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-


Premature (Early) Ejaculation 443
ence of desire across men and women, and the fact that desire fluctuates over time and is
dependent on contextual factors, men do repo rt a significantly higher intensity and fre-
quency of sexual desire compared with women.
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 explai n the lack of sexual desire. If  the lack of desire is better
explained by another mental disorder, then a diagnosis of male hypoactive sexual desire
disorder would not be made.
Substance/medication use. Substance/medication use may explain the lack of sexual
desire.
Another medical condition. If the low/absent desire and de ficient/absent erotic thoughts
or fantasies are better explained by the effect s of another medical co ndition (e.g., hypogo-
nadism, diabetes mellitus, thyroid dysfunction, central nervous system disease), then a di-
agnosis of male hypoactive sexual desire disorder w ould not be made.
Interpersonal factors. If interpersonal or significant co ntextual factors, such as severe
relationship distress or other sig nificant stressors, are associated with the loss of desire in
the man, then a diagnosis of male hypoactive sexual desire disorder would not be made.
Other sexual dysfunctions. The presence of another sexual dysfunction does not rule out a
diagnosis of male hypoactive sexu al desire disorder; there is some evidence that up to one-half
of men with low sexual desire also have erecti le difficulties, and slightly fewer may also have
early ejaculation difficulties. If the man’s low desire is explained by self-identification as an


early ejaculation difficulties. If the man’s low desire is explained by self-identification as an
asexual, then a diagnosis of male hypoac tive sexual desire disorder is not made.
Comorbidity
Depression and other ment al disorders, as well as endocr inological factors, are often co-
morbid with male hypoacti ve sexual desire disorder.
Premature (Early) Ejaculation
Diagnostic Criteria 302.75 (F52.4)
A. A persistent or recurrent pattern of ejacul ation occurring during partnered sexual activ-
ity within approximately 1 minute following  vaginal penetration and before the individ-
ual wishes it.
Note: Although the diagnosis of premature (early ) ejaculation may be applied to indi-
viduals engaged in nonvaginal sexual activities, specific duration criteria have not been
established for these activities.
B. The symptom in Criterion A must have been present for at least 6 months and must be
experienced on almost all or all (approximately 75%–100%) occasions of sexual activ-
ity (in identified situational contexts or, if generalized, in all contexts).
C. The symptom in Criterion A causes 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.
Acquired:  The disturbance began after a period of relatively normal sexual function.


444 Sexual Dysfunctions
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:  Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal
penetration.
Moderate: Ejaculation occurring within approximately 15–30 seconds of vaginal pen-
etration.
Severe:  Ejaculation occurring prior to sexual activity, at the start of sexual activity, or
within approximately 15 seconds of vaginal penetration.
Diagnostic Features
Premature (early) ejaculation is manifested by ej aculation that occurs prior to or shortly af-
ter vaginal penetration, operationalized by an individual’s estimate of ejaculatory latency
(i.e., elapsed time before ej aculation) after vaginal penetr ation. Estimated and measured
intravaginal ejaculatory latencies are highly co rrelated as long as the ejaculatory latency is
of short duration; therefore, self-reported esti mates of ejaculatory latency are sufficient for
diagnostic purposes. A 60-second intravaginal ejaculatory latency time is an appropriate
cutoff for the diagnosis of lifelong prematur e (early) ejaculation in heterosexual men.
There are insufficient data to determine if th is duration criterion can be applied to ac-
quired premature (early) ejaculation. The du rational definition may apply to males of
varying sexual orientations, since ejaculatory latencies appear to be  similar across men of
different sexual orientations and ac ross different sexual activities.
Associated Features Supporting Diagnosis
Many males with premature (early) ejaculation complain of a sense of lack of control over
ejaculation and report apprehension about thei r anticipated inability to delay ejaculation
on future sexual encounters.
The following factors may be relevant in the evaluation of any sexual dysfunction:


The following factors may be relevant in the evaluation of any sexual dysfunction:
1) partner factors (e.g., partner’s sexual problems, partner’s health status); 2) relationship fac-
tors (e.g., poor communication, discrepancies in  desire for sexual activity); 3) individual
vulnerability factors (e.g.,  poor body image, history of sexual or emotional abuse), psychiatric
comorbidity (e.g., depression, anxiety), and stressors (e.g., job loss, bereavement); 4) cultural/
religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes
toward sexuality); and 5) medical factors relevant to prognosis, course, or treatment.
Prevalence
Estimates of the prevalence of premature (ear ly) ejaculation vary widely depending on the
definition utilized. Internationally, more than 20%–30% of men ages 18–70 years report
concern about how rapidly they ejaculate. Wi th the new definition of premature (early)
ejaculation (i.e., ejaculation occurring within approximately 1 minute  of vaginal penetra-
tion), only 1%–3% of men woul d be diagnosed with the disorder. Prevalence of premature
(early) ejaculation may increase with age.
Development and Course
By definition, lifelong premature (early) ejaculat ion starts during a male’s initial sexual ex-
periences and persists thereafter. Some men may experience prematur e (early) ejaculation
during their initial sexual encoun ters but gain ejaculatory contro l over time. It is the persis-
tence of ejaculatory problems fo r longer than 6 months that determines the diagnosis of pre-
mature (early) ejaculation. In contrast, some  men develop the disorder after a period of


Premature (Early) Ejaculation 445
having a normal ejaculat ory latency, known as acquired premature (early) ejaculation.  There is
far less known about acquired premature (early) ejaculation than about lifelong premature
(early) ejaculation. The acquired form likely has a later onset, usually appearing during or af-
ter the fourth decade of life. Lifelong is relative ly stable throughout life.  Little is known about
the course of acquired prematur e (early) ejaculation. Reversal of medical conditions such as
hyperthyroidism and prostatitis appears to rest ore ejaculatory latencies to baseline values.
Lifelong premature (early) ejac ulation begins with early sexual experiences and persists
throughout an individual’s life. In approxim ately 20% of men with premature (early) ejacu-
lation, ejaculatory latencies decrease further wi th age. Age and relationship length have been
found to be negatively associated with pr evalence of prematur e (early) ejaculation.
Risk and Prognostic Factors
Temperamental. Premature (early) ejaculation may be more common in men with anx-
iety disorders, especially social  anxiety disorder (social phobia).
Genetic and physiological. There is a moderate genetic contribution to lifelong prema-
ture (early) ejaculation. Premature (early) ejaculation may be associated with dopamine
transporter gene polymorphism or serotonin transporter gene polymorphism. Thyroid
disease, prostatitis, and drug withdrawal are associated with acquired premature (early)
ejaculation. Positron emission tomography measu res of regional cerebral blood flow dur-
ing ejaculation have shown primary activation in the mesocephalic tr ansition zone, includ-
ing the ventral tegmental area.
Culture-Related Diagnostic Issues


ing the ventral tegmental area.
Culture-Related Diagnostic Issues
Perception of what constitutes a normal ejac ulatory latency is different in many cultures.
Measured ejaculatory latencies may differ in so me countries. Such differences may be ex-
plained by cultural or religious factors as well as genetic differences between populations.
Gender-Related Diagnostic Issues
Premature (early) ejaculation is a sexual disorder in males. Males and their sexual partners
may differ in their perception of what consti tutes an acceptable ejaculatory latency. There
may be increasing concerns in females about early ejaculation in their sexual partners,
which may be a reflection of changing societal  attitudes concerning female sexual activity.
Diagnostic Markers
Ejaculatory latency is usually mo nitored in research settings by  the sexual partner utilizing
a timing device (e.g., stopwatch), though this is  not ideal in real-life sexual situations. For
vaginal intercourse, the time between intravag inal penetration and ejaculation is measured.
Functional Consequences of
Premature (Early) Ejaculation
A pattern of premature (early) ejaculation may be associated with decreased self-esteem, a
sense of lack of control, and adverse conseq uences for partner relationships. It may also
cause personal distress in the sexual partner and decreased sexual satisfaction in the sexual
partner. Ejaculation prior to penetration may be  associated with diffi culties in conception.
Differential Diagnosis
Substance/medication-induced sexual dysfunction. When problems with premature
ejaculation are due exclusively to substance use, intoxicati on, or withdrawal, substance/
medication-induced sexual dysfunction should be diagnosed.


446 Sexual Dysfunctions
Ejaculatory concerns that do not meet diagnostic criteria. It is necessary to identify
males with normal ejaculatory latencies who de sire longer ejaculatory latencies and males
who have episodic premature (early) ejaculat ion (e.g., during the fi rst sexual encounter
with a new partner when a short ejaculatory la tency may be common or normative). Neither
of these situations would lead to a diagnosis of premature (early) ejaculation, even though
these situations may be d istressing to some males.
Comorbidity
Premature (early) ejaculation may be associated  with erectile problems. In many cases, it
may be difficult to determin e which difficulty preceded the other. Lifelong premature
(early) ejaculation may be associated with ce rtain anxiety disorders.  Acquired premature
(early) ejaculation may be associated with pros tatitis, thyroid disease, or drug withdrawal
(e.g., during opioid withdrawal).
Substance/Medication-Induced
 Sexual Dysfunction
Diagnostic Criteria
A. A clinically significant disturbance in sexual function is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.
C. The disturbance is not better explained by a sexual dysfunction that is not substance/
medication-induced. Such evidence of an independent sexual dysfunction could in-
clude the following:
The symptoms precede the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence suggesting the


acute withdrawal or severe intoxication; or there is other evidence suggesting the
existence of an independent non-substance/medication-induced sexual dysfunc-
tion (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress in the individual.
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced sexual dysfunctions are indicated in the table below. Note that the ICD-10-CM
code depends on whether or not there is a comorbid substance use disorder present for the
same class of substance. If a mild substance use disorder is comorbid with the substance-
induced sexual dysfunction, the 4th position character is “1,” and the clinician should record
“mild [substance] use disorder” before the substance-induced sexual dysfunction (e.g., “mild
cocaine use disorder with cocaine-induced sexual dysfunction”). If a moderate or severe
substance use disorder is comorbid with the substance-induced sexual dysfunction, the 4th
position character is “2,” and the clinician sh ould record “moderate [substance] use disorder”
or “severe [substance] use disorder,” depending on the severity of the comorbid substance


Substance/Medication-Induced Sexual Dysfunction 447
use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy
use of the substance), then the 4th position character is “9,” and the clinician should record
only the substance-induced sexual dysfunction.
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):
With onset during intoxication:  If the criteria are met for intoxication with the sub-
stance and the symptoms develop during intoxication.
With onset during withdrawal:  If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use:  Symptoms may appear either at initiation of medi-
cation or after a modification or change in use.
Specify current severity:
Mild:  Occurs on 25%–50% of occasions of sexual activity.
Moderate: Occurs on 50%–75% of occasions of sexual activity.
Severe:  Occurs on 75% or more of occasions of sexual activity.
Recording Procedures
ICD-9-CM. The name of the substance/medication-induced sexual dysfunction begins
with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the
sexual dysfunction. The diagnost ic code is selected from the table included in the criteria
set, which is based on the drug class. For substa nces that do not fit into any of the classes
(e.g., fluoxetine), the code for “other substa nce” should be used; and in cases in which a
substance is judged to be an etiological factor but the specific class of substance is un-
known, the category “unknown substance” should be used.


known, the category “unknown substance” should be used.
The name of the disorder is followed by the sp ecification of onset (i.e., onset during in-
toxication, onset during withdrawal, with onse t after medication use), followed by the se-
verity specifier (e.g., mild, moderate, severe ). Unlike the recording procedures for ICD-10-
CM, which combine the substance-induced disord er and substance use disorder into a sin-
gle code, for ICD-9-CM a separate diagnostic code is given for the su bstance use disorder.
For example, in the case of erectile dysfun ction occurring during intoxication in a man
with a severe alcohol use diso rder, the diagnosis is 291.89 al cohol-induced sexual dysfunc-
tion, with onset during intoxication, modera te. An additional diagnosis of 303.90 severe
alcohol use disorder is also given. When more  than one substance is judged to play a sig-ICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.89 F10.181 F10.281 F10.981
Opioid 292.89 F11.181 F11.281 F11.981
Sedative, hypnotic, or
anxiolytic292.89 F13.181 F13.281 F13.981
Amphetamine (or other
stimulant)292.89 F15.181 F15.281 F15.981
Cocaine 292.89 F14.181 F14.281 F14.981
Other (or unknown) substance 292.89 F19.181 F19.281 F19.981


448 Sexual Dysfunctions
nificant role in the development of the sexual dysfunction, each should be listed separately
(e.g., 292.89 cocaine-induced sexual dysfunctio n with onset during intoxication, moderate;
292.89 fluoxetine-induced sexu al dysfunction, with onset after medication use).
ICD-10-CM. The name of the substance/medication-induced sexual dysfunction begins
with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the
sexual dysfunction. The diagnost ic code is selected from the table included in the criteria
set, which is based on the drug class and presence or absence of a comorbid substance use
disorder. For substances that do not fit into any of the classes (e.g., fluoxetine), the code for
“other substance” should be used; and in cases in which a substance is judged to be an eti-
ological factor but the specific class of subs tance is unknown, the category “unknown sub-
stance” 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
sexual dysfunction, followed by the specification of onset (i.e., onset during intoxication,
onset during withdrawal, with onset after medi cation use), followed by the severity spec-
ifier (e.g., mild, moderate, severe). For example,  in the case of erectile dysfunction occur-
ring during intoxication in a man with a severe alcohol use disorder, the diagnosis is
F10.281 moderate alcohol use disorder with alcohol-induced se xual dysfunction, with on-
set during intoxication, moderate. A separate diagnosis of the comorbid severe alcohol use
disorder is not given. If the substance-induced sexual dysfunction occurs without a co-


disorder is not given. If the substance-induced sexual dysfunction occurs without a co-
morbid substance use disorder (e.g., after a one-time heavy use of the substance), no ac-
companying substance use disorder is note d (e.g., F15.981 amphetamine-induced sexual
dysfunction, with onset during intoxication).  When more than one substance is judged to
play a significant role in the development of the sexual dysfunction, each should be listed
separately (e.g., F14.181 mild cocaine use di sorder with cocaine-induced sexual dysfunc-
tion, with onset during intoxication, mode rate; F19.981 fluoxetine-induced sexual dys-
function, with onset after medication use, moderate).
Diagnostic Features
The major feature is a disturbance in sexual function that has a temporal relationship with
substance/medication initiation, dose increa se, or substance/medication discontinuation.
Associated Features Supporting Diagnosis
Sexual dysfunctions can occur in association wi th intoxication with the following classes of
substances: alcohol; opioids; sedatives, hypnotic s, or anxiolytics; stimulants (including co-
caine); and other (or unknown) substances. Sexual dysfunctions can occur in association
with withdrawal from the following classes of substances: alcohol; opioids; sedatives, hyp-
notics, or anxiolytics; and other (or unknown)  substances. Medications that can induce sex-
ual dysfunctions include antidepressants, an tipsychotics, and horm onal contraceptives.
The most commonly reported side effect of antidepressant drugs is difficulty with or-
gasm or ejaculation. Problems with desire and erection are less frequent. Approximately
30% of sexual complaints are clinically sign ificant. Certain agents, such as bupropion and


mirtazapine, appear not to be associated with sexual side effects.
The sexual problems associated with anti psychotic drugs, including problems with
sexual desire, erection, lubrication, ejaculation, or orgasm, have occurred with typical as
well as atypical agents. However, problems are less common with prolactin-sparing anti-
psychotics than with agents that cause significant prolactin elevation.
Although the effects of mood stabilizers on se xual function are unclear, it is possible
that lithium and anticonvulsants, with the poss ible exception of lamotrigine, have adverse


Although the effects of mood stabilizers on se xual function are unclear, it is possible
that lithium and anticonvulsants, with the poss ible exception of lamotrigine, have adverse
effects on sexual desire. Problems with orgasm  may occur with gabape ntin. Similarly, there
may be a higher prevalence of erectile and orgasmic problems associ ated with benzodiaz-
epines. There have not been such reports with buspirone.


Substance/Medication-Induced Sexual Dysfunction 449
Many nonpsychiatric medications, such as ca rdiovascular, cytotoxic, gastrointestinal,
and hormonal agents, are associated with distur bances in sexual function. Illicit substance
use is associated with decreased sexual desire, erectile dysfunction, and difficulty reach-
ing orgasm. Sexual dysfunctions are also seen  in individuals receiving methadone but are
seldom reported by patients receiving buprenorphine. Chro nic alcohol abuse and chronic
nicotine abuse are associated  with erectile problems.
Prevalence
The prevalence and the incidence of substa nce/medication-induced sexual dysfunction
are unclear, likely because of  underreporting of treatment-em ergent sexual side effects.
Data on substance/medication-induced sexual  dysfunction typically concern the effects of
antidepressant drugs. The prevalence of an tidepressant-induced sexual dysfunction var-
ies in part depending on the specific agent.  Approximately 25%–80% of individuals taking
monoamine oxidase inhibitors, tricyclic anti depressants, serotone rgic antidepressants,
and combined serotonergic-adrenergic antidepr essants report sexual side effects. There
are differences in the incidence of sexual si de effects between some  serotonergic and com-
bined adrenergic-serotonergic antidepressants, although it is unclear if these differences
are clinically significant.
Approximately 50% of individuals taking antipsychotic medications will experience
adverse sexual side e ffects, including problems with se xual desire, erection, lubrication,
ejaculation, or orgasm. The incidence of thes e side effects among different antipsychotic
agents is unclear.
Exact prevalence and incidence of sexual dysfunctions among users of nonpsychiatric
medications such as cardiovascular, cytotoxic, gastrointestinal, and hormonal agents are


medications such as cardiovascular, cytotoxic, gastrointestinal, and hormonal agents are
unknown. Elevated rates of sexual dysfunction have been reported with methadone or
high-dose opioid drugs for pain. There are incr eased rates of decrease d sexual desire, erec-
tile dysfunction, and difficulty reaching org asm associated with illicit substance use. The
prevalence of sexual problems appears related to chronic drug abuse and appears higher
in individuals who abuse heroin (approximately 60%–70%) than in individuals who abuse
amphetamines or 3,4-methylenedioxymethamphe tamine (i.e., MDMA, ecstasy). Elevated
rates of sexual dysfunction are also seen in  individuals receiving methadone but are sel-
dom reported by patients receiving bupren orphine. Chronic alcohol abuse and chronic
nicotine abuse are related to higher rates of erectile problems.
Development and Course
The onset of antidepressant-induced sexual dy sfunction may be as early as 8 days after the
agent is first taken. Approximately 30% of indi viduals with mild to moderate orgasm de-
lay will experience spontaneous remission of the dysfunction within 6 months. In some
cases, serotonin reuptake inhibitor–induce d sexual dysfunction may persist after the
agent is discontinued. The time to onset of sexual dysfunctio n after initiation of antipsy-
chotic drugs or drugs of abuse is unknown. It  is probable that the adverse effects of nico-
tine and alcohol may not appear until after ye ars of use. Premature (early) ejaculation can
sometimes occur after cessation of opioid use. There is some evidence that disturbances in
sexual function related to substance/medication use increase with age.
Culture-Related Diagnostic Issues
There may be an interaction among cultural fa ctors, the influence of medications on sexual


There may be an interaction among cultural fa ctors, the influence of medications on sexual
functioning, and the response of the individual to those changes.
Gender-Related Diagnostic Issues
Some gender differences in sexual side effects may exist.


450 Sexual Dysfunctions
Functional Consequences of
Substance/Medication-Indu ced Sexual Dysfunction
Medication-induced sexual dysfunction ma y result in medication noncompliance.
Differential Diagnosis
Non-substance/medication-induced sexual dysfunctions. Many mental conditions, such
as depressive, bipolar, anxiet y, and psychotic disorders, ar e associated with disturbances
of sexual function. Thus, differentiating a substance/medication-induced sexual dys-
function from a manifestation of the underlying  mental disorder can be  quite difficult. The
diagnosis is usually established if a close re lationship between substance/medication ini-
tiation or discontinuation is observed. A clear diagnosis can be established if the problem
occurs after substance/medication initiation, dissipates with substance/medication dis-
continuation, and recurs with introduction of the same agent. Most substance/medication-in-
duced side effects occur shortly after initiation  or discontinuation. Sexual side effects that
only occur after chronic use of  a substance/medication may be extremely difficult to di-
agnose with certainty.
Other Specified Sexual Dysfunction
302.79 (F52.8)
This category applies to presentations in which symptoms characteristic of a sexual dys-
function that cause clinically significant di stress in the individual predominate but do not
meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class.
The other specified sexual dysfunction category is used in situations in which the clinician
chooses to communicate the specific reason that the presentation does not meet the cri-
teria for any specific sexual dysfunction. This is done by recording “other specified sexual
dysfunction” followed by the specific reason (e.g., “sexual aversion”).
Unspecified Sexual Dysfunction
302.70 (F52.9)
This category applies to presentations in which symptoms characteristic of a sexual dys-


This category applies to presentations in which symptoms characteristic of a sexual dys-
function that cause clinically significant di stress in the individual predominate but do not
meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class.
The unspecified sexual dysfunction category is used in situations in which the clinician
chooses not to specify the reason that the criteria are not met for a specific sexual dys-
function, and includes presentations for which there is insufficient information to make a
more specific diagnosis.


451 Gender
 Dysphoria
In this chapter,  there is one overarching diagnosis of gender dysphoria, with sepa-
rate developmentally appropriate criteria sets  for children and for adolescents and adults.
The area of sex and gender is highly controve rsial and has led to a proliferation of terms
whose meanings vary over time and within and between disciplines. An additional source
of confusion is that in English “sex” connotes  both male/female and se xuality. This chapter
employs constructs and terms as they are wide ly used by clinicians from various disci-
plines with specialization in this area. In this chapter, sex and sexual  refer to the biological
indicators of male and female (understood in  the context of reproductive capacity), such
as in sex chromosomes, gonads, sex hormon es, and nonambiguous internal and external
genitalia. Disorders of sex deve lopment denote condit ions of inborn somatic deviations of
the reproductive tract from the norm and/or discrepancies among the biological indica-
tors of male and female. Cross-sex  hormone treatment denotes the use of feminizing hor-
mones in an individual assigned male at birth based on traditional biological indicators or
the use of masculinizing hormones in an individual assigned female at birth.
The need to introduce the term gender  arose with the realization that for individuals
with conflicting or ambiguous biological indicato rs of sex (i.e., “intersex”), the lived role in
society and/or the identification as male or female could not be uniformly associated with
or predicted from the biological indicators and, later, that some individuals develop an
identity as female or male at variance with their uniform set of classical biological indica-
tors. Thus, gender is used to denote the public (and usually legally recognized) lived role as


boy or girl, man or woman, but, in contrast to  certain social construc tionist theories, biolog-
ical factors are seen as contributing, in intera ction with social and psychological factors, to
gender development. Gender assignment  refers to the initial assignment as male or female.
This occurs usually at birth and, thereby, yields the “natal gender.” Gender-atypical  refers to
somatic features or behaviors th at are not typical (in a statisti cal sense) of individuals with
the same assigned gender in a given so ciety and historical era; for behavior, gender-noncon-
forming  is an alternative descriptive term. Gender reassignment  denotes an official (and usu-
ally legal) change of gender. Gender identity  is a category of social identity and refers to an
individual’s identification as male, female, or, occasionally, some ca tegory other than male
or female. Gender dysphoria  as a general descriptive term refers to an individual’s affective/
cognitive discontent with the assigned gender  but is more specific ally defined when used
as a diagnostic category. Transgender  refers to the broad spectrum of individuals who tran-
siently or persistently identify with a gender different from their natal gender. Transsexual
denotes an individual who seeks,  or has undergone, a social transition from male to female
or female to male, which in many, but not all,  cases also involves a somatic transition by
cross-sex hormone treatment and genital surgery ( sex reassignment surgery).
Gender dysphoria  refers to the distress that ma y accompany the incongruence between
one’s experienced or expressed gender and one’s assigned gender. Although not all indi-
viduals will experience distress as a result of such incongruence , many are distressed if the


desired physical interventions by means of hormones and/or surg ery are not avail able.
The cu rrent term is more descriptive than the previous DSM-IV term gender identity disor-
der and focuses on dysphoria as the clin ical problem, not identity per se.


452 Gender Dysphoria
Gender Dysphoria
Diagnostic Criteria
Gender Dysphoria in Children 302.6 (F64.2)
A. A marked incongruence between one’s experienced/expressed gender and assigned
gender, of at least 6 months’ duration, as manifested by at least six of the following
(one of which must be Criterion A1):
1. A strong desire to be of the other gender or an insistence that one is the other gen-
der (or some alternative gender different from one’s assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or simulating fe-
male attire; or in girls (assigned gender), a strong preference for wearing only typ-
ical masculine clothing and a strong resistance to the wearing of typical feminine
clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or  activities stereotypically used or en-
gaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine toys, games,
and activities and a strong avoidance of rough-and-tumble play; or in girls (as-
signed gender), a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match
one’s experienced gender.
B. The condition is associated with clinically significant distress or impairment in social,
school, or other important areas of functioning.
Specify if:
With a disorder of sex development  (e.g., a congenital adrenogenital disorder such


as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensi-
tivity syndrome).
Coding note:  Code the disorder of sex development as well as gender dysphoria.
Gender Dysphoria in Adolescents and Adults 302.85 (F64.1)
A. A marked incongruence between one’s experienced/expressed gender and assigned
gender, of at least 6 months’ duration, as manifested by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and pri-
mary and/or secondary sex characteristics (or in young adolescents, the antici-
pated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics be-
cause of a marked incongruence with one’s experienced/expressed gender (or in
young adolescents, a desire to prevent the development of the anticipated second-
ary sex characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other
gender.
4. A strong desire to be of the other gender (or some alternative gender different from
one’s assigned gender).
5. A strong desire to be treated as the ot her gender (or some alternative gender dif-
ferent from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gen-
der (or some alternative gender different from one’s assigned gender).


Gender Dysphoria 453
B. The condition is associated with clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
With a disorder of sex development  (e.g., a congenital adrenogenital disorder such
as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensi-
tivity syndrome).
Coding note:  Code the disorder of sex development as well as gender dysphoria.
Specify if:
Posttransition:  The individual has transitioned to full-time living in the desired gender
(with or without legalization of gender change) and has undergone (or is preparing to
have) at least one cross-sex medical proc edure or treatment regimen—namely, regu-
lar cross-sex hormone treatment or gender reassignment surgery confirming the desired
gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in
a natal female).
Specifiers
The posttransition specifier may be used in th e context of continuing  treatment procedures
that serve to support the new gender assignment.
Diagnostic Features
Individuals with gender dysphoria have a ma rked incongruence between the gender they
have been assigned to (usually  at birth, referred to as natal gender) and their experienced/
expressed gender. This discrepancy is the core componen t of the diagnosis. There must
also be evidence of distress about this inco ngruence. Experienced gender may include al-
ternative gender identities beyond binary stereotypes. Consequently, the distress is not
limited to a desire to simply be of the other gender, but may incl ude a desire to be of an al-


ternative gender, provided that it differs from the individual’s assigned gender.
Gender dysphoria manifests itself differently in different age groups. Prepubertal natal
girls with gender dysphoria may express the wish  to be a boy, assert they are a boy, or as-
sert they will grow up to be a man. They prefer boys’ clothing and hairstyles, are often
perceived by strangers as boys, and may ask to be called by a boy’s na me. Usually, they dis-
play intense negative reactions to parental attempts to have them wear dresses or other
feminine attire. Some may refuse to attend sc hool or social events where such clothes are
required. These girls may demonstrate marked cr oss-gender identification in role-playing,
dreams, and fantasies. Contac t sports, rough-and-tumble pl ay, traditional boyhood games,
and boys as playmates are most often preferred. They show lit tle interest in stereotypically
feminine toys (e.g., dolls) or activities (e.g.,  feminine dress-up or role-play). Occasionally,
they refuse to urinate in a sitting position. Some natal girls may express a desire to have a
penis or claim to have a penis or that they will  grow one when older. They may also state that
they do not want to deve lop breasts or menstruate.
Prepubertal natal boys with gender dysphoria may express the wish to be a girl or as-
sert they are a girl or that they will grow up to be a woman. They have a preference for
dressing in girls’ or women’s clothes or ma y improvise clothing from available materials
(e.g., using towels, aprons, and scarves for lo ng hair or skirts). These children may role-


play female figures (e.g., play ing “mother”) and often are intensely interested in female
fantasy figures. Traditional feminine activities, stereotypical games, and pastimes (e.g.,
“playing house”; drawing feminine pictures; watc hing television or videos of favorite fe-
male characters) are most often preferred. Stereotypical female-type dolls (e.g., Barbie) are
often favorite toys, and girls are their prefer red playmates. They avoid rough-and-tumble
play and competitive sports and have little inte rest in stereotypically masculine toys (e.g.,
cars, trucks). Some may pretend not to have a penis and insist on sitting to urinate. More


454 Gender Dysphoria
rarely, they may state that they find their penis or testes disgusting, that they wish them re-
moved, or that they have, or wish to have, a vagina.
In young adolescents with gender dysphoria,  clinical features may resemble those of
children or adults with the co ndition, depending on develo pmental level. As secondary
sex characteristics of young adolescents are no t yet fully developed, these individuals may
not state dislike of them, but they are co ncerned about imminent physical changes.
In adults with gender dysphoria, the di screpancy between experienced gender and
physical sex characteristics is often, but not always, accompanied by a desire to be rid of
primary and/or secondary sex ch aracteristics and/or a strong desire to acquire some pri-
mary and/or secondary sex characteristics of  the other gender. To varying degrees, adults
with gender dysphoria may ad opt the behavior, clothing, and mannerisms of the experi-
enced gender. They feel uncomfortable being re garded by others, or functioning in soci-
ety, as members of their assigned gender. Some adults may have a strong desire to be of a
different gender and treated as such, and they may have an inner certainty to feel and re-
spond as the experienced gender without seek ing medical treatment to alter body char-
acteristics. They may find other ways to resolve the incongruence between experienced/
expressed and assigned gender by partially livin g in the desired role or by adopting a gen-
der role neither conventionally male nor conventionally female.
Associated Features Supporting Diagnosis
When visible signs of puberty develop, natal bo ys may shave their legs at the first signs of
hair growth. They sometimes bind their genitals to make erections less visible. Girls may


hair growth. They sometimes bind their genitals to make erections less visible. Girls may
bind their breasts, walk with a stoop, or use lo ose sweaters to make breasts less visible. In-
creasingly, adolescents request, or may obta in without medical prescription and supervi-
sion, hormonal suppressors (“blockers”) of gonadal steroids (e.g., gonadotropin-releasing
hormone [GnRH] analog, spironolactone). Clinically refe rred adolescents often want hor-
mone treatment and many also wish for gender reassignment surgery. Adolescents living in
an accepting environment may open ly express the desire to be and be treated as the experi-
enced gender and dress partly or completely as the experienced gender, have a hairstyle typ-
ical of the experienced gender, preferentially s eek friendships with peer s of the other gender,
and/or adopt a new first name consistent with the experienced gender. Older adolescents,
when sexually active, usually do  not show or allow partners to touch their sexual organs. For
adults with an aversion toward their genitals, sexual activity is constrained by the preference
that their genitals not be seen  or touched by their partners. Some adults may seek hormone
treatment (sometimes without medical prescrip tion and supervision) and gender reassign-
ment surgery. Others are satisfied with either hormone treatment or surgery alone.
Adolescents and adults with gender dysphoria before gender reassignment are at in-
creased risk for suicidal ideation, suicide a ttempts, and suicides. After gender reassign-
ment, adjustment may vary, an d suicide risk may persist.
Prevalence
For natal adult males, prevalence ranges from 0.005% to 0.014%, and for natal females,


from 0.002% to 0.003%. Since not all adults seeking hormone treatment and surgical reas-
signment attend specialty clinics, these rate s are likely modest underestimates. Sex differ-
ences in rate of referrals to specialty clinics vary by age group. In children, sex ratios of
natal boys to girls range from 2:1 to 4.5:1. In adolescents, the sex ratio is close to parity; in
adults, the sex ratio favors natal males, with ratios ranging from 1:1 to 6.1:1. In two coun-
tries, the sex ratio appears to favor nata l females (Japan: 2.2:1; Poland: 3.4:1).
Development and Course


tries, the sex ratio appears to favor nata l females (Japan: 2.2:1; Poland: 3.4:1).
Development and Course
Because expression of gender dysphoria varies wi th age, there are separate criteria sets for
children versus adolescents and adults. Criter ia for children are defined in a more con-


Gender Dysphoria 455
crete, behavioral manner than those for adolescents and adults. Many of the core criteria
draw on well-documented behavioral gender differences between typically developing
boys and girls. Young children are less likely than older children, ad olescents, and adults
to express extreme and persistent anatomic dysphoria. In adolescents and adults, incon-
gruence between experienced gender and somati c sex is a central feature of the diagnosis.
Factors related to distress and impairment al so vary with age. A very young child may
show signs of distress (e.g., intense crying) on ly when parents tell the child that he or she
is “really” not a member of the other gender but only “desires” to be. Distress may not be
manifest in social environments supportive of the child’s desire to live in the role of the
other gender and may emerge only if the desi re is interfered with. In adolescents and
adults, distress may manifest because of stro ng incongruence between experienced gender
and somatic sex. Such distress may, however, be mitigated by  supportive environments and
knowledge that biomedical treatments exist to reduce incongruence. Impairment (e.g.,
school refusal, development of  depression, anxiety, and substance abuse) may be a conse-
quence of gender dysphoria.
Gender dysphoria without a disorder of sex development. For clinic-referred children,
onset of cross-gender behaviors is usually betw een ages 2 and 4 years. This corresponds to
the developmental time period in which most  typically developing children begin ex-
pressing gendered behaviors and interests. For some preschool-age children, both perva-
sive cross-gender behaviors and the expressed desire to be the other gender may be
present, or, more rarely, labeling oneself as a member of the other gender may occur. In


some cases, the expressed desire to be the othe r gender appears later, usually at entry into
elementary school. A small minority of childre n express discomfort wi th their sexual anat-
omy or will state the desire to have a sexual anatomy correspondin g to the experienced
gender (“anatomic dysphoria”). Expressions of anatomic dysphoria become more com-
mon as children with ge nder dysphoria approach and anticipate puberty.
Rates of persistence of gender dysphoria fr om childhood into adolescence or adulthood
vary. In natal males, persistence has ranged fr om 2.2% to 30%. In natal females, persistence
has ranged from 12% to 50%. Persistence of gender dysphoria is mo destly correlated with
dimensional measures of severity ascertaine d at the time of a childhood baseline assess-
ment. In one sample of natal males, lower socioeconomic background was also modestly
correlated with persistence. It is unclear if particular therapeutic approaches to gender
dysphoria in children are related to rates of  long-term persistence. Extant follow-up sam-
ples consisted of children receiving no formal  therapeutic interventi on or receiving ther-
apeutic interventions of various types, ranging from ac tive efforts to reduce gender
dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “en-
couraged” or supported to live socially in the desired gender will show  higher rates of per-
sistence, since such children have not yet b een followed longitudinally in a systematic
manner. For both natal male and female ch ildren showing persistence, almost all are
sexually attracted to individuals of their na tal sex. For natal male  children whose gender


sexually attracted to individuals of their na tal sex. For natal male  children whose gender
dysphoria does not per sist, the majority are androphilic  (sexually attracted to males) and of-
ten self-identify as gay or homosexual (rangi ng from 63% to 100%). In natal female chil-
dren whose gender dysphoria does no t persist, the percentage who are gynephilic  (sexually
attracted to females) and sel f-identify as lesbian is lower (ranging from 32% to 50%).
In both adolescent and adult natal males, there are t wo broad trajectories for develop-


attracted to females) and sel f-identify as lesbian is lower (ranging from 32% to 50%).
In both adolescent and adult natal males, there are t wo broad trajectories for develop-
ment of gender dysphoria: early onset and late onset. Early-onset gender dysphoria  starts in
childhood and continues into adolescence and adulthood; or, there is an intermittent pe-
riod in which the gender dysphoria desists and these individuals self-i dentify as gay or ho-
mosexual, followed by recurren ce of gender dysphoria. Late-onset gender dysphoria  occurs
around puberty or much later in life. Some of these individuals report having had a desire
to be of the other gender in childhood that was not expressed verbally to others. Others do
not recall any signs of childhood gender dysp horia. For adolescent males with late-onset
gender dysphoria, parents often report surpri se because they did not see signs of gender


456 Gender Dysphoria
dysphoria during childhood. Expressions of anatomic dysphoria are more common and
salient in adolescents and adults once seco ndary sex characterist ics have developed.
Adolescent and adult natal males with earl y-onset gender dysphoria are almost al-
ways sexually attracted to men (androphilic). Adolescents and adults with late-onset gen-
der dysphoria frequently engage in transves tic behavior with sexual excitement. The
majority of these individuals are gynephilic or  sexually attracted to other posttransition
natal males with late-onset ge nder dysphoria. A substantia l percentage of adult males
with late-onset gender dyspho ria cohabit with or are marrie d to natal females. After gen-
der transition, many self-identify as lesbian. Among adult natal males with gender dyspho-
ria, the early-onset group seeks out clinical  care for hormone treatment and reassignment
surgery at an earlier age than does the late-onset group. The late-onset group may have more
fluctuations in the degree of gender dyspho ria and be more ambivalent about and less
likely satisfied after gender  reassignment surgery.
In both adolescent and adult natal females, the most common  course is the early-onset
form of gender dysphoria. The late-onset fo rm is much less common in natal females com-
pared with natal males. As in natal males with gender dysphoria, there may have been a
period in which the gender dysphoria desisted and these individuals self-identified as les-
bian; however, with recurrence of gender dysphoria, clinical consultation is sought, often
with the desire for hormone treatment and reas signment surgery. Parents of natal adoles-


with the desire for hormone treatment and reas signment surgery. Parents of natal adoles-
cent females with the late-onset form also report surprise, as no signs of childhood gender
dysphoria were evident. Expressions of anat omic dysphoria are mu ch more common and
salient in adolescents and adults than in children.
Adolescent and adult natal females with early-onset gender dysphoria are almost
always gynephilic. Adolescents and adults with  the late-onset form of gender dysphoria
are usually androphilic and after gender transit ion self-identify as gay men. Natal females
with the late-onset form do not have co-occu rring transvestic behavi or with sexual ex-
citement.
Gender dysphoria in association with a disorder of sex development. Most individuals
with a disorder of sex development who develop gender dysphoria have already come to
medical attention at an early age. For many, st arting at birth, issues of gender assignment
were raised by physicians and parents. More over, as infertility is quite common for this
group, physicians are more willing to perfor m cross-sex hormone treatments and genital
surgery before adulthood.
Disorders of sex development in general are frequently as sociated with gender-atypi-
cal behavior starting in early childhood. Howeve r, in the majority of cases, this does not
lead to gender dysphoria. As individuals with a disorder of sex development become
aware of their medical history and condition, many experience uncertainty about their
gender, as opposed to developing a firm co nviction that they are another gender. How-
ever, most do not progress to gender transit ion. Gender dysphoria and gender transition
may vary considerably as a function of a disord er of sex development, its severity, and as-
signed gender.


signed gender.
Risk and Prognostic Factors
Temperamental. For individuals with gender dyspho ria without a disorder of sex de-
velopment, atypical gender behavior among individuals with early-onset gender dyspho-
ria develops in early preschool age, and it is possible that a high degree of atypicality
makes the development of gender dysphoria and its persistence into adolescence and
adulthood more likely.
Environmental. Among individuals with gender dysphoria without a disorder of sex de-
velopment, males with gender dysphoria (in both childhood and adolescence) more com-


adulthood more likely.
Environmental. Among individuals with gender dysphoria without a disorder of sex de-
velopment, males with gender dysphoria (in both childhood and adolescence) more com-
monly have older brothers than do males without the condition. Additional predisposing


Gender Dysphoria 457
factors under consideration, especially in indi viduals with late-onset gender dysphoria (ad-
olescence, adulthood), include habitual fetishistic transvesti sm developing into autogyne-
philia (i.e., sexual arousal asso ciated with the thought or imag e of oneself as  a woman) and
other forms of more general social, psychological, or developmental problems.
Genetic and physiological. For individuals with gender dy sphoria without a disorder of
sex development, some genetic contribution is suggested by evidence for (weak) familial-
ity of transsexualism among nontwin siblings, increased concordance for transsexualism
in monozygotic compared with dizygotic same -sex twins, and some degree of heritability
of gender dysphoria. As to endocrine findin gs, no endogenous systemic abnormalities in
sex-hormone levels have been found in 46,XY individuals, whereas there appear to be in-
creased androgen levels (in the range found in hirsute women but far below normal male
levels) in 46,XX individuals. Overall, current evidence is insufficient to label gender dys-
phoria without a disorder of sex development as  a form of intersexuality limited to the cen-
tral nervous system.
In gender dysphoria associated with a disorder of sex development, the likelihood of
later gender dysphoria is increased if pren atal production and utilization (via receptor
sensitivity) of androgens are grossly atypical re lative to what is usually seen in individuals
with the same assigned gender. Examples incl ude 46,XY individuals with a history of nor-
mal male prenatal hormone milieu but inborn nonhormonal genital defects (as in cloacal


bladder exstrophy or penile agenesis) and who have been assigned to the female gender.
The likelihood of gender dysphoria is furthe r enhanced by additional, prolonged, highly
gender-atypical postnatal androgen exposure with somatic virilization as may occur in fe-
male-raised and noncastrated 46,XY individu als with 5-alpha reductase-2 deficiency or
17-beta-hydroxysteroid dehydrog enase-3 deficiency or in female-raised 46,XX individuals
with classical congenital adrenal hyperplasi a with prolonged periods of non-adherence to
glucocorticoid replacement therapy. Howeve r, the prenatal androgen milieu is more
closely related to gendered behavior than to gender identity. Many individuals with dis-
orders of sex development and markedly gend er-atypical behavior do not develop gender
dysphoria. Thus, gender-atypical behavior by itself should not be interpreted as an indi-
cator of current or future gend er dysphoria. There appears to be a higher rate of gender
dysphoria and patient-initiated gender change from assigned female to male than from as-
signed male to female in 46,XY individu als with a disorder of sex development.
Culture-Related Diagnostic Issues
Individuals with gender dysphoria have be en reported across many countries and cul-
tures. The equivalent of gender dysphoria ha s also been reported in individuals living in
cultures with institutionalized gender categories other than ma le or female. It is unclear
whether with these individuals the diagnostic criteria for gender dysphoria would be met.
Diagnostic Markers
Individuals with a somatic disorder of sex development show some correlation of final
gender identity outcome with the degree of prenatal androgen production and utilization.


gender identity outcome with the degree of prenatal androgen production and utilization.
However, the correlation is not robust enough for the biological factor, where ascertain-
able, to replace a detailed an d comprehensive diagnostic in terview evaluation for gender
dysphoria.
Functional Consequences  of Gender Dysphoria
Preoccupation with cross-gender wishes may de velop at all ages after the first 2–3 years of
childhood and often interfere with daily activities. In older children, failure to develop
age-typical same-sex peer relationships and skills may lead to isolation from peer groups
and to distress. Some children may refuse to attend school because of teasing and harass-


458 Gender Dysphoria
ment or pressure to dress in attire associated  with their assigned sex. Also in adolescents
and adults, preoccupation with cross-gender w ishes often interferes with daily activities.
Relationship difficulties, including sexual relationship problems, are common, and func-
tioning at school or at work may be impa ired. Gender dysphoria, along with atypical
gender expression, is associated with high le vels of stigmatization , discrimination, and
victimization, leading to nega tive self-concept, increased ra tes of mental disorder comor-
bidity, school dropout, and economic marginalization, including unemployment, with at-
tendant social and mental health risks, especially in individuals from resource-poor family
backgrounds. In addition, these individuals’ access to health services and mental health
services may be impeded by structural barriers,  such as institutional discomfort or inex-
perience in working with this patient population.
Differential Diagnosis
Nonconformity to gender roles. Gender dysphoria should be distinguished from sim-
ple nonconformity to stereotypical gender role behavior by the strong desire to be of an-
other gender than the assigned one and by th e extent and pervasivene ss of gender-variant
activities and interests. The diagnosis is not meant to mere ly describe nonconformity to
stereotypical gender role behavior (e.g., “t omboyism” in girls, “girly-boy” behavior in
boys, occasional cross-dressing in adult men). Given the increased openness of atypical
gender expressions by individuals across the entire range of the transgender spectrum, it
is important that the clinical diagnosis be lim ited to those individuals whose distress and
impairment meet the specified criteria.
Transvestic disorder. Transvestic disorder occurs in he terosexual (or bisexual) adoles-


cent and adult males (rarely in females) fo r whom cross-dressing behavior generates sex-
ual excitement and causes distress and/or  impairment without drawing their primary
gender into question. It is occasionally ac companied by gender dysphoria. An individual
with transvestic disorder who also has clinica lly significant gender dysphoria can be given
both diagnoses. In many cases of late-onset  gender dysphoria in gynephilic natal males,
transvestic behavior with sexu al excitement is a precursor.
Body dysmorphic disorder. An individual with body dy smorphic disorder focuses on
the alteration or removal of a sp ecific body part because it is perceived as abnormally formed,
not because it represents a repudiated assign ed gender. When an individual’s presenta-
tion meets criteria for both gender dysphori a and body dysmorphic disorder, both diag-
noses can be given. Individuals wishing to  have a healthy limb amputated (termed by
some body integrity identity disorder) because it makes them feel more “complete” usually
do not wish to change gender, but rather desi re to live as an amput ee or a disabled person.
Schizophrenia and other psychotic disorders. In schizophrenia, there may rarely be
delusions of belonging to some  other gender. In the absence of psychotic symptoms, in-
sistence by an individual with gender dysphori a that he or she is of some other gender is
not considered a delusion. Schizophrenia (or other psychotic disorders) and gender dys-
phoria may co-occur.
Other clinical presentations. Some individuals with an emasculinization desire who
develop an alternative, nonmale/nonfemale ge nder identity do have  a presentation that


develop an alternative, nonmale/nonfemale ge nder identity do have  a presentation that
meets criteria for gender dys phoria. However, some males seek castration and/or penec-
tomy for aesthetic reasons or to remove psychological effects of androgens without chang-
ing male identity; in these cases, the cr iteria for gender dysphoria are not met.
Comorbidity
Clinically referred children with gender dysphoria show elevated le vels of emotional and
behavioral problems—most commonly, anxiety, disruptive and impulse-control, and de-


Other Specified Gender Dysphoria 459
pressive disorders. In prepub ertal children, increasing age is associated with having more
behavioral or emotional problems; this is rela ted to the increasing non-acceptance of gen-
der-variant behavior by others. In older chil dren, gender-variant behavior often leads to
peer ostracism, which may lead to more be havioral problems. The prevalence of mental
health problems differs among cultures; these differences may also be  related to differences
in attitudes toward gender variance in child ren. However, also in  some non-Western cul-
tures, anxiety has been found to be relatively  common in individuals with gender dysphoria,
even in cultures with accepting attitudes to ward gender-variant be havior. Autism spec-
trum disorder is more prevalent in clinica lly referred children with gender dysphoria than
in the general population. Clinically referred adolescents with gender dysphoria appear to
have comorbid mental disorders, with anxi ety and depressive disorders being the most
common. As in children, autism spectrum disorder is more pr evalent in clinically referred
adolescents with gender dysphoria than in the general population. Clinically referred
adults with gender dysphoria may have coexisting mental he alth problems, most commonly
anxiety and depres sive disorders.
Other Specified Gender Dysphoria
302.6 (F64.8)
This category applies to presentations in which symptoms characteristic of gender dys-
phoria 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 gender dys-
phoria. The other specified gender dysphoria category is used in situations in which the
clinician chooses to communicate the specific reason that the presentation does not meet


clinician chooses to communicate the specific reason that the presentation does not meet
the criteria for gender dysphoria. This is done by recording “other specified gender dys-
phoria” followed by the specific r eason (e.g., “brief gender dysphoria”).
An example of a presentation that can be specified using the “other specified” desig-
nation is the following:
The current disturbance meets symptom cr iteria for gender dysphoria, but the
duration is less than 6 months.
Unspecified Gender Dysphoria
302.6 (F64.9)
This category applies to presentations in which symptoms characteristic of gender dys-
phoria that cause clinically significant distress or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for gender
dysphoria. The unspecified gender dysphoria category is used in situations in which the
clinician chooses not to specify the reason that the criteria are not met for gender dyspho-
ria, and includes presentations in which there is insufficient information to make a more
specific diagnosis.


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461Disruptive, Impulse-Control,
and Conduct Disorders
Disruptive, impulse-control,  and conduct disorders include conditions involv-
ing problems in the self-control of emotions  and behaviors. While other disorders in DSM-
5 may also involve problems in  emotional and/or behavioral  regulation, the disorders in
this chapter are unique in that these problems  are manifested in behaviors that violate the
rights of others (e.g., aggression, destructio n of property) and/or that bring the individual
into significant conflict with societal norms or  authority figures. The underlying causes of
the problems in the self-control of emotions  and behaviors can vary greatly across the dis-
orders in this chapter and among individu als within a given diagnostic category.
The chapter includes opposition al defiant disorder, intermi ttent explosive disorder, con-
duct disorder, antisocial person ality disorder (which is described in the chapter “Personality
Disorders”), pyromania, kleptomania, and ot her specified and unspecified disruptive, im-
pulse-control, and conduct disorders. Althou gh all the disorders in the chapter involve
problems in both emotional and behavioral re gulation, the source of variation among the
disorders is the relative emphas is on problems in the two types of self-control. For example,
the criteria for conduct disorder focus largely on poorly controlled behaviors that violate the
rights of others or that violat e major societal norms. Many of  the behavioral symptoms (e.g.,
aggression) can be a result of poorly controlled  emotions such as anger. At the other extreme,
the criteria for intermittent explosive disorder  focus largely on such poorly controlled emo-
tion, outbursts of anger that are disproportionate to the interpersonal or other provocation
or to other psychosocial  stressors. Intermediate in impact to these two disorders is opposi-


tional defiant disorder, in which the criteria  are more evenly distributed between emotions
(anger and irritation) and be haviors (argumentati veness and defiance). Pyromania and
kleptomania are less commonly used diagnoses characterized by poor impulse control re-
lated to specific behaviors (fire setting or stealing) that reliev e internal tension. Other speci-
fied disruptive, impulse-control, and conduct disorder is a category for conditions in which
there are symptoms of conduct disorder, oppositional defiant disorder, or other disruptive,
impulse-control, and conduct disorders, but th e number of symptoms does not meet the di-
agnostic threshold for any of th e disorders in this chapter, even though there is evidence of
clinically significant impairment  associated with the symptoms.
The disruptive, impulse-control, and conduct disorders all tend to be more common in
males than in females, although the relative degree of male predominance may differ both
across disorders and within a disorder at differe nt ages. The disorders in  this chapter tend to
have first onset in childhood or adolescence. In fact, it is very rare for ei ther conduct disorder or
oppositional defiant disorder to first emerge in adulthood. There is a developmental relation-
ship between oppositional defiant disorder and conduct disorder, in th at most cases of con-
duct disorder previously would have met criteria for opposition al defiant disorder, at least in
those cases in which conduct disorder emerges prior to adolescence. However, most children
with oppositional defiant disorder do not ev entually develop conduct disorder. Furthermore,
children with opposition al defiant disorder are at risk fo r eventually developing other prob-
lems besides conduct disorder, includ ing anxiety and depr essive disorders.
Many of the symptoms that define the disruptive, impulse-control, and conduct disor-
ders are behaviors that can occur to some degree in typically developing individuals.


ders are behaviors that can occur to some degree in typically developing individuals.
Thus, it is critical that the frequency, persistence , pervasiveness across situations, and im-


462 Disruptive, Impulse-Control, and Conduct Disorders
pairment associated with the behaviors indica tive of the diagnosis be considered relative
to what is normative for a person’s age, gend er, and culture when determining if they are
symptomatic of a disorder.
The disruptive, impulse-control, and conduc t disorders have been linked to a common
externalizing spectrum associated with the personality dimensions labeled as disinhibition
and (inversely) constraint  and, to a lesser extent, negative emotionality. These shared per-
sonality dimensions could acco unt for the high level of como rbidity among these disorders
and their frequent comorbidity with substanc e use disorders and antisocial personality
disorder. However, the specific nature of th e shared diathesis that constitutes the exter-
nalizing spectrum remains unknown.
Oppositional Defiant Disorder
Diagnostic Criteria 313.81 (F91.3)
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting
at least 6 months as evidenced by at least four symptoms from any of the following cate-
gories, and exhibited during interaction with at least one individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or
with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.


Note:  The persistence and frequency of these behaviors should be used to distinguish
a behavior that is within normal limits from a behavior that is symptomatic. For children
younger than 5 years, the behavior should occur on most days for a period of at least
6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the
behavior should occur at least once per week for at least 6 months, unless otherwise
noted (Criterion A8). While these frequency criteria provide guidance on a minimal lev-
el of frequency to define symptoms, other factors should also be considered, such as
whether the frequency and intensity of the behaviors are outside a range that is nor-
mative for the individual’s developmental level, gender, and culture.
B. The disturbance in behavior is associated with distress in the individual or others in his or
her immediate social context (e.g., family, peer  group, work colleagues), or it impacts neg-
atively on social, educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance
use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood
dysregulation disorder.
Specify current severity:
Mild:  Symptoms are confined to only one setting (e.g., at home, at school, at work, with
peers).


Oppositional Defiant Disorder 463
Moderate: Some symptoms are present in at least two settings.
Severe:  Some symptoms are present in three or more settings.
Specifiers
It is not uncommon for individuals with oppositional defiant disorder to show symptoms
only at home and only with family member s. However, the pervasiveness of the symp-
toms is an indicator of the severity of the disorder.
Diagnostic Features
The essential feature of oppositional defiant disorder is a frequent and persistent pattern
of angry/irritable mood, argumentative/defi ant behavior, or vindictiveness (Criterion
A). It is not unusual for individuals with oppositional defiant disorder to show the behav-
ioral features of the disorder without proble ms of negative mood. However, individuals
with the disorder who show the angry/irrita ble mood symptoms typically show the be-
havioral features as well.
The symptoms of oppositional  defiant disorder may be confined to only one setting,
and this is most frequently the home. Indi viduals who show enough symptoms to meet
the diagnostic threshold, even if it is only at  home, may be significantly impaired in their
social functioning. However, in more severe cases, the symptoms of the disorder are pres-
ent in multiple settings. Given that the pervas iveness of symptoms is an indicator of the
severity of the disorder, it is critical that the individual’s behavior be assessed across mul-
tiple settings and relationships. Because these behaviors are common among siblings, they
must be observed during interactions with  persons other than siblings. Also, because
symptoms of the disorder are ty pically more evident in intera ctions with adults or peers
whom the individual knows well, they may not be apparent during a clinical examination.
The symptoms of oppositional defiant disord er can occur to some degree in individu-


The symptoms of oppositional defiant disord er can occur to some degree in individu-
als without this disorder. There are several ke y considerations for de termining if the be-
haviors are symptomatic of oppo sitional defiant disorder. First, the diagnostic threshold
of four or more symptoms within the preceding 6 months must be met. Second, the per-
sistence and frequency of the symptoms should  exceed what is normative for an individ-
ual’s age, gender, and culture. For example, it is not unusual for preschool children to
show temper tantrums on a weekly basis. Te mper outbursts for a preschool child would be
considered a symptom of oppositional defiant d isorder only if they occurred on most days
for the preceding 6 months, if they occurred with at least three other symptoms of the dis-
order, and if the temper outbursts contribu ted to the significant impairment associated
with the disorder (e.g., led to destruction of  property during outbursts, resulted in the
child being asked to leave a preschool).
The symptoms of the disorder often are part  of a pattern of pr oblematic interactions
with others. Furthermore, individuals with this  disorder typically do not regard themselves
as angry, oppositional, or defian t. Instead, they often justify their behavior as a response to
unreasonable demands or circumstances. Thus, it can be difficult to disentangle the rela-
tive contribution of the individual with the disorder to the problematic interactions he or
she experiences. For example, children with oppositional defiant disorder may have ex-
perienced a history of hostile parenting, and it is often impossible to determine if the
child’s behavior caused the parents to act in a more hostile manner toward the child, if the


child’s behavior caused the parents to act in a more hostile manner toward the child, if the
parents’ hostility led to the ch ild’s problematic behavior, or if there was so me combination
of both. Whether or not the clinician can sepa rate the relative contributions of potential
causal factors should not influence whether or not the diagnosis is made. In the event that
the child may be living in particularly poor conditions where neglect or mistreatment may
occur (e.g., in institutional settings), clinical attention to reducing the contribution of the


the child may be living in particularly poor conditions where neglect or mistreatment may
occur (e.g., in institutional settings), clinical attention to reducing the contribution of the
environment may be helpful.


464 Disruptive, Impulse-Control, and Conduct Disorders
Associated Features Supporting Diagnosis
In children and adolescents, oppositional defian t disorder is more prevalent in families in
which child care is disrupted by a succession of different caregivers or in families in which
harsh, inconsistent, or negl ectful child-rearing practice s are common. Two of the most
common co-occurring conditions with oppositi onal defiant disorder are attention-deficit/
hyperactivity disorder (ADHD)  and conduct disorder (see the section “Comorbidity” for
this disorder). Oppositional defiant disorder has been associated with increased risk for
suicide attempts, even after comorb id disorders are controlled for.
Prevalence
The prevalence of oppositional defiant disord er ranges from 1% to 11%, with an average
prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary
depending on the age and gender of the child . The disorder appears to be somewhat more
prevalent in males than in females (1.4:1) pr ior to adolescence. This male predominance is
not consistently found in samples of adolescents or adults.
Development and Course
The first symptoms of oppositional defiant di sorder usually appear during the preschool
years and rarely later than early adolescence.  Oppositional defiant disorder often precedes
the development of conduct disorder, especial ly for those with the childhood-onset type
of conduct disorder. However, many children and adolescents with oppositional defiant
disorder do not subsequently develop cond uct disorder. Oppositional defiant disorder
also conveys risk for the development of anxi ety disorders and major depressive disorder,
even in the absence of conduct disorder. The defiant, argumentative,  and vindictive symp-
toms carry most of the risk for conduct disorder, whereas the angry-irritable mood symp-


toms carry most of the risk for emotional disorders.
Manifestations of the disorder across de velopment appear consistent. Children and
adolescents with oppositional defiant disorder are at increase d risk for a number of prob-
lems in adjustment as adults, including anti social behavior, impu lse-control problems,
substance abuse, anxiety, and depression.
Many of the behaviors associated with oppositional defiant disorder increase in fre-
quency during the preschool period and in adol escence. Thus, it is especially critical dur-
ing these development periods that the freq uency and intensity of these behaviors be
evaluated against normative leve ls before it is decided that they are symptoms of opposi-
tional defiant disorder.
Risk and Prognostic Features
Temperamental. Temperamental factors related to problems in emotional regulation
(e.g., high levels of emotiona l reactivity, poor frustration to lerance) have been predictive
of the disorder.
Environmental. Harsh, inconsistent, or neglectful child-rearing practices are common in
families of children and adolescents with oppo sitional defiant disorder, and these parent-
ing practices play an important role in many causal theories of the disorder.
Genetic and physiological. A number of neurobiological markers (e.g., lower heart rate
and skin conductance reactivity; reduced basal cortisol reactivity; abnormalities in the pre-
frontal cortex and amygdala) have been associated with oppositional defiant disorder.
However, the vast majority of studies have not separated children with oppositional de-
fiant disorder from those with conduct diso rder. Thus, it is unclear whether there are
markers specific to oppositional defiant disorder.


Oppositional Defiant Disorder 465
Culture-Related Diagnostic Issues
The prevalence of the disorder in children an d adolescents is relatively consistent across
countries that differ in race and ethnicity.
Functional Consequences of
Oppositional Defiant Disorder
When oppositional defiant disorder is pers istent throughout deve lopment, individuals
with the disorder experience frequent conflic ts with parents, teachers, supervisors, peers,
and romantic partners. Such problems often re sult in significant impairments in the indi-
vidual’s emotional, social, academ ic, and occupational adjustment.
Differential Diagnosis
Conduct disorder. Conduct disorder and oppositional defiant disorder are both related
to conduct problems that  bring the individual in conflict  with adults and other authority
figures (e.g., teachers, work supervisors). Th e behaviors of oppositional defiant disorder
are typically of a less severe nature than those of conduct disorder and do not include ag-
gression toward people or anima ls, destruction of property, or a pattern of theft or deceit.
Furthermore, oppositional defian t disorder includes problems  of emotional dysregulation
(i.e., angry and irritable mood) that are not in cluded in the definition of conduct disorder.
Attention-deficit/hyperactivity disorder. ADHD is often comorbid  with oppositional de-
fiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is impor-
tant to determine that the indivi dual’s failure to conform to requ ests of others is not solely in
situations that demand sustained effort and attention or demand that the individual sit still.
Depressive and bipolar disorders. Depressive and bipolar di sorders often involve neg-
ative affect and irritability. As a result, a di agnosis of oppositional defiant disorder should


not be made if the symptoms occur exclusiv ely during the course of a mood disorder.
Disruptive mood dysregulation disorder. Oppositional defiant disorder shares with dis-
ruptive mood dysregulation disorder the symp toms of chronic negative mood and temper
outbursts. However, the severity, frequency, and chronicity of temp er outbursts are more
severe in individuals with di sruptive mood dysregulation disorder than in those with
oppositional defiant disorder. Thus, only a minority of ch ildren and adolescents whose
symptoms meet criteria for oppo sitional defiant disorder woul d also be diagnosed with dis-
ruptive mood dysregulation disorder. When the mood disturbance is severe enough to meet
criteria for disruptive mood dysregulation disorder, a diagnosis of oppositional defiant dis-
order is not given, even if all criteria for oppositional defiant disorder are met.
Intermittent explosive disorder. Intermittent explosive disorder also involves high
rates of anger. However, indi viduals with this disorder sh ow serious aggr ession toward
others that is not part of the defini tion of oppositional defiant disorder.
Intellectual disability (intell ectual developmental disorder). In individuals with intel-
lectual disability, a diagnosis of oppositional defiant disorder is gi ven only if the opposi-
tional behavior is markedly greater than  is commonly observed among individuals of
comparable mental age and with comparab le severity of intellectual disability.
Language disorder. Oppositional defiant disorder must  also be distinguished from a
failure to follow directions that is the resu lt of impaired language comprehension (e.g.,
hearing loss).
Social anxiety disorder (social phobia). Oppositional defiant disord er must also be dis-
tinguished from defiance due to  fear of negative evaluation associated with social anxiety
disorder.


466 Disruptive, Impulse-Control, and Conduct Disorders
Comorbidity
Rates of oppositional defiant disorder are mu ch higher in samples of children, adoles-
cents, and adults with ADHD, and this may be the result of shared temperamental risk fac-
tors. Also, oppositional defiant disorder of ten precedes conduct di sorder, although this
appears to be most common in children wi th the childhood-onset subtype. Individuals
with oppositional defiant disorder are also at  increased risk for anxiety disorders and ma-
jor depressive disorder, and this seems largel y attributable to the presence of the angry-
irritable mood symptoms. Adolescents and adul ts with oppositional defiant disorder also
show a higher rate of substance use disorders, al though it is unclear if this association is in-
dependent of the comorbidity with conduct disorder.
Intermittent Explosive Disorder
Diagnostic Criteria 312.34 (F63.81)
A. Recurrent behavioral outbursts representing a failure to control aggressive impulses
as manifested by either of the following:
1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or
physical aggression toward property, animals, or other individuals, occurring twice
weekly, on average, for a period of 3 months. The physical aggression does not re-
sult in damage or destruction of property and does not result in physical injury to
animals or other individuals.
2. Three behavioral outbursts involving damage or destruction of property and/or
physical assault involving physical injury against animals or other individuals occur-
ring within a 12-month period.
B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly
out of proportion to the provocation or to any precipitating psychosocial stressors.


out of proportion to the provocation or to any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/
or anger-based) and are not committed to achieve some tangible objective (e.g.,
money, power, intimidation).
D. The recurrent aggressive outbursts cause either marked distress in the individual or
impairment in occupational or interpersonal functioning, or are associated with finan-
cial or legal consequences.
E. Chronological age is at least 6 years (or equivalent developmental level).
F. The recurrent aggressive outbursts are not better explained by another mental disor-
der (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation
disorder, a psychotic disorder, antisocial personality disorder, borderline personality
disorder) and are not attributable to another  medical condition (e.g., head trauma, Alz-
heimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse,
a medication). For children ages 6–18 years, aggressive behavior that occurs as part
of an adjustment disorder should not be considered for this diagnosis.
Note:  This diagnosis can be made in addition to the diagnosis of attention-deficit/hyper-
activity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum dis-
order when recurrent impulsive aggressive outbursts are in excess of those usually seen
in these disorders and warrant independent clinical attention.
Diagnostic Features
The impulsive (or anger-based) aggressive outb ursts in intermittent explosive disorder have
a rapid onset and, typically, li ttle or no prodromal period. Ou tbursts typically last for less


Intermittent Explosive Disorder 467
than 30 minutes and commonly occur in respon se to a minor provocation by a close intimate
or associate. Individuals with intermittent ex plosive disorder often have less severe epi-
sodes of verbal and/or nondamaging, nondestruc tive, or noninjurious physical assault (Cri-
terion A1) in between more severe destructive/ assaultive episodes (Cri terion A2). Criterion
A1 defines frequent (i.e., twice weekly, on aver age, for a period of 3 months) aggressive out-
bursts characterized by  temper tantrums, tirades, verbal  arguments or fights, or assault
without damage to objects or without injury to animals or other individuals. Criterion A2
defines infrequent (i.e., three in a 1-year pe riod) impulsive aggressi ve outbursts character-
ized by damaging or destroying an object, regardless of its tangible value, or by assaulting/
striking or otherwise causing physical injury to an animal or to another individual. Regard-
less of the nature of the impulsive aggressive outburst, the core feature of intermittent
explosive disorder is failure to control impulsiv e aggressive behavior in  response to subjec-
tively experienced provocation (i.e., psychosocial  stressor) that would not typically result in
an aggressive outburst (Criterion B). The aggressive outbursts are generally impulsive and/
or anger-based, rather than premeditated or instrumental (Criterion C) and are associated
with significant distress or impairment in psyc hosocial function (Cri terion D). A diagnosis
of intermittent explosive disorder should not be given to individuals younger than 6 years,
or the equivalent developmental level (Criterion  E), or to individual s whose aggressive out-


or the equivalent developmental level (Criterion  E), or to individual s whose aggressive out-
bursts are better explained by another mental di sorder (Criterion F). A diagnosis of intermit-
tent explosive disorder should not be gi ven to individuals with disruptive mood
dysregulation disorder or to individuals whose impulsive aggressive outbursts are attribut-
able to another medical condition or to the phys iological effects of a substance (Criterion F).
In addition, children ages 6–18 years should not receive this diagnosis when impulsive ag-
gressive outbursts occur in the context of an adjustment disorder (Criterion F).
Associated Features Supporting Diagnosis
Mood disorders (unipolar), anxiety disorders, and substance use disorders are associated
with intermittent explosive di sorder, although onset of thes e disorders is typically later
than that of intermitte nt explosive disorder.
Prevalence
One-year prevalence data for intermittent expl osive disorder in the United States is about
2.7% (narrow definition). Intermittent explosive disorder is more prevalent among
younger individuals (e.g., youn ger than 35–40 years), compared with older individuals
(older than 50 years), and in individuals with a high school education or less.
Development and Course
The onset of recurrent, problematic, impulsive aggressive beha vior is most common in late
childhood or adolescence and ra rely begins for the first time  after age 40 years. The core
features of intermitte nt explosive disorder, typically, ar e persistent and continue for many
years.
The course of the disorder may be episodic, with recurrent periods of impulsive ag-
gressive outbursts. Intermittent  explosive disorder appears to follow a chronic and persis-
tent course over many years. It also appears to be quite common regardless of the presence


tent course over many years. It also appears to be quite common regardless of the presence
or absence of attentio n-deficit/hyperactivity disorder (ADHD) or disruptive, impulse-
control, and conduct disorders (e.g., conduct disorder, oppo sitional defiant disorder).
Risk and Prognostic Factors
Environmental. Individuals with a history of physica l and emotional trauma during the
first two decades of life are at increased risk for intermittent  explosive disorder.


468 Disruptive, Impulse-Control, and Conduct Disorders
Genetic and physiological. First-degree relatives of individuals with intermittent ex-
plosive disorder are at increase d risk for intermittent explos ive disorder, and twin studies
have demonstrated a substantial geneti c influence for impulsive aggression.
Research provides neurobiolo gical support for the presence of serotonergic abnormal-
ities, globally and in the brain, specifically in areas of the limbic sy stem (anterior cingulate)
and orbitofrontal cortex in individuals with  intermittent explos ive disorder. Amygdala
responses to anger stimuli, during function al magnetic resonance imaging scanning, are
greater in individuals with intermittent expl osive disorder compared with healthy indi-
viduals.
Culture-Related Diagnostic Issues
The lower prevalence of intermittent explosive disorder in some regions (Asia, Middle
East) or countries (Romania, Nigeria), compared  with the United States, suggests that in-
formation about recurrent, prob lematic, impulsive aggressive behaviors either is not elic-
ited on questioning or is less likely to be present, because of cultural factors.
Gender-Related Diagnostic Issues
In some studies the prevalence of intermittent explosive diso rder is greater in males than
in females (odds ratio = 1.4–2.3); other st udies have found no gender difference.
Functional Consequences of
Intermittent Explosive Disorder
Social (e.g., loss of friends, relatives, marita l instability), occupational (e.g., demotion, loss
of employment), financial (e.g., due to value of objects destroyed), and legal (e.g., civil
suits as a result of aggressive behavior against person or prop erty; criminal charges for as-
sault) problems often develop as a result of intermit tent explosive disorder.
Differential Diagnosis


Differential Diagnosis
A diagnosis of intermittent ex plosive disorder shou ld not be made when Criteria A1 and/
or A2 are only met during an  episode of another mental disorder (e.g., major depressive
disorder, bipolar disorder, psychotic disorder ), or when impulsive aggressive outbursts
are attributable to another me dical condition or to the physio logical effects of a substance
or medication. This diagnosis also should not be made, particularly in children and ado-
lescents ages 6–18 years, when the impulsive aggressive outbursts occur in the context of
an adjustment disorder. Other examples in which recurrent, proble matic, impulsive ag-
gressive outbursts may, or may not, be diag nosed as intermittent explosive disorder in-
clude the following.
Disruptive mood dysregulation disorder. In contrast to intermittent explosive disorder,
disruptive mood dysregulation disorder is charac terized by a persistently  negative mood state
(i.e., irritability, anger) most of the day, nearly every day, between impulsive aggressive out-
bursts. A diagnosis of disruptive mood dysregul ation disorder can only be given when the on-
set of recurrent, problematic, impulsive aggressive outbursts is before age 10 years. Finally, a
diagnosis of disruptive mood dysregulation di sorder should not be made for the first time
after age 18 years. Otherwise, these diagnoses are mutually exclusive.
Antisocial personality disorder or  borderline personality disorder. Individuals with an-
tisocial personality disorder or borderline personality disorder often display recurrent,
problematic impulsive aggressive outbursts. However, the level of impulsive aggression
in individuals with antisocial personality di sorder or borderline personality disorder is
lower than that in individuals with  intermittent explosive disorder.


Conduct Disorder 469
Delirium, major neurocognitive disorder, an d personality change due to another med-
ical condition, aggressive type. A diagnosis of intermittent ex plosive disorder should not
be made when aggressive outbur sts are judged to result from the physiological effects of an-
other diagnosable medical condition (e.g., brain in jury associated with a change in personality
characterized by aggressive outbursts; comple x partial epilepsy). Nonspecific abnormalities
on neurological examination (e.g., “soft signs”) and nonspecific electroencephalographic
changes are compatible with a diagnosis of interm ittent explosive disorder  unless there is a di-
agnosable medical condition that better expl ains the impulsive aggressive outbursts.
Substance intoxication or substance withdrawal. A diagnosis of inte rmittent explosive
disorder should not be made when impulsive aggressive outbursts are nearly always as-
sociated with intoxicati on with or withdrawal from substa nces (e.g., alcohol, phencyclidine,
cocaine and other stimulants, barbiturates, inhalants). However, when  a sufficient number
of impulsive aggressive outbur sts also occur  in the absence of substance intoxication or
withdrawal, and these warrant in dependent clinical attention,  a diagnosis of intermittent
explosive disorder may be given.
Attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disor-
der, or autism spectrum disorder. Individuals with any of these childhood-onset dis-
orders may exhibit impulsive aggressive outbursts. Individu als with ADHD are typically
impulsive and, as a result, may also exhibit impulsive aggressive outbursts. While indi-
viduals with conduct disorder can exhibit impulsive aggressive outbur sts, the form of ag-