic surgical injury to the
lumbar sympathetic ganglia, abdominoperitoneal surgery, or lumbar sympathectomy.
Ejaculation is thought to be under autonomic nervous system control involving the hypo-
gastric (sympathetic) and pudendal (parasym pathetic) nerves. A number of neurodegen-
erative diseases, such as multiple sclerosis and diabetic and alcoholic neuropathy, can
cause inability to ejaculate. Delayed ejaculat ion should also be diffe rentiated from retro-
grade ejaculation (i.e., ejaculation into the bladder), which may follow transurethral pros-
tatic resection.
Substance/medication use. A number of pharmacological agents, such as antidepres-
sants, antipsychotics, alpha sympathetic drugs, and opioid drugs, can cause ejaculatory
problems.
Dysfunction with orgasm. It is important in the history to ascertain whether the com-
plaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs
in the genitals, whereas the experience of orga sm is believed to be primarily subjective.
Ejaculation and orgasm usually occur together  but not always. For example, a man with a
normal ejaculatory pattern may complain of decreased pleasure (i.e., anhedonic ejacula-
tion). Such a complaint would not be coded as delayed ejaculation but could be coded as
other specified sexual dysfunction or  unspecified sexual dysfunction.
Comorbidity


other specified sexual dysfunction or  unspecified sexual dysfunction.
Comorbidity
There is some evidence to sugge st that delayed ejaculation may be more common in severe
forms of major de pressive disorder.
Erectile Disorder
Diagnostic Criteria 302.72 (F52.21)
A. At least one of the three following symptoms must be experienced on almost all or all
(approximately 75%–100%) occasions of sexual activity (in identified situational con-
texts or, if generalized, in all contexts):
1. Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of sexual activity.
3. Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress or other significant stressors and is not at-
tributable to the effects of a substance/medication or another medical condition.
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually ac-
tive.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify whether:
Generalized:  Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.


Erectile Disorder 427
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
The essential feature of erectile disorder is the repeated failure to obtain or maintain erec-
tions during partnered sexual activities (Crite rion 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 majo rity of sexual occasions (i.e., at least 75%
of the time). Symptoms may occur only in sp ecific situations involving certain types of
stimulation or partners, or they may occur in  a generalized manner in all types of situa-
tions, stimulatio n, or partners.
Associated Features Supporting Diagnosis
Many men with erectile disorder may have lo w self-esteem, low self-c onfidence, and a de-
creased sense of masculinity, and may experience depressed affect. Fear and/or avoid-
ance of future sexual encounters may occu r. Decreased sexual satisfaction and reduced
sexual desire in the individual’s partner are common.
In addition to the subtypes “lifelong/acqu ired” and “generalized/situational,” the fol-
lowing 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., part-
ner’s sexual problems, partner’s health status); 2) relationship factors (e.g., poor communi-
cation, discrepancies in desire for sexual activity); 3) in dividual 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, cour se, or treatment. Each of these factors may con-
tribute differently to the pr esenting symptoms of differe nt men with this disorder.
Prevalence
The prevalence of lifelong vers us acquired erectile disorder  is unknown. There is a strong
age-related increase in both prevalence and incidence of problems with erection, particu-
larly after age 50 years. Approximately 13%–21%  of men ages 40–80 years complain of oc-
casional problems with erections. Approxim ately 2% of men younger than age 40–50 years
complain of frequent problems with erecti ons, whereas 40%–50% of men older than 60–70
years may have significant problems with erec tions. About 20% of me n fear erectile prob-
lems on their first sexual experience, wherea s approximately 8% experienced erectile prob-
lems that hindered penetration duri ng their first sexual experience.
Development and Course
Erectile failure on first sexual attempt has been found to be related to having sex with a pre-
viously unknown partner, concomit ant use of drugs or alcohol, not wanting to have sex, and
peer pressure. There is minimal evidence rega rding the persistence of  such problems after
the first attempt. It is assumed that most of these problems spontane ously remit without pro-
fessional intervention, but some men may contin ue to have episodic problems. In contrast,


fessional intervention, but some men may contin ue to have episodic problems. In contrast,
acquired erectile disorder is of ten associated with biological factors such as diabetes and car-
diovascular disease. Acquired er ectile disorder is likely to  be persistent in most men.
The natural history of lifelong erectile disorder is unknown. Clinical observation sup-
ports the association of lifelong erectile diso rder with psychological factors that are self-


428 Sexual Dysfunctions
limiting or responsive to ps ychological interventions, wher eas, as noted above, acquired
erectile disorder is more likely to be related to biological factors and to be persistent. The
incidence of erectile disorder increases with  age. A minority of men diagnosed as having
moderate erectile failure ma y experience spontaneous remission of symptoms without
medical intervention. Distress as sociated with erectile disord er is lower in older men as
compared with younger men.
Risk and Prognostic Factors
Temperamental. Neurotic personality traits may be associated with erectile problems in col-
lege students, and submissive personality traits may be associated with erectile problems in
men age 40 years and older. Alexithymia  (i.e., deficits in cognitive processing of emotions) is
common in men diagnosed with “psychogenic” er ectile dysfunction. Erectile problems are
common in men diagnosed with depression and posttraumatic stress disorder.
Course modifiers. Risk factors for acquired erectile disorder include age, smoking to-
bacco, lack of physical exercise, diabetes, and decreased desire.
Culture-Related Diagnostic Issues
Complaints of erectile disorder have been foun d to vary across countries. It is unclear to
what extent these differences represent differ ences in cultural expectations as opposed to
genuine differences in the fr equency of erectile failure.
Diagnostic Markers
Nocturnal penile tumescence testing and meas ured erectile turgidity during sleep can be
employed to help differentiate organic from  psychogenic erectile problems on the as-
sumption that adequate erections during ra pid eye movement sleep indicate a psycholog-
ical etiology to the problem. A number of other diagnostic procedures may be employed
depending on the clinician’s assessment of their relevance given the individual’s age, co-


depending on the clinician’s assessment of their relevance given the individual’s age, co-
morbid medical problems, and clinical pres entation. Doppler ultrasonography and intra-
vascular injection of vasoactive drugs, as we ll as invasive diagnostic procedures such as
dynamic infusion cavernosography, can be used to assess vascular integrity. Pudendal
nerve conduction studies, including somato sensory evoked potentials, can be employed
when a peripheral neuropathy is suspected. In men also complaining of decreased sexual
desire, serum bioavailable or free testosterone is frequently assessed to determine if the
difficulty is secondary to endocrinological factors. Thyroid function may also be assessed.
Determination of fasting serum glucose is useful to screen for the pres ence of diabetes mel-
litus. The assessment of serum lipids is important, as erectile disorder in men 40 years and
older is predictive of the future risk of coronary artery disease.
Functional Consequences  of Erectile Disorder
Erectile disorder can interfere with fertility and produce both indivi dual and interpersonal
distress. Fear and/or avoidance of sexual en counters may interfere with the ability to de-
velop intimate relationships.
Differential Diagnosis
Nonsexual mental disorders. Major depressive disorder and erectile disorder are closely
associated, and erectile diso rder accompanying severe de pressive disorder may occur.
Normal erectile function. The differential should include consideration of normal erec-
tile function in men with  excessive expectations.


Female Orgasmic Disorder 429
Substance/medication use. Another major differential diagnosis is whether the erectile
problem is secondary to substa nce/medication use. An onset that coincides with the be-
ginning of substance/medication use and that dissipates with discontinuation of the sub-
stance/medication or dose reduction is su ggestive of a substance/medication-induced
sexual dysfunction.
Another medical condition. The most difficult aspect of the differential diagnosis of erec-
tile disorder is ruling out erec tile problems that are fully explained by medical factors. Such
cases would not receive a diagnosis of a ment al disorder. The distinction between erectile
disorder as a mental disorder and erectile dy sfunction as the result of another medical con-
dition is usually unclear, and many cases will have complex, interactive biological and psy-
chiatric etiologies. If the individual is older than 40–50 years and/or has concomitant
medical problems, the differential diagnosis should include medical etiologies, especially
vascular disease. The presence of an organic disease known to  cause erectile problems does
not confirm a causal relationship. For exampl e, a man with diabetes mellitus can develop
erectile disorder in response to psychological stress. In general, erectile dysfunction due to
organic factors is generalized and gradual in onset. An exception would be erectile problems
after traumatic injury to the nervous innervation of the genital organs (e.g., spinal cord injury).
Erectile problems that are situational and inco nsistent and that have an acute onset after a
stressful life event are most often due to psychological events. An age of less than 40 years is
also suggestive of a psychologi cal etiology to the difficulty.
Other sexual dysfunctions. Erectile disorder may coexist with premature (early) ejacu-
lation and male hypoactive sexual desire disorder.


lation and male hypoactive sexual desire disorder.
Comorbidity
Erectile disorder can be comorbid with other sexual diagnoses, such  as premature (early)
ejaculation and male hypoactive sexual desire  disorder, as well as  with anxiety and de-
pressive disorders. Erectile disorder is co mmon in men with lowe r urinary tract symptoms
related to prostatic hypertrophy. Erectile diso rder may be comorbid with dyslipidemia, car-
diovascular disease, hypogonadism, multiple sclerosis, diabetes mellitus, and other diseases
that interfere with the vascular, neurological , or endocrine function  necessary for normal
erectile function.
Relationship to Internationa l Classification of Diseases
Erectile response is coded as failure of  genital response in ICD-10 (F2.2).
Female Orgasmic Disorder
Diagnostic Criteria 302.73 (F52.31)
A. Presence of either of the following symptoms and experienced on almost all or all (ap-
proximately 75%–100%) occasions of sexual ac tivity (in identified situational contexts
or, if generalized, in all contexts):
1. Marked delay in, marked infrequency of, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress (e.g., partner violence) or other significant


430 Sexual Dysfunctions
stressors and is not attributable to the effects of a substance/medication or another
medical condition.
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually active.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify whether:
Generalized:  Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify if:
Never experienced an orgasm under any situation.
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
Female orgasmic disorder is characterize d by difficulty experiencing orgasm and/or
markedly reduced intensity of orgasmic sensat ions (Criterion A). Women show wide vari-
ability in the type or intensity of stimulation that elicits orgasm. Similarly, subjective descrip-
tions of orgasm are extremely varied, suggesti ng 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 (approx-
imately 75%–100%) occasions of sexual activity  (in identified situational contexts or, if
generalized, in all contexts) and have a mi nimum 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 “approx-
imately” in Criterion B allows for clinician judgment in cases in which symptom duration
does not meet the recommended 6-month threshold.


does not meet the recommended 6-month threshold.
For a woman to have a diagnosis of female or gasmic disorder, clinically significant dis-
tress must accompany the symptoms (Criterion C). In many cases of orgasm problems, the
causes are multifactorial or cannot be determined. If female org asmic disorder is deemed
to be better explained by another mental diso rder, the effects of a substance/medication,
or a medical condition, then a diagnosis of fe male orgasmic disorder  would not be made.
Finally, if interpersonal or significant contextual factors, such as severe relationship dis-
tress, intimate partner violence, or other signi ficant stressors, are present, then a diagnosis
of female orgasmic diso rder would not be made.
Many women require clitoral stimulation to  reach orgasm, and a relatively small pro-
portion of women report that they always ex perience orgasm during penile-vaginal inter-
course. Thus, a woman’s experiencing orgasm through clitoral stim ulation but not during
intercourse does not meet criteria for a clinic al diagnosis of female orgasmic disorder. It is
also important to consider whether orgasmic difficulties are the result of inadequate sex-
ual stimulation; in these cases, there may still be a need for care, but a diagnosis of female
orgasmic disorder would not be made.
Associated Features Supporting Diagnosis
Associations between specific patterns of personality traits  or psychopathology and orgas-
mic dysfunction have generally not been su pported. Compared with women without the
disorder, some women with female orgasmic disorder may have greater difficulty com-
municating about sexual issues. Overall sexual satisfaction, however, is not strongly cor-
related with orgasmic experien ce. Many women report high le vels of sexual satisfaction


Female Orgasmic Disorder 431
despite rarely or never experiencing orgasm . Orgasmic difficulties in women often co-
occur with problems related to  sexual interest and arousal.
In addition to the subtypes “lifelong/acquired” and “generalized/situational,” the fol-
lowing five factors must be considered during assessment and diagnosis of female orgas-
mic 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, discre pancies in desire for sexual activity); 3) individual vul-
nerability factors (e.g., poor body  image, history of sexual or  emotional abuse), psychiatric
comorbidity (e.g., depression, anxiety), or st ressors (e.g., job loss, bereavement); (4) cul-
tural/religious factors (e.g., inhibitions relate d to prohibitions against sexual activity;
attitudes toward sexuality); and 5) medical fact ors relevant to prognosis, course, or treat-
ment. Each of these factors may contribute differently to the presenting symptoms of dif-
ferent women with this disorder.
Prevalence
Reported prevalence rates for female orgasmic problems in women vary widely, from 10%
to 42%, depending on multiple factors (e.g., ag e, culture, duration, and severity of symp-
toms); however, these estimates do not take into account the presence of distress. Only a
proportion of women experiencing orgasm di fficulties also report associated distress.
Variation in how symptoms are assessed (e.g., the duration of symptoms and the recall pe-
riod) also influence prevalence rates. Approx imately 10% of women do not experience or-


gasm throughout their lifetime.
Development and Course
By definition, lifelong female orgasmic disorder indicates that the orgasmic difficulties have
always been present, whereas the acquired subtype would be assigned if the woman’s or-
gasmic difficulties developed after a pe riod of normal orgasmic functioning.
A woman’s first experience of orgasm can occur any time from the prepubertal period
to well into adulthood. Women show a more variable pattern in age at first orgasm than do
men, and women’s reports of having experien ced orgasm increase with age. Many women
learn to experience orgasm as they experien ce a wide variety of stimulation and acquire
more knowledge about their bodies. Women’s rates of orgasm consistency (defined as
“usually or always” experiencing orgasm) are higher during masturbation than during
sexual activity with a partner.
Risk and Prognostic Factors
Temperamental. A wide range of psychological factors, such as anxiety and concerns
about pregnancy, can potentially interfere wi th a woman’s ability to experience orgasm.
Environmental. There is a strong association betw een relationship problems, physical
health, and mental health and orgasm difficulties in women. Sociocultural factors (e.g.,
gender role expectations and religious norms)  are also important influences on the expe-
rience of orgasmic difficulties.
Genetic and physiological. Many physiological factors may influence a woman’s expe-
rience of orgasm, including medical conditio ns and medications. Conditions such as mul-
tiple sclerosis, pelvic nerve da mage from radical hysterectomy, and spinal cord injury can
all influence orgasmic functioning in women. Selective serotonin reuptake inhibitors are
known to delay or inhibit orgasm in women.  Women with vulvovaginal atrophy (charac-
terized by symptoms such as vaginal dryness, itching, and pain) are significantly more


terized by symptoms such as vaginal dryness, itching, and pain) are significantly more
likely to report orgasm difficulties than are women without this condition. Menopausal
status is not consistently associated with the likelihood of orgasm difficulties. There may
be a significant genetic contribution to vari ation in female orgasmic function. However,


432 Sexual Dysfunctions
psychological, sociocultural, and physiological factors likely interact in complex ways to
influence women’s experience of orgasm and of orgasm difficulties.
Culture-Related Diagnostic Issues
The degree to which lack of orgasm in women is regarded as a problem that requires treat-
ment may vary depending on cultural context. In addition, women differ in how important
orgasm is to their sexual satisfaction. Ther e may be marked sociocultural and generational
differences in women’s orgasmic ability. For example, the prevalence of inability to reach or-
gasm has ranged from 17.7% (in Northern  Europe) to 42.2% (i n Southeast Asia).
Diagnostic Markers
Although measurable physiological change s occur during female  orgasm, including
changes in hormones, pelvic floor musculature,  and brain activation, there is significant
variability in these indicators of orgasm across  women. In clinical situations, the diagnosis
of female orgasmic disorder is based on a woman’s self-report.
Functional Consequences of  Female Orgasmic Disorder
The functional consequences of female orgasmic  disorder are unclear.  Although there is a
strong association between relationship proble ms and orgasmic difficulties in women, it is
unclear whether relationship factors are risk fa ctors for orgasmic difficulties or are conse-
quences of those difficulties.
Differential Diagnosis
Nonsexual mental disorders. Nonsexual mental disorders,  such as major depressive
disorder, which is characterized by markedly dimi nished interest or pleasure in all, or al-
most all, activities, may explain female orgasm ic disorder. If the orgasmic difficulties are
better explained by another me ntal disorder, then a diagnosis  of female orgasmic disorder
would not be made.
Substance/medication-induced sexual dysfunction. Substance/medication use may
explain the orgasmic difficulties.


explain the orgasmic difficulties.
Another medical condition. If the disorder is due to an other medical condition (e.g.,
multiple sclerosis, spinal cord injury), then a diagnosis of female orgasmic disorder would
not be made.
Interpersonal factors. If interpersonal or significant co ntextual factors, such as severe
relationship distress, intimate partner violen ce, or other significant stressors, are associ-
ated with the orgasmic difficulties, then a diagnosis of female orgasmic disorder would
not be made.
Other sexual dysfunctions. Female orgasmic disorder may occur in association with other
sexual dysfunctions (e.g., female sexual intere st/arousal disorder). Th e presence of another
sexual dysfunction does not rule out a diagnosi s of female orgasmic disorder. Occasional or-
gasmic difficulties that are short-term or infreq uent and are not accompanied by clinically sig-
nificant distress or impairment are not diagno sed as female orgasmic disorder. A diagnosis is
also not appropriate if the problems are the result of inadequate sexual stimulation.
Comorbidity
Women with female orgasmic disorder may have co-occurring sexu al interest/arousal
difficulties. Women with diagnoses of other no nsexual mental disorder s, such as major de-
pressive disorder, may experience lower sexu al interest/arousal, and this may indirectly
increase the likelihood of  orgasmic difficulties.


Female Sexual Interest/Arousal Disorder 433
Female Sexual Interest/Arousal Disorder
Diagnostic Criteria 302.72 (F52.22)
A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least
three of the following:
1. Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s at-
tempts to initiate.
4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or
all (approximately 75%–100%) sexual encounters (in identified situational contexts
or, if generalized, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or external sex-
ual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or nongenital sensations during sexual activity in almost all
or all (approximately 75%–100%) sexual encounters (in identified situational con-
texts or, if generalized, in all contexts).
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress (e.g., partner violence) or other significant
stressors and is not attributable to the effects of a substance/medication or another
medical condition.
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually
active.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify whether:


Specify whether:
Generalized:  Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
In assessing female sexual interest/arousal di sorder, interpersonal co ntext must be taken
into account. A “desire discrepancy,” in whic h a woman has lower desire for sexual activ-
ity than her partner, is not suff icient to diagnose female sexu al interest/arousal disorder.
In order for the criteria for the disorder to be met, there must be absence or reduced fre-
quency or intensity of at least three of six indicators (Criterion A) for a minimum duration
of approximately 6 months (Criterion B). Th ere may be different symptom profiles across
women, as well as variability in how sexual in terest and arousal are expressed. For exam-
ple, in one woman, sexual interest/arousal di sorder may be expressed as a lack of interest
in sexual activity, an absence of erotic or se xual thoughts, and reluct ance to initiate sexual
activity and respond to a partner’s sexual invi tations. In another woman, an inability to be-
come sexually excited, to resp ond to sexual stimuli with se xual desire, and a correspond-


434 Sexual Dysfunctions
ing lack of signs of physical sexual arousa l may be the primary features. Because sexual
desire and arousal frequently coex ist and are elicited in respon se to adequate sexual cues,
the criteria for female sexual in terest/arousal disorder take into account that difficulties in
desire and arousal often simult aneously characterize the co mplaints of women with this
disorder. Short-term changes in  sexual interest or arousal are common and may be adaptive
responses to events in a woma n’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 determin ed by clinical judgment when a duration of
6 months cannot be ascertained precisely.
There may be absent or reduced frequency or inte nsity of interest in se xual activity (Crite-
rion A1), which was previously termed hypoactive sexual desire disorder.  The frequency or inten-
sity of sexual and erotic thoughts or fantasie s 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 ab sent or reduced sexual excitement or pleasure
during sexual activity in almos t all or all (approximately 75%– 100%) sexual encounters (Cri-


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). Freque ncy or intensity of genital or nongenital sensations during sex-
ual activity may be reduced or absent (Crite rion 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.
Associated Features Supporting Diagnosis
Female sexual interest/arousal disorder is fr equently 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 intere st or arousal, along


pectations and norms regarding the “appropriate” level of sexual intere st or arousal, along
with poor sexual techniques and lack of info rmation 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 importan t factors to consider.


in women diagnosed with female sexual interest/arousal disorder. The latter, as well as
normative beliefs about gender roles, are importan t factors to consider.
In addition to the subtypes “lifelong/acquired” and “generalized/situational,” the follow-
ing five factors must be considered during asse ssment 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 prob lems, partner’s health status); 2)  relationship factors (e.g., poor
communication, discrepancies in de sire for sexual activity); 3) individual vulnerability factors
(e.g., poor body image, history of sexual or emotional abuse), ps ychiatric comorbidity (e.g., de-
pression, anxiety), or stressors (e.g., job loss, bereavement); 4) cultural/religious  factors (e.g.,
inhibitions related to prohibitions against sexu al activity; attitudes toward sexuality); and


Female Sexual Interest/Arousal Disorder 435
5) medical factors relevant to pr ognosis, course, or treatment. Note that each of these factors
may contribute differently to the presenting sy mptoms of different women with this disorder.
Prevalence
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. Regard-
ing duration of symptoms, there are striking  differences in prevalence estimates between
short-term and persistent problems related to lack of sexual intere st. When distress about
sexual functioning is requir ed, prevalence estimates are markedly lower. Some older
women report less distress ab out low sexual desire than y ounger women, although sexual
desire may decrease with age.
Development and Course
By definition, lifelong female sexual interest /arousal disorder suggests that the lack of
sexual interest or arousal has been present fo r the woman’s entire sexual life. For Criteria
A3, A4, and A6, which assess functioning duri ng sexual activity, a subtype of lifelong
would mean presence of symptoms since the in dividual’s first sexual experiences. The ac-
quired subtype would be assigned if the difficu lties with sexual interest or arousal de-
veloped after a period of nonproblematic se xual functioning. Adaptive and normative
changes in sexual functioning may result from  partner-related, interpersonal, or personal
events and may be transient in nature. Howe ver, persistence of symptoms for approxi-
mately 6 months or more would constitute a sexual dysfunction.
There are normative changes in  sexual interest and arousal across the life span. Fur-


There are normative changes in  sexual interest and arousal across the life span. Fur-
thermore, women in relationships of longer du ration are more likely to report engaging in
sex despite no obvious feelings of sexual desi re at the outset of a sexual encounter com-
pared with women in shorter-duration relationships. Vaginal dryness in older women is
related to age and menopausal status.
Risk and Prognostic Factors
Temperamental. Temperamental factors include negati ve cognitions and attitudes about
sexuality and past history of mental disorders. Differences in propensity for sexual excitation
and sexual inhibition may also predict the likelihood of developi ng sexual problems.
Environmental. Environmental factors include relationship difficulties, partner sexual
functioning, and developmental history, such as early relationships with caregivers and
childhood stressors.
Genetic and physiological. Some medical conditions (e.g., diabetes mellitus, thyroid
dysfunction) can be risk factors for female se xual interest/arousal disorder. There appears
to be a strong influence of genetic factors on vulnerability to sexual problems in women.
Psychophysiological research using vaginal photoplethysmography has not found differ-
ences between women with and without perceived lack of genital arousal.
Culture-Related Diagnostic Issues
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 quanti fy desire. A judgment about whether low sexual


436 Sexual Dysfunctions
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.
Gender-Related Diagnostic Issues
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.
Functional Consequences of
Female Sexual Intere st/Arousal Disorder
Difficulties in sexual interest/a rousal are often associated with decreased relationship sat-
isfaction.
Differential Diagnosis
Nonsexual mental disorders. Nonsexual mental disorders,  such as major depressive
disorder, in which there is “markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day,” may explain the lack of sexual interest/
arousal. If the lack of interest or arousal is completely attributable to another mental dis-
order, then a diagnosis of female sexual in terest/arousal disorder  would not be made.
Substance/medication use. Substance or medication use may explain the lack of inter-
est/arousal.
Another medical condition. If the sexual symptoms are co nsidered to be almost exclu-
sively associated with the effe cts of another medical conditio n (e.g., diabetes mellitus, en-
dothelial disease, thyroid dysfunction, centra l nervous system diseas e), then a diagnosis
of female sexual inte rest/arousal disorder would not be made.
Interpersonal factors. If interpersonal or significant co ntextual factors, such as severe
relationship distress, intimate partner violence , or other significant stressors, explain the


relationship distress, intimate partner violence , or other significant stressors, explain the
sexual interest/arousal symptoms, then a diag nosis of female sexual interest/arousal dis-
order would not be made.
Other sexual dysfunctions. The presence of another sexu al dysfunction does not rule
out a diagnosis of female sexual  interest/arousal disorder. It  is common for women to ex-
perience more than one sexual  dysfunction. For example, the presence of chronic genital
pain may lead to a lack of desire for the (p ainful) sexual activity. Lack of interest and
arousal during sexual activity may impair or gasmic ability. For some women, all aspects
of the sexual response may be unsatisfying and distressing.
Inadequate or absent sexual stimuli. When differential diagnoses are being considered,
it is important to assess the adequacy of se xual stimuli within the woman’s sexual experi-
ence. In cases where inadequate or absent sexual stimuli are co ntributing to the clinical pic-
ture, there may be evidence for clinical care , but a sexual dysfunction diagnosis would not
be made. Similarly, transient and adaptive alte rations in sexual functioning that are second-
ary to a significant life or personal event must  be considered in the differential diagnosis.
Comorbidity
Comorbidity between sexual interest/arousal problems and other sexual difficulties is
extremely common. Sexual distress and dissatis faction with sex life are also highly cor-
related in women with low sexual desire. Dist ressing low desire is associated with depres-
sion, thyroid problems, anxiety, urinary incontinence, and other medical factors. Arthritis
and inflammatory or i rritable bowel disease are also associated with sexual arousal prob-


Genito-Pelvic Pain/Penetration Disorder 437
lems. Low desire appears to be comorbid wi th depression, sexual and physical abuse in
adulthood, global mental functioning, and use of alcohol.
Genito-Pelvic Pain/Penetration Disorder
Diagnostic Criteria 302.76 (F52.6)
A. Persistent or recurrent difficulties with one (or more) of the following:
1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during,
or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal
penetration.
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of a severe relationship distress (e.g., partner violence) or other signifi-
cant stressors and is not attributable to the effects of a substance/medication or an-
other medical condition.
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually active.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
Genito-pelvic pain/penetration disorder refe rs to four commonly comorbid symptom di-


mensions: 1) difficulty having in tercourse, 2) genito-pelvic pain , 3) fear of pain or vaginal
penetration, and 4) tension of the pelvic fl oor muscles (Criterion A). Because major diffi-
culty in any one of these symptom dimensions is often sufficient to cause clinically sig-
nificant distress, a diagnosis can be made on the basis of marked difficulty in only one
symptom dimension. However, a ll four symptom dimensions should be assessed even if a
diagnosis can be made on the basis of only one symptom dimension.
Marked difficulty having vaginal intercourse/penetration  (Criterion A1) can vary from a total in-
ability to experience vaginal penetration in an y situation (e.g., interc ourse, gynecological ex-
aminations, tampon insertion) to the ability to easily experience penetration in one situation
and but not in another. Although the most comm on clinical situation is when a woman is un-
able to experience intercourse or penetration with a partner, difficult ies in undergoing re-
quired gynecological examinat ions may also be present. Marked vulvovaginal or pelvic pain
during vaginal intercourse  or penetration attempts  (Criterion A2) refers to pain occurring in differ-
ent locations in the genito-pelvic area. Location of pain as well as intensity should be assessed.
Typically, pain can be characterized as superf icial (vulvovaginal or occurring during penetra-
tion) or deep (pelvic; i.e., not felt until deeper penetrat ion). 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 stim-


438 Sexual Dysfunctions
ulation); other genito-pelvic pa in may be spontaneous as well as provoked. Genito-pelvic pain
can also be usefully characterized qualitatively (e.g., “burning,” “cutting,” “shooting,” “throb-
bing”). The pain may persist for a period afte r intercourse is completed and may also occur
during urination. Typically, the pain experience d during sexual intercourse can be reproduced
during a gynecological examination.
Marked fear or anxiety about vulvov aginal 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 inte rcourse. This “normal” reaction may lead to
avoidance of sexual/intimate situations. In ot her cases, this marked fear does not appear
to be closely related to the experience of pa in but nonetheless leads to avoidance of inter-
course and vaginal penetration situations. Some have describe d 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 at-
tempted vaginal entry to “normal/voluntary” muscle guarding in response to the antici-
pated or the repeated experience of pain or to fear or anxiety. In the case of “normal/
guarding” reactions, penetratio n may be possible under circumstances of relaxation. The
characterization and assessment of pelvic floo r dysfunction is often best undertaken by a
specialist gynecologist or by a pelvic floor physical therapist.
Associated Features Supporting Diagnosis


Associated Features Supporting Diagnosis
Genito-pelvic pain/penetration di sorder is frequently associated with other sexual dysfunc-
tions, particularly reduced sexual desire and interest (female sexual interest/arousal disor-
der). Sometimes desire and interest are preserved in sexual situations that are not painful or
do not require penetration. Even when indivi duals with geni to-pelvic pain/p enetration dis-
order report sexual interest/mot ivation, there is of ten behavioral avoidance of sexual situ-
ations and opportunities. Avoidance of gynecological examinations despite medical
recommendations is also frequen t. The pattern of avoidance is si milar to that seen in phobic
disorders. It is common for women who have no t succeeded in having sexual intercourse to
come for treatment only when they wish to conceive. Many women wi th genito-pelvic pain/
penetration disorder will experience associated  relationship/marital problems; they also of-
ten report that the symptoms significantly diminish their fee lings of femininity.
In addition to the subtype “lifelong/acquired,” five factors should  be considered dur-
ing assessment and diagnosis of genito-pelvi c pain/penetration di sorder because they
may be relevant to etiology and/or treatmen t: 1) partner factors (e.g., partner’s sexual
problems, partner’s health status); 2) relationship factors (e.g., poor communication, dis-
crepancies 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, bereavemen t); 4) cultural/religious factors (e.g., inhi-


bitions related to prohibitions against sexual  activity; attitudes toward sexuality); and
5) medical factors relevant to prognosis, cour se, or treatment. Each of these factors may
contribute differently to the presenting symp toms of different women with this disorder.
There are no valid physiological measures  of any of the component symptom dimen-
sions of genito-pelvic pain/penetration diso rder. Validated psychome tric inventories may
be used to formally assess the pain and anxiety components related to genito-pelvic pain/
penetration disorder.
Prevalence


be used to formally assess the pain and anxiety components related to genito-pelvic pain/
penetration disorder.
Prevalence
The prevalence of genito-pelvic pain/penetration disorder is  unknown. Howe ver, approx-
imately 15% of women in North America report  recurrent pain during intercourse. Diffi-
culties having intercourse appear to be a freque nt referral to sexual dysfunction clinics and
to specialist clinicians.


Genito-Pelvic Pain/Penetration Disorder 439
Development and Course
The development and course of genito-pelvic pa in/penetration disorder  is unclear. Because
women generally do not seek treatment until they experience problems in sexual functioning,
it can, in general, be difficult to characterize genito-pelvic pain/penetration disorder as life-
long (primary) or acquired (secondary). Alth ough women typically come to clinical atten-
tion after the initiation of sexual activity, there are often earlier clinical signs. For example,
difficulty with or the avoidanc e of use of tampons is an important predictor of later problems.
Difficulties with vaginal penetration (inability or fear or pain) may not be obvious until sex-
ual intercourse is attempted. Ev en once intercourse is attemp ted, the frequency of attempts
may not be significant or regular. In cases where it is difficult to establish whether symptom-
atology is lifelong or acquired, it is useful to  determine the presence of any consistent period
of successful pain-, fear-, and tension-free intercourse. If the ex perience of such a period can
be established, then genito-pelvic pain/penet ration disorder can be characterized as ac-
quired. Once symptomatology is well establishe d for a period of approximately 6 months,
the probability of spontaneous and significan t symptomatic remission appears to diminish.
Complaints related to genito-pelvic pain pe ak during early adulthood and in the peri-
and postmenopausal period. Women with compla ints about difficulty having intercourse
appear to be primarily premenopausal. There may also be an increa se in genito-pelvic
pain–related symptoms in  the postpartum period.
Risk and Prognostic Factors


Risk and Prognostic Factors
Environmental. Sexual and/or physical abuse have often been cited as predictors of the
DSM-IV-defined sexual pain di sorders dyspareunia and vaginismus. This is a matter of con-
troversy in the current literature.
Genetic and physiological. Women experiencing superficial pain during sexual inter-
course often report the onset of the pain after a history of vaginal infections. Even after the in-
fections have resolved and there are no known residual physical findings, the pain persists.
Pain during tampon insertion or the inability to  insert tampons before any sexual contact has
been attempted is an importan t risk factor for genito-pelvic pain/penetration disorder.
Culture-Related Diagnostic Issues
In the past, inadequate sexual education and religious orthodoxy have often been consid-
ered to be culturally related predisposing fa ctors to the DSM-IV diagnosis of vaginismus.
This perception appears to be confirmed by recent reports from Turkey, a primarily Mus-
lim country, indicating a strikingly high prev alence for the disorder. However, most avail-
able research, although limited in scope, does  not support this notion (Lahaie et al. 2010).
Gender-Related Diagnostic Issues
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 syn-
drome in men, suggesting that men may expe rience some similar problems. The research
and clinical experience are not sufficiently de veloped yet to justify the application of this
diagnosis to men. Other specified sexual dy sfunction or unspecified sexual dysfunction
may be diagnosed in men appearing to fit this pattern.
Functional Consequences of
Genito-Pelvic Pain/Penetration Disorder


Functional Consequences of
Genito-Pelvic Pain/Penetration Disorder
Functional difficulties in ge nito-pelvic pain/pen etration disorder are often associated
with interference in relationship satisfacti on and sometimes with the ability to conceive
via penile/vaginal intercourse.


440 Sexual Dysfunctions
Differential Diagnosis
Another medical condition. In many instances, women with genito-pelvic pain/pene-
tration disorder will also be diagnosed with another medical condition (e.g., lichen scle-
rosus, endometriosis, pelvic inflammatory disease, vulvovaginal atrophy). In some cases,
treating the medical condition may alleviate the genito-pelvic pain/penetration disorder.
Much of the time, this is not the case. There are no reliable tools or diagnostic methods to
allow clinicians to know whether the medica l condition or genito-pelvic pain/penetration
disorder is primary. Often, the associated medi cal conditions are difficult to diagnose and
treat. For example, the increased incidence of postmenopausal pain during intercourse
may sometimes be attributable to vaginal dr yness or vulvova ginal atrophy as sociated with
declining estrogen levels. The relationship, however, between vulv ovaginal atrophy/dry-
ness, estrogen, and pain is not well understood.
Somatic symptom and related disorders. Some women with genito-pelvic pain/pene-
tration disorder may also be  diagnosable with somatic symptom disorder. Since both
genito-pelvic pain/penetration  disorder and the somatic symptom and related disorders
are new diagnoses, it is not yet clear whet her they can be reliably differentiated. Some
women diagnosed with genito-pelvic pain/penetration disorder will also be diagnosed
with a specific phobia.
Inadequate sexual stimuli. It is important that the clinician,  in considering differential diag-
noses, assess the adequacy of se xual stimuli within the woman’s sexual experience. Sexual sit-
uations in which there is inadequate foreplay or arousal may lead to difficulties in penetration,


uations in which there is inadequate foreplay or arousal may lead to difficulties in penetration,
pain, or avoidance. Erectile dysfunction or premature ejacul ation in the male partner may
result in difficulties with penetration. These conditions should be carefully assessed. In some
situations, a diagnosis of genito-pelvic pain/p enetration disorder may not be appropriate.
Comorbidity
Comorbidity between genito-pel vic pain/penetration disorder  and other sexual difficul-
ties appears to be common. Comorbidity with relationship distress is also common. This is
not surprising, since in Western cultures the inability to have (pain-free) intercourse with
a desired partner and the avoidance of sexual  opportunities may be either a contributing
factor to or the result of other sexual or re lationship problems. Because pelvic floor symp-
toms are implicated in the diagnosis of geni to-pelvic pain/penetrati on disorder, there is
likely to be a higher prevalence of other diso rders related to the pelvic floor or reproduc-
tive organs (e.g., interstitial cystitis, constipation, vaginal infection, endometriosis, irrita-
ble bowel syndrome).
Male Hypoactive Sexual Desire Disorder
Diagnostic Criteria 302.71 (F52.0)
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and
desire for sexual activity. The judgment of deficiency is made by the clinician, taking
into account factors that affect sexual functioning, such as age and general and socio-
cultural contexts of the individual’s life.
B. The symptoms in Criterion A have persist ed for a minimum duration of approximately
6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a


D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of severe relationship distress or other significant stressors and is not at-
tributable to thes effects of a substance/medication or another medical condition.


Male Hypoactive Sexual Desire Disorder 441
Specify whether:
Lifelong:  The disturbance has been present since the individual became sexually
active.
Acquired:  The disturbance began after a period of relatively normal sexual function.
Specify whether:
Generalized:  Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:
Mild:  Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress ov er the symptoms in Criterion A.
Severe:  Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnostic Features
When an assessment for male hypoactive sexu al desire disorder is being made, inter-
personal context must be take n into account. A “desire discrepancy,” in which a man has
lower desire for sexual activity than his partne r, is not sufficient to diagnose male hypo-
active sexual desire d isorder. Both low/absent desire fo r sex and deficient/absent sexual
thoughts or fantasies are required for a diag nosis 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 though ts or fantasies must be per-
sistent or recurrent and must occur for a mi nimum duration of approximately 6 months.
The inclusion of this duration criterion is me ant 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 ter-
minating the relationship). The introduction of “approximately” in Criterion B allows for
clinician judgment in cases in which sympto m duration does not meet the recommended
6-month threshold.


6-month threshold.
Associated Features Supporting Diagnosis
Male hypoactive sexual desire disorder is some times associated with erectile and/or ejac-
ulatory 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 minima lly receptive to a part-
ner’s attempt to initiate. Sexual activities (e.g ., masturbation or part nered sexual activity)
may sometimes occur even in the presence of low sexual desire. Relationship-specific pref-
erences regarding patterns of sexual initiation  must be taken into account when making a
diagnosis of male hypoactive sexual desire di sorder. Although men are more likely to ini-
tiate sexual activity, and thus low desire may be characterized by a pattern of non-initiation,
many men may prefer to have their partner init iate sexual activity. In such situations, the
man’s lack of receptivity to a partner’s initiati on should be considered  when evaluating low
desire.
In addition to the subtypes “lifelong/acquired” and “generalized/situational,” the fol-
lowing five factors must be considered duri ng assessment and diagnosis of male hypo-
active sexual desire disorder given that they may be relevant to et iology and/or treatment:
1) partner factors (e.g., partne r’s sexual problems, partner’s health status); 2) relationship
factors (e.g., poor communication , discrepancies in desire for sexual activity); 3) individ-
ual vulnerability factors (e.g., po or body image, history of se xual or emotional abuse), psy-
chiatric 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 fact ors relevant to prognosis, course, or treat-


442 Sexual Dysfunctions
ment. Each of these factors may contribute differently to the presenting symptoms of dif-
ferent men with this disorder.
Prevalence
The prevalence of male hypoactive sexual de sire disorder varies depending on country of
origin and method of assess ment. 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%).
Development and Course
By definition, lifelong male hypoactive sexual desire disorder indicates that low or no sex-
ual desire has always been present, whereas th e acquired subtype would be assigned if the
man’s low desire developed afte r a period of normal sexual desire. There is a requirement
that low desire persist for approximately 6 months or more; thus, short-term changes in
sexual desire should not be diagnosed as  male hypoactive se xual desire disorder.
There is a normative age-related decline in se xual desire. Like women, men identify a
variety of triggers for their sexual desire, and they describe a wide  range of reasons that
they choose to engage in sexual activity. Although erotic visual cues may be more potent
elicitors of desire in younger men, the potenc y of sexual cues may decrease with age and
must be considered when evaluating men for hypoactive sexual desire disorder.
Risk and Prognostic Factors
Temperamental. Mood and anxiety symptoms appear to be strong predictors of low de-
sire in men. Up to half of men with a past  history of psychiatric symptoms may have mod-
erate or severe loss of desire, compared with only 15% of those without such a history. A


man’s feelings about himself, his perception of his partner’s sexual desire toward him,
feelings of being emotionally connected, and contextual vari ables may all negatively (as
well as positively) affect sexual desire.
Environmental. Alcohol use may increase the occurr ence of low desire. Among gay men,
self-directed homophobia, interp ersonal problems, attitudes, lack of adequate sex educa-
tion, and trauma resulting from early life ex periences must be taken into account in ex-
plaining the low desire. Social and cultural co ntextual factors should  also be considered.
Genetic and physiological. Endocrine disorders such as hyperprolactinemia signifi-
cantly affect sexual desire in me n. Age is a significant risk fact or for low desire in men. It is
unclear whether or not men with low desire a lso have abnormally low levels of testoster-
one; however, among hypogonadal men, low desire is common. There also may be a crit-
ical threshold below which testosterone will af fect sexual desire in men and above which
there is little effect of test osterone on men’s desire.
Culture-Related Diagnostic Issues
There is marked variability in prevalence rate s of low desire across cultures, ranging from
12.5% in Northern European me n 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 lo w desire. Guilt about se x may mediate this as-
sociation between East  Asian ethnicity and sexual desire in men.
Gender-Related Diagnostic Issues
In contrast to the classification of sexual d isorders in women, desire  and arousal disorders


In contrast to the classification of sexual d isorders in women, desire  and arousal disorders
have been retained as separate constructs in men. Despite some similarities in the experi-