Sexual dysfunctions

Sexual Dysfunctions
Dan Andrei Elbambuena Navarro Navarette
Bagao, RPm

Sexual Dysfunctions include delayed ejaculation, erectile
disorder, female orgasmic disorder, female sexual
interest/arousal disorder, genito-pelvic pain/penetration
disorder, male hypoactive sexual desire disorder,
premature (early) ejaculation, substance/medication-
induced sexual dysfunction, other specified sexual
dysfunction, and unspecified sexual dysfunction.
Sexual dysfunctions are a heterogeneous group of
disorders that are typically characterized by a clinically
significant disturbance in a person's ability to respond
sexually or to experience sexual pleasure. An individual
may have several sexual dysfunctions at the same time. In
such cases, all of the dysfunctions should be diagnosed.

Lifelong refers to a sexual problem that has
been present from first sexual experiences, and
acquired applies to sexual disorders that develop
after a period of relatively normal sexual
function. Generalized refers to sexual
difficulties that are not limited to certain types of
stimulation, situations, or partners, and
situational refers to sexual difficulties that only
occur with certain types of stimulation,
situations, or partners.

Diagnostic Criteria
A. Either of the following symptoms must be experienced on
almost all or all occasions (approximately 75%-1 00%) of
partnered sexual activity (in identified situational contexts or, if
generalized, in all contexts) , and without the individual desiring
delay:
1 . Marked delay in ejaculation.
2 . Marked infrequency or absence of ejaculation .
B. The symptoms in Criterion A have persisted for a minimum
duration of approximately 6 months.
C . The symptoms in Criterion A cause clinically significant
distress in the individual .
D. The sexual dysfunction is not better explained by a nonsexual
mental disorder or as a consequence of severe relationship
distress or other significant stressors and is not attributable to the
effects of a substance/medication or another medical condition.

Specify whether:
Lifelong: The disturbance has been present since the individual
became sexually active.
Acquired : The disturbance began after a period of relatively
normal sexual function .
Specify whether:
Generalized : Not limited to certain types of stimulation,
Situational : Only occurs with certain types of stimulation,
Specify current severity:
Mild: Evidence of mild distress over the symptoms in Criterion
A.
Moderate: Evidence of moderate distress over the symptoms in
Criterion A.
Severe: Evidence of severe or extreme distress over the
symptoms in Criterion A.

Associated Features Supporting Diagnosis
The man and his partner may report prolonged thrusting to achieve orgasm to
the point of exhaustion or genital discomfort and then ceasing efforts. Some
men may report avoiding sexual activity because of a repetitive pattern of
difficulty ejaculating. Some sexual partners may report feeling less sexually
attractive because their partner cannot ejaculate easily. In addition to the
subtypes "lifelong/acquired" and "generalized /situational," the following five
factors must be considered during assessment and diagnosis of delayed
ejaculation, given that they may be relevant to etiology and/ or treatment: 1)
partner factors (e.g., partner's sexual problems, partner's health status); 2)
relationship factors (e.g., poor communication, discrepancies in desire for
sexual activity); 3) individual vulnerability factors (e.g., poor body image;
history of sexual or emotional abuse), psychiatric comorbidity (e.g., depression,
anxiety), or stressors (e.g., job loss, bereavement); 4)cultural/religious factors
(e.g., inhibitions related to prohibitions against sexual activity; attitudes toward
sexuality); and 5) medical factors relevant to prognosis, course, or treatment.
Each of these factors may contribute differently to the presenting symptoms of
different men with this disorder.

Prevalence
Prevalence is unclear because of the lack of a
precise definition of this syndrome. It is the least
common male sexual complaint. Only 75% of
men report always ejaculating during sexual
activity, and less than 1% of men will
complain of problems with reaching
ejaculation that last more than 6 months.

Development and Course
Lifelong delayed ejaculation begins with early sexual
experiences and continues throughout life. By
definition, acquired delayed ejaculation begins after a
period of normal sexual function. There is minimal
evidence concerning the course of acquired delayed
ejaculation. The prevalence of delayed ejaculation
appears to remain relatively constant until around
age 50 years, when the incidence begins to increase
significantly. Men in their 80s report twice as much
difficulty ejaculating as men younger than 59 years.

Culture-Related Diagnostic Issues
Complaints of ejaculatory delay vary across
countries and cultures. Such complaints are
more common among men in Asian
populations than in men living in Europe,
Australia, or the United States. This variation
may be attributable to cultural or genetic
differences between cultures.

Comorbidity
There is some evidence to suggest that delayed
ejaculation may be more common in severe
forms of major depressive disorder.

Sometimes called retarded ejaculation, delayed
ejaculation disorder refers to the persistent inability to
ejaculate during intercourse (see “DSM-5 Criteria” on
p. 432). It occurs in only about 3 to 10 percent of men.
Men who are completely unable to ejaculate are rare.
About 85 percent of men who have difficulty
ejaculating during intercourse can nevertheless
achieve orgasm by other means of stimulation, notably
through solitary masturbation (Wincze et al., 2008). In
milder cases a man can ejaculate in the presence of a
partner but only by means of manual or oral
stimulation.

In other cases, delayed ejaculation can be related to
specific physical problems such as multiple sclerosis
or to the use of certain medications. For example, we
noted that antidepressants that block serotonin
reuptake appear to be an effective treatment for early
ejaculation. However, in other men, these same
medications—especially the SSRIs—sometimes
delay or prevent orgasm to an unpleasant extent
(Ashton et al., 1997; Meston & Rellini, 2008). These
side effects are common but can sometimes be
treated pharmacologically with medications like
Viagra (Ashton et al., 1997).

Diagnostic Criteria
A. At least one of the three following symptoms must be experienced on almost
all or all (approximately 75%-1 00%) occasions of sexual activity (in identified
situational contexts or, if generalized , in all contexts) :
1 . Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of
sexual activity.
3. Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persisted for a minimum d u ration of
approximately 6 months.
C . The symptoms in Criterion A cause clinically significant distress in the
individual.
D . The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other significant
stressors and is not attributable to the effects of a substance/medication or
another medical condition.

Associated Features Supporting Diagnosis
Many men with erectile disorder may have low self-esteem, low self-
confidence, and a decreased sense of masculinity, and may experience
depressed affect. Fear and / or avoidance of future sexual encounters may
occur. Decreased sexual satisfaction and reduced sexual desire in the
individual's partner are common. In addition to the subtypes "lifelong/acquired"
and "generalized/situational," the following five factors must be considered
during assessment and diagnosis of erectile disorder given that they may be
relevant to etiology and/ or treatment: 1) partner factors (e.g., partner's sexual
problems, partner's health status); 2) relationship factors (e.g., poor
communication, discrepancies in desire for sexual activity); 3) individual
vulnerability factors (e.g., poor body image, history of sexual or emotional
abuse), psychiatric comorbidity (e.g., depression, anxiety), or stressors (e.g., job
loss, bereavement); 4) cultural/ religious factors (e.g., inhibitions related to
prohibitions against sexual activity; attitudes toward sexuality); and 5) medical
factors relevant to prognosis, course, or treatment. Each of these factors may
contribute differently to the presenting symptoms of different men with this
disorder.

Prevalence
The prevalence of lifelong versus acquired erectile
disorder is unknown. There is a strong age-related
increase in both prevalence and incidence of problems
with erection, particularly after age 50 years.
Approximately 13%-21% of men ages 40-80 years
complain of occasional problems with erections.
Approximately 2% of men younger than age 40-50 years
complain of frequent problems with erections, whereas
40%-50% of men older than 60-70 years may have
significant problems with erections. About 20% of men
fear erectile problems on their first sexual experience,
whereas approximately 8% experienced erectile problems
that hindered penetration during their first sexual
experience.

Erectile failure on first sexual attempt has been found to be related to having
sex with a previously unknown partner, concomitant use of drugs or alcohol,
not wanting to have sex, and peer pressure. There is minimal evi-2t most of
these problems spontaneously remit without professional intervention, but some
men may continue to have episodic problems. In contrast, acquired erectile
disorder is often associated with biological factors such as diabetes and
cardiovascular disease. Acquired erectile disorder is likely to be persistent in
most men. The natural history of lifelong erectile disorder is unknown. Clinical
observation supports the association of lifelong erectile disorder with
psychological factors that are self limiting or responsive to psychological
interventions, whereas, as noted above, acquired erectile disorder is more likely
to be related to biological factors and to be persistent. The incidence of erectile
disorder increases with age. A minority of men diagnosed as having
moderate erectile failure may experience spontaneous remission of
symptoms without medical intervention. Distress associated with erectile
disorder is lower in older men as compared with younger men.

Comorbidity
Erectile disorder can be comorbid with other sexual
diagnoses, such as premature (early) ejaculation and
male hypoactive sexual desire disorder, as well as with
anxiety and depressive
disorders. Erectile disorder is common in men with
lower urinary tract symptoms related to prostatic
hypertrophy. Erectile disorder may be comorbid with
dyslipidemia, cardiovascular disease, hypogonadism,
multiple sclerosis, diabetes mellitus, and other diseases
that interfere with the vascular, neurological, or endocrine
function necessary for normal erectile function.

Inability to achieve or maintain an erection sufficient for successful
sexual intercourse was formerly called impotence. It is now known as
male erectile disorder and can be diagnosed only when the difficulties
are considered to originate from either psychogenic or a combination
of psychogenic and medical factors (see “DSM-5 Criteria” on p. 432).
In lifelong erectile disorder, a man with adequate sexual desire
has never been able to sustain an erection long enough to
accomplish a satisfactory duration of penetration. In acquired or
situational erectile disorder, a man with adequate sexual desire
has had at least one successful experience of sexual activity
requiring an erection but is presently unable to produce or
maintain the required level of penile rigidity. Lifelong erectile
disorder is relatively rare, but most men of all ages occasionally have
difficulty obtaining or maintaining an erection. Laumann et al. (1999)
landmark study on the prevalence of sexual dysfunction estimates that
7 percent of 18- to 19-year-old men and 18 percent of 50- to 59-year-
old men reported having erectile disorder.

Masters and Johnson (1975; Masters et al., 1992) and Kaplan (1987)
hypothesized that erectile dysfunction is primarily a function of anxiety
about sexual performance. In other reviews of the accumulated evidence,
however, Barlow and colleagues (Beck & Barlow, 1984a; Sbrocco & Barlow,
1996) have played down the role of anxiety per se—because under some
circumstances, anxiety can actually enhance sexual performance in normally
functioning men and women (Barlow et al., 1983; Palace & Gorzalka, 1990;
see Sbrocco & Barlow, 1996, for a review). Barlow (2002) emphasizes that it
is the cognitive distractions frequently associated with anxiety in
dysfunctional people that seem to interfere with their sexual arousal. For
example, one study found that nondysfunctional men who were distracted by
material they were listening to on earphones while watching an erotic film
showed less sexual arousal than men who were not distracted (Abrahamson et
al., 1985). Barlow and colleagues hypothesize that sexually dysfunctional
men and women get distracted by negative thoughts about their
performance during a sexual encounter (“I’ll never get aroused” or “She’ll
think I’m inadequate”).

Their research suggests that this preoccupation with negative thoughts,
rather than anxiety per se, is responsible for inhibiting sexual arousal (see
also Weiner & Rosen, 1999; Wincze et al., 2008). Moreover, such self-
defeating thoughts not only decrease pleasure but also can increase
anxiety if the erection does not happen, and this in turn can fuel further
negative, self-defeating thoughts (Sbrocco & Barlow, 1996). A related
finding is that men with erectile dysfunction make more internal and stable
causal attributions for hypothetical negative sexual events than do men
without sexual dysfunction, much as depressed people do for more general
hypothetical negative events (Nobre, 2010; Scepkowski et al., 2004).
Combined with Bancroft and colleagues’ (2005) findings that fear of
performance failure is a strong predictor of erectile dysfunction in both
gay and heterosexual men, one can see how a vicious cycle develops in
which fears of failure are sometimes followed by erectile dysfunction,
which is then attributed to internal and stable causes, thereby
perpetuating the problem.

Erectile problems occur in as many as 90 percent of men on
certain antidepressant medications (especially the SSRIs)
and are one of the primary reasons men cite for
discontinuing these medications (Rosen & Marin, 2003). These
problems are also a common consequence of aging. One large
study of over 1,400 men found that 37 percent between ages
57 and 85 reported significant erectile difficulties, with the
problems gradually increasing with age (Lindau et al., 2007).
However, complete and permanent erectile disorder before the
age of 60 is relatively rare. Moreover, studies have indicated
that men and women in their 80s and 90s are often quite
capable of enjoying intercourse (Masters et al., 1992; Meston
& Rellini, 2008). For example, in one study of 202 healthy men
and women between the ages of 80 and 102, it was found that
nearly two-thirds of the men and one-third of the women were
still having sexual intercourse, although this was generally not
their most common form of sexual activity (Bretschneider &
McCoy, 1988).

The most frequent cause of erectile disorder in older men is
vascular disease, which results in decreased blood flow to the
penis or in diminished ability of the penis to hold blood to
maintain an erection. Thus hardening of the arteries, high blood
pressure, and other diseases such as diabetes that cause vascular
problems often account for erectile disorder. Smoking, obesity, and
alcohol abuse are associated lifestyle factors, and lifestyle changes
can improve erectile function (Gupta et al., 2011). Diseases that
affect the nervous system, such as multiple sclerosis, can also cause
erectile problems. For young men, one cause of erectile problems is
having had priapism—that is, an erection that will not diminish
even after a couple of hours, typically unaccompanied by sexual
excitement. Priapism can occur as a result of prolonged sexual
activity, as a consequence of disease, or as a side effect of certain
medications. Untreated cases of priapism are likely to result in
erectile dysfunction and thus should be regarded as a medical
emergency (Morrison & Burnett, 2011).

Diagnostic Criteria
A. Presence of either of the following symptoms and experienced on
almost all or all (approximately 75%-1 00%) occasions of sexual
activity (in identified situational contexts or, if generalized, in all
contexts) :
1 . Marked delay in , marked infrequency of, or absence of
orgasm.
2 . Markedly reduced intensity of orgasmic sensations.
C. The symptoms in Criterion A cause clinically significant distress in
the individual.
D . The sexual dysfunction is not better explained by a nonsexual
mental disorder or as a consequence of severe relationship distress (e .
g . , partner violence) or other significant stressors and is not
attributable to the effects of a substance/medication or another
medical condition.

Specify whether:
Acquired : The disturbance began after a period of relatively normal
sexual function.
Specify whether:
Generalized : Not limited to certain types of stimulation, situations,
or partners.
Situational: Only occurs with certain types of stimulation, situations,
or partners.
Specify if:
Never experienced an orgasm under any situation.
Mild: Evidence of m i ld distress over the symptoms in Criterion A.
Criterion A.
Severe: Evidence of severe or extreme distress over the symptoms in
Criterion A.

Prevalence
Reported prevalence rates for female orgasmic
problems in women vary widely, from 10% to 42%,
depending on multiple factors (e.g., age, culture,
duration, and severity of symptoms); however, these
estimates do not take into account the presence of
distress. Only a proportion of women experiencing
orgasm difficulties also report associated distress.
Variation in how symptoms are assessed (e.g., the
duration of symptoms and the recall period) also
influence prevalence rates. Approximately 10% of
women do not experience orgasm throughout their
lifetime.

By definition, lifelong female orgasmic disorder indicates that
the orgasmic difficulties have always been present, whereas
the acquired subtype would be assigned if the woman's
orgasmic difficulties developed after a period of normal
orgasmic functioning. A woman's first experience of orgasm
can occur any time from the prepubertal periodto well into
adulthood. Women show a more variable pattern in age at first
orgasm than do men, and women's reports of having experienced
orgasm increase with age. Many womenlearn to experience
orgasm as they experience a wide variety of stimulation and
acquire more knowledge about their bodies. Women's rates of
orgasm consistency (defined as "usually or always"
experiencing orgasm) are higher during masturbation than
during sexual activity with a partner.

The degree to which lack of orgasm in women is
regarded as a problem that requires treatment may
vary depending on cultural context. In addition,
women differ in how important orgasm is to their
sexual satisfaction. There may be marked sociocultural
and generational differences in women's orgasmic
ability. For example, the prevalence of inability to
reach orgasm has ranged from 17.7% (in Northern
Europe) to 42.2% (in Southeast Asia).

Comorbidity
Women with female orgasmic disorder may have co-
occurring sexual interest/ arousal difficulties.
Women with diagnoses of other nonsexual mental
disorders, such as major depressive disorder, may
experience lower sexual interest/ arousal, and this
may indirectly increase the likelihood of orgasmic
difficulties.

Orgasmic Disorders
As with other sexual dysfunctions, the DSM-5 includes separate diagnoses
for problems in achieving orgasm for women and men. Female orgasmic
disorder refers to the persistent absence or reduced intensity of orgasm after
sexual excitement. Women have different thresholds for orgasm. Although
some have orgasms quickly and without much clitoral stimulation, others
need prolonged clitoral stimulation. Given this, it is not surprising that
about one-third of women report that they do not consistently
experience orgasms with their partners (Laumann et al., 2005). Female
orgasmic disorder is not diagnosed unless the absence of orgasms is
persistent and troubling. About two-thirds of women report that they
have faked an orgasm, and most say that they did so to try to protect
their partner’s feelings (Muehlenhard & Shippee, 2010). Many men are
unaware (or at least don’t report) that their partners don’t achieve
orgasms (Herbenick et al., 2010a).

Women’s problems reaching orgasm are distinct from problems
with sexual arousal. Many women achieve arousal during sexual
activity but then do not reach orgasm. Indeed, laboratory
research has shown that arousal levels while viewing erotic stimuli
do not distinguish women with orgasmic disorder from those
without orgasmic disorder (Meston & Gorzalka, 1995). The DSM-5
includes two orgasmic disorders of men: premature ejaculation,
defined by ejaculation that occurs too quickly, and delayed ejaculation
disorder, defined by persistent difficulty in ejaculating. Although
researchers do not know how many men meet formal diagnostic
criteria, 20 to 30 percent of men reported premature ejaculation
and 10 to 20 percent of men reported that they had trouble
reaching orgasm for at least a couple of months in the past year in
the Laumann survey (2005). Although brief periods of symptoms
may be fairly common, less than 3 percent of men acknowledged
symptoms of premature ejaculation lasting for 6 months or more
(Segraves, 2010). The criteria for premature ejaculation are drawn
from diagnostic criteria used by the International Society for Sexual
Medicine (McMahon, Althof, Waldinger, et al., 2008).

The diagnosis of orgasmic dysfunction in women is complicated by the fact that the
subjective quality of orgasm varies widely among women, within the same woman
from time to time, and in regard to mode of stimulation (Graham, 2010). Nevertheless,
according to DSM-5, female orgasmic disorder can be diagnosed in women who are
readily sexually excitable and who otherwise enjoy sexual activity but who show
persistent or recurrent delay in or absence of orgasm following a normal sexual
excitement phase and who are distressed by this (see “DSM-5 Criteria” on p. 433). Of
these women, many do not routinely experience orgasm during sexual intercourse
without direct supplemental stimulation of the clitoris; indeed, this pattern is so
common that it is generally not considered dysfunctional (Meston & Bradford,
2007). A small percentage of women are able to achieve orgasm only through direct
mechanical stimulation of the clitoris, as in vigorous digital manipulation, oral
stimulation, or the use of an electric vibrator. Even fewer are unable to have the
experience under any known conditions of stimulation; this condition, which is called
lifelong orgasmic dysfunction, is analogous to lifelong erectile disorder in males. More
commonly, women experience difficulty having an orgasm only in certain
situations or were able to achieve orgasm in the past but currently can rarely do so
(Meston & Bradford, 2007). Laumann et al. (1999) found that rates of this disorder are
highest in the 21- to 24-year-old age category and decline thereafter, and other studies
have estimated that about one in three or four women report having had significant
orgasmic difficulties in the past year (Meston & Bradford, 2007).

What causes female orgasmic disorder is not well understood, but a multitude
of contributory factors have been hypothesized. For example, some women feel
fearful and inadequate in sexual relations. A woman may be uncertain whether
her partner finds her sexually attractive, and this may lead to anxiety and
tension, which then interfere with her sexual enjoyment. Or she may feel
inadequate or experience sexual guilt (especially common in religious women)
because she is unable to have an orgasm or does so infrequently. Sometimes a
nonorgasmic woman will pretend to have orgasms to make her sexual
partner feel fully adequate. The longer a woman maintains such a pretense,
however, the more likely she is to become confused and frustrated; in addition,
she is likely to resent her partner for being insensitive to her real feelings and
needs. This in turn only adds to her sexual difficulties. Possible biological
causal factors sometimes contributing to orgasmic difficulties in women (as
they do in men) include intake of the SSRIs as antidepressant medications.
Many medical conditions already mentioned with other sexual disorders are
also sometimes associated with orgasmic difficulties (Meston & Rellini, 2008).
Recent evidence suggests that differences between women in their genital
anatomy may allow some women to have orgasms during intercourse more
easily than other women can (Wallen & Lloyd, 2011).

Female Sexual Interest/Arousal Disorder

Diagnostic Criteria
A. Lack of, or significantly reduced, sexual interest/arousal , as manifested by at least three of the following:
1 . Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive to a partner's attempts to initiate.
4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-
1 00%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/ erotic cues (e .
g . , written , verbal, visual) .
6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately
75%-1 00%) sexual encounters (in identified situational contexts or, if generalized, in all contexts) .
B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexuai mental disorder or as a consequence of
severe relationship distress (e.g . , partner violence) or other significant stressors and is not attributable to the
effects of a substance/medication or another medical condition.

Specify whether:
Acqu i red : The distu rbance began after a period of relatively
normal sexual function .
Specify whether:
General ized : Not limited to certain types of stimulation,
Situational : Only occurs with certain types of stimulation,
A.
Criterion A.

Prevalence
The prevalence of female sexual interest/ arousal disorder, as
defined in this manual, is unknown. The prevalence of low
sexual desire and of problems with sexual arousal (with and
without associated distress), as defined by DSM-IV or ICD-10,
may vary markedly in relation to age, cultural setting, duration
of symptoms, and presence of distress. Regarding duration of
symptoms, there are striking differences in prevalence estimates
between short-term and persistent problems related to lack of
sexual interest. When distress about
sexual functioning is required, prevalence estimates are
markedly lower. Some older women report less distress about
low sexual desire than younger women, although sexual
desire may decrease with age.

By definition, lifelong female sexual interest/ arousal disorder suggests that the
lack of sexual interest or arousal has been present for the woman's entire sexual
life. For Criteria A3, A4, and A6, which assess functioning during sexual
activity, a subtype of lifelong would mean presence of symptoms since the
individual's first sexual experiences. The acquired subtype would be assigned if
the difficulties with sexual interest or arousal developed after a period of
nonproblematic sexual functioning. Adaptive and normative changes in
sexual functioning may result from partner-related, interpersonal, or
personal events and may be transient in nature. However, persistence of
symptoms for approximately 6 months or more would constitute a sexual
dysfunction. There are normative changes in sexual interest and arousal across
the life span. Furthermore, women in relationships of longer duration are
more likely to report engaging in sex despite no obvious feelings of sexual
desire at the outset of a sexual encounter compared with women in shorter-
duration relationships. Vaginal dryness in older women is related to age
and menopausal status.

There is marked variability in prevalence rates of low desire
across cultures. Lower rates of sexual desire may be more
common among East Asian women compared with Euro-
Canadian women. Although the lower levels of sexual desire
and arousal found in men and women from East Asian
countries compared with Euro-American groups may reflect
less interest in sex in those cultures, the possibility remains
that such group differences are an artifact of the measures
used to quantify desire. A judgment about whether low sexual
desire reported by a woman from a certain ethno-cultural group
meets criteria for female sexual interest/ arousal disorder must
take into account the fact that different cultures may pathologize
some behaviors and not others.

Gender-Related Diagnostic Issues
By definition, the diagnosis of female sexual
interest/ arousal disorder is only given to
women. Distressing difficulties with sexual
desire in men would be considered under male
hypoactive sexual desire disorder.

Comorbidity
Comorbidity between sexual interest/ arousal problems
and other sexual difficulties is extremely common. Sexual
distress and dissatisfaction with sex life are also highly
correlated in women with low sexual desire. Distressing
low desire is associated with depression, thyroid
problems, anxiety, urinary incontinence, and other
medical factors. Arthritis and inflammatory or irritable
bowel disease are also associated with sexual arousal
problems. Low desire appears to be comorbid with
depression, sexual and physical abuse in adulthood,
global mental functioning, and use of alcohol.

Disorders Involving Sexual Interest,
Desire, and Arousal
The DSM-5 includes three disorders relevant to sexual interest,
desire, and arousal. Female sexual interest/arousal disorder
refers to persistent deficits in sexual interest (sexual fantasies
or urges), biological arousal, or subjective arousal (see p. 369
for diagnostic criteria). For men, the DSM-5 diagnoses consider
sexual interest and arousal separately. Male hypoactive sexual
desire disorder refers to deficient or absent sexual fantasies
and urges, and erectile disorder refers to failure to attain or
maintain an erection through completion of the sexual
activity. It is important to rule out biological explanations for
these symptoms for both men and women. For example,
laboratory tests of hormone levels are a routine part of
assessment for postmenopausal women (Bartlik & Goldberg,
2000).

Among people seeking treatment for sexual dysfunctions,
more than half complain of low desire. Diagnoses related
to low sexual desire became more common among men
and women seeking treatment from the 1970s to the 1990s
(Beck, 1995). As Table 12.3 shows, women are more
likely than men to report at least occasional concerns
about their level of sexual desire. Postmenopausal women
are two to four times as likely as women in their 20s are to
report low sexual desire. On the other hand, older
women are less likely to be distressed over this low
sexual desire (Derogatis & Burnett, 2008). Occasional
symptoms of erectile disorder are the most common
sexual concern among men, with rates ranging from 13
to 28 percent, depending on the country (Laumann et
al., 2005).

Male erectile disorder increases greatly with age,
with as many as 15 percent of men in their 70s
reporting erectile disorder (Feldman, Goldstein,
Hatzichristou, et al., 1994) and as many as 70
percent reporting occasional erectile dysfunction
(Kim & Lipshultz, 1997). Of all the DSM-5 diagnoses,
the sexual desire disorders, often colloquially referred
to as low sex drive, seem the most subjective. How
often should a person want sex? And with what
intensity? Often, partners are the ones who encourage
a person to see a clinician.

The hypoactive desire category may owe its existence
to the high expectations some people have about being
sexual. Data attest to the significance of subjective and
cultural factors in defining low sex drive; for example,
hypoactive sexual desire disorder is reported more
often by American men than by British (Hawton,
Catalan, Martin, et al., 1986) or German men
(Arentewicz & Schmidt, 1983) despite similar levels
of sexual activity across these cultures. Cultural
norms seem to influence perceptions of how much
sex a person “should” want.

As shown in Figure 12.4, DSM-IV-TR distinguishes
sexual desire disorder from sexual arousal disorder in
women. The decision to combine these disorders into
one diagnosis in the DSM-5 is based on the evidence
we described earlier about desire and arousal being
hard to distinguish for many women. Indeed, almost
all women who seek treatment for sexual arousal
disorder also report low desire (Segraves &
Segraves, 1991). The DSM-5 categories are designed
to fit with these changes in understanding of sexual
dysfunctions. In DSM-IV-TR, female sexual arousal
disorder is based on inadequate genital arousal.

Research suggests that women with low
desire tend to have low levels of sexual
arousal during sexual activity and vice versa.
There are no common syndromes in which
women with low sexual desire have normal
levels of sexual arousal, or vice versa. Thus for
women, DSM-5 has combined dysfunctionally
low desire with dysfunctionally low sexual
arousal in the disorder Female Sexual
Interest/Arousal Disorder.

Another interesting change from DSM-IV-TR to
DSM-5 is the elimination of sexual aversion disorder,
in which a person shows extreme aversion to, and
avoidance of, all genital sexual contact with a partner.
A leading researcher on sexual dysfunction has
recently argued that sexual aversion disorder should be
considered as an anxiety disorder akin to simple
phobias rather than as a sexual dysfunction (Brotto,
2010). Perhaps this is one reason why it was
eliminated from the Sexual Dysfunctions section of
DSM-5.

Research on the degree to which the diminished sex drive has a
biological basis remains controversial, but in many (and perhaps
most) cases (and especially in women), psychological factors
appear to be more important than biological factors (Meston &
Bradford, 2007; Segraves & Woodard, 2006). In the past, these
people usually came to the attention of clinicians primarily at the
request of their partners (who typically complained of
insufficient sexual interaction), but as public knowledge about
the frequency of this disorder has increased, more people are
presenting for treatment on their own. This fact exposes one
problem with the diagnosis, because it is known that preferences
for frequency of sexual contact vary widely among otherwise
normal individuals. Who is to decide what is “not enough”?
DSM-5 explicitly indicates that this judgment is left to the
clinician, taking into account the person’s age and the context of
his or her life.

Prior or current depression or anxiety disorders may contribute to many cases
of sexual desire disorders (Meston & Bradford, 2007). Although sexual desire
disorders typically occur in the absence of obvious physical pathology, there is
evidence that physical factors sometimes play a role. For example, in both men
and women, sexual desire depends in part on testosterone (Alexander &
Sherwin, 1993; Meston & Rellini, 2008). That sexual desire problems increase
with age may be in part attributable to declining levels of testosterone, but
testosterone replacement therapy is usually not beneficial, except in men and
women who have very low testosterone levels (Meston & Rellini, 2008). In
addition, medications from the SSRI category of antidepressants (see Chapters
7 and 16) not uncommonly reduce sexual desire. Different antidepressants vary
considerably in their negative effect on sexual function, and psychiatrists have
not always paid close enough attention to the impact that these effects have on
patients’ general functioning (Serretti & Chiesa, 2009). Psychological factors
thought to contribute to sexual desire disorders include low relationship
satisfaction, daily hassles and worries, increased disagreements and conflicts,
low levels of feelings, and reduced cues of emotional bonding (Meston &
Rellini, 2008). In some cases a history of unwanted sexual experiences such as
rape may also contribute.

Among the DSM-IV-TR diagnoses hypoactive sexual
desire disorder was the most common female sexual
dysfunction in the United States and most other countries
across the world (Laumann et al., 1994, 1999, 2005), and
there is no reason to doubt that female sexual
interest/arousal disorder is the most common DSM-5
female sexual dysfunction. Despite this fact, disorders of
female sexual desire have inspired far less research into its
origins and treatment than have most male dysfunctions,
especially erectile disorder and early ejaculation. One
main reason for this disparity is doubtless the great
importance that many men place on their ability to
perform sexually. Until recently, there has also been a
more general neglect of female sexuality and an implicit
(though largely mistaken) societal attitude that women
simply do not care much about sex.

Fortunately, this has been changing gradually in recent years
(e.g., Althof et al., 2005; Basson, 2005; Meston & Bradford,
2007). One emerging finding is that it is uncommon for women
to cite sexual desire as a reason or incentive for sexual activity.
For many women, sexual desire is experienced only after
sexual stimuli have led to subjective sexual arousal (Basson,
2003a; Meston & Bradford, 2007), and for others, motivation
for sexual activity may involve a desire for increasing
emotional intimacy or increasing one’s sense of well-being
and one’s self-image as an attractive female (Basson, 2003,
2005). Thus, some research suggests that the supposedly linear
sequence of desire leading to arousal, leading to orgasm that was
originally posited for women as well as men by Masters and
Johnson (1970) and the DSM is not very accurate for women
(e.g., Basson, 2005; Meston &
Bradford, 2007).

Although the causes of low sexual arousal are not
well understood, possible reasons range from early
sexual traumatization; to excessive and distorted
socialization about the “evils” of sex; to dislike of,
or disgust with, a current partner’s sexuality; to
her partner’s restricted repertoire of sexual
activity. One interesting study also found that women
with sexual arousal disorder show lower tactile
sensitivity than is seen in other women; the lower their
level of tactile sensitivity, the more severe their
arousal dysfunction (Frolich & Meston, 2005).

Biological causal factors include the use of SSRIs for
anxiety and depression, the occurrence of certain
medical illnesses (e.g., spinal cord injury, cancer
treatment, diabetes, etc.), and the decreases in estrogen
levels that occur during and following menopause.
Some difficulties with physiological arousal and
lubrication have been noted in 20 to 30 percent of
sexually active women and in as many as 44 percent of
postmenopausal women. Moreover, arousal problems in
women very frequently co-occur with low levels of sexual
desire; thus the new DSM-5 combined diagnosis. Indeed,
having problems with sexual arousal may often lead to
lack of desire (Meston & Bradford, 2007).

Genito- Pelvic Pain/Penetration Disorder

Diagnostic Criteria
A. Persistent or recurrent difficulties with one (or more) of the following:
1 . Vaginal penetration during intercourse.
2. Marked vulvo-vaginal or pelvic pain during vaginal intercourse or
penetration attempts.
3. Marked fear or anxiety about vulvo-vaginal or pelvic pain in anticipation of,
during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted
vaginal penetration.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C . The symptoms in Criterion A cause clinically significant distress in the
individual .
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of a severe relationship distress (e.g . , partner
violence) or other significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

Specify whether:
Lifelong: The disturbance has been present since the
individual became sexually active.
Acquired : The disturbance began after a period of
relatively normal sexual function .
Mild: Evidence of mild distress over the symptoms in
Criterion A.
Moderate: Evidence of moderate distress over the
Severe: Evidence of severe or extreme distress over
the symptoms in Criterion A.

Prevalence
The prevalence of genito-pelvic pain/penetration
disorder is unknown. However, approximately
15% of women in North America report
recurrent pain during intercourse. Difficulties
having intercourse appear to be a frequent
referral to sexual dysfunction clinics and to
specialist clinicians.

The development and course of genito-pelvic pain/penetration disorder is unclear.
Because women generally do not seek treatment until they experience problems in
sexual functioning, it can, in general, be difficult to characterize genito-pelvic
pain/penetration disorder as lifelong (primary) or acquired (secondary). Although
women typically come to clinical attention after the initiation of sexual activity, there
are often earlier clinical signs. For example, difficulty with or the avoidance of use of
tampons is an important predictor of later problems. Difficulties with vaginal
penetration (inability or fear or pain) may not be obvious until sexual intercourse is
attempted. Even once intercourse is attempted, the frequency of attempts may not be
significant or regular. In cases where it is difficult to establish whether symptomatology
is lifelong or acquired, it is useful to determine the presence of any consistent period of
successful pain-, fear-, and tension-free intercourse. If the experience of such a period
can be established, then genito-pelvic pain/penetration disorder can be characterized as
acquired. Once symptomatology is well established for a period of approximately 6
months, the probability of spontaneous and significant symptomatic remission appears
to diminish. Complaints related to genito-pelvic pain peak during early adulthood and
in the peri and postmenopausal period. Women with complaints about difficulty having
intercourse appear to be primarily premenopausal. There may also be an increase in
genito-pelvic pain-related symptoms in the postpartum period.

In the past, inadequate sexual education and religious
orthodoxy have often been considered to be culturally
related predisposing factors to the DSM-IV diagnosis
of vaginismus. This perception appears to be
confirmed by recent reports from Turkey, a primarily
Muslim country, indicating a strikingly high
prevalence for the disorder. However, most available
research, although limited in scope, does not support
this notion (Lahaie et al. 2010).

By definition, the diagnosis of genito-pelvic
pain/penetration disorder is only given to women.
There is relatively new research concerning urological
chronic pelvic pain syndrome in men, suggesting that
men may experience some similar problems. The
research and clinical experience are not sufficiently
developed yet to justify the application of this
diagnosis to men. Other specified sexual dysfunction
or unspecified sexual dysfunction may be diagnosed in
men appearing to fit this pattern.

Comorbidity
Comorbidity between genito-pelvic pain/penetration disorder
and other sexual difficulties appears to be common. Comorbidity
with relationship distress is also common. This is not surprising,
since in Western cultures the inability to have (pain-free)
intercourse with a desired partner and the avoidance of sexual
opportunities may be either a contributing factor to or the result
of other sexual or relationship problems. Because pelvic floor
symptoms are implicated in the diagnosis of genito-pelvic pain /
penetration disorder, there is likely to be a higher prevalence of
other disorders related to the pelvic floor or reproductive organs
(e.g., interstitial cystitis, constipation, vaginal infection,
endometriosis, irritable bowel syndrome).

Sexual Pain Disorders
In the DSM-5, genito-pelvic pain/penetration disorder is defined by persistent or recurrent pain
during intercourse. Some women report that the pain starts at entry, whereas others report pain
only after penetration (Meana, Binik, Khalife, et al., 1997). A first step in making this diagnosis is
ensuring that the pain is not caused by a medical problem, such as an infection (McCormick,
1999), or, in women, by a lack of vaginal lubrication due to low desire or postmenopausal
changes. Although sexual pain disorders can be diagnosed in both men and women, we focus on
women because it is extremely rare for men to seek treatment for these concerns.
Most women with this sexual pain disorder experience sexual arousal and can have orgasms from
manual or oral stimulation that does not involve penetration. Women who experience pain when
attempting sexual intercourse show normative sexual arousal to films of oral sex, but, not
surprisingly, their arousal declines when they watch a depiction of intercourse (Wouda, Hartman,
Bakker, et al., 1998). Prevalence rates for occasional symptoms of pain during intercourse among
women have been estimated to range from 10 to 30 percent (Laumann et al., 2005). This is a very
common complaint heard by gynecologists (Leiblum, 1997).
As shown in Figure 12.4, the DSM-IV-TR distinguished two pain disorders: dyspareunia and
vaginismus. Dyspareunia is defined by persistent or recurrent pain during sexual intercourse.
Vaginismus is defined by involuntary muscle spasms of the outer third of the vagina to a degree
that makes intercourse impossible. These disorders are combined in the DSM-5 because it has
become clear that they typically co-occur. In research that directly measures muscle tension of
the vagina, women with dyspareunia and vaginismus demonstrate comparable levels of muscle
tension (Binik, 2010). Given that dyspareunia and vaginismus are virtually impossible to
discriminate in practice, combining them seems to be a good idea.

This disorder represents an important change in DSM-5. In past versions of
DSM-IV-TR were distinguished two “sexual pain disorders”: vaginismus and
dyspareunia. The disorders have been combined in DSM-5 because scientific
research did not support their distinction (Binik, 2010a, 2010b). In particular,
vaginismus has been believed to be an involuntary spasm of the muscles near
the entrance of the vagina, preventing penetration and sexual intercourse.
However, no scientific evidence exists that women with vaginismus have
vaginal spasms or that vaginismus could be reliably diagnosed. In contrast,
women diagnosed with vaginismus commonly complained of pain during
penetration and anxiety before and during sexual encounters (Reissing et al.,
2003). The latter symptoms made the distinction between vaginismus and
dyspareunia (which is genital pain associated with sexual intercourse) unclear.
That is, women with a past diagnosis of vaginismus were not clearly distinct
from those with a past diagnosis of dyspareunia. Furthermore, as noted, the
hallmark “symptom” of vaginismus, does not clearly occur, while the hallmark
symptom of dyspareunia, genital pain during penetration, occurs commonly in
women with vaginismus as well. Thus, in DSM-5 there is only one genito-
pelvic pain/penetration disorder, which combines the genital pain of
dyspareunia with muscle tension (not
muscle spasms) and fear and anxiety related to genital pain or penetrative
sexual activity.

Based on past studies of women with “sexual pain disorders” it appears that
genito-pelvic pain/penetration disorder is more likely to have organic than
psychological causes. Some examples of physical causes include acute or
chronic infections or inflammations of the vagina or internal reproductive
organs, vaginal atrophy that occurs with aging, scars from vaginal tearing, or
insufficiency of sexual arousal. Understandably, dyspareunia is often associated
with vaginismus, and some have questioned whether they are indeed distinct
disorders. Recently, some prominent sex researchers have argued against
classifying sexual pain disorders as “sexual disorders” rather than as “pain
disorders” (e.g., Binik, 2005; Binik et al., 2007). For example, Binik and
colleagues argue that the pain in “sexual pain disorders” is qualitatively similar
to the pain in other, nonsexual areas of the body and that the causes of “sexual
pain disorder” are more similar to the causes of other pain disorders (e.g., lower
back pain) than to the causes of other sexual dysfunctions. This concern is
represented in the new name for the diagnosis (i.e., genito-pelvic
pain/penetration disorder). It is also interesting to note in this regard that the
disorder sometimes precedes any sexual experiences—for example, in some
adolescent girls trying to use a tampon.

Male Hypoactive Sexual Desire Disorder

Diagnostic Criteria
A. Persistently or recurrently deficient (or absent) sexual/erotic
thoughts or fantasies and desire for sexual activity. The judgment
of deficiency is made by the clinician , taking into account
factors that affect sexual functioning, such as age and general
and sociocultural
contexts of the individual's life.
C. The symptoms in Criterion A cause clinically significant
distress in the individual.
D . The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress or other significant stressors and is not
attributable to the effects of a substance/medication or another
medical condition.

Specify whether:
Acquired : The distu rbance began after a period of relatively
normal sexual function.
Specify whether:
Generaiized : Not limited to certain types of stimulation ,
Situational: Only occurs with certain types of stimulation ,
A.
Criterion A.

Prevalence
The prevalence of male hypoactive sexual desire
disorder varies depending on country of origin and
method of assessment. Approximately 6% of younger
men (ages 18-24 years)and 41% of older men (ages
66-74 years) have problems with sexual desire.
However, a persistent lack of interest in sex, lasting 6
months or more, affects only a small proportion of
men ages 16-44 (1 .8%).

By definition, lifelong male hypoactive sexual desire disorder
indicates that low or no sexual desire has always been present,
whereas the acquired subtype would be assigned if the man's low
desire developed after 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 sexual desire disorder.
There is a normative age-related decline in sexual 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 potency of sexual cues may
decrease with age and must be considered when evaluating men for
hypoactive sexual desire disorder.

There is marked variability in prevalence rates of low
desire across cultures, ranging from 12.5% in Northern
European men to 28% in Southeast Asian men ages
40-80 years. Just as there are higher rates of low desire
among East Asian subgroups of women, men of East
Asian ancestry also have higher rates of low desire.
Guilt about sex may mediate this association between
East Asian ethnicity and sexual desire in men.

In contrast to the classification of sexual disorders in
women, desire and arousal disorders have been
retained as separate constructs in men. Despite some
similarities in the experience of desire across men and
women, and the fact that desire fluctuates over time
and is dependent on contextual factors, men do report
a significantly higher intensity and frequency of sexual
desire compared with women.

Comorbidity
Depression and other mental disorders, as
well as endocrinological factors, are often
comorbid with male hypoactive sexual
desire disorder.

Hypoactive sexual desire disorder is diagnosed in men who have for at least 6
months been distressed or impaired due to low levels of sexual thoughts,
desires, or fantasies. Men given this diagnosis are also assessed for the course
of the dysfunction (i.e., lifelong or acquired) and possible causal factors,
including problems emanating from partners, relationships, cultural beliefs or
attitudes, personal vulnerabilities (e.g., poor body image), or medical
conditions. Despite the historically higher level of attention to male than to
female sexual dysfunctions, this is one disorder in men that has received
relatively little attention—and substantially less than its parallel disorder in
women (Brotto, 2010). In the large American survey conducted by Laumann et
al. (1999), men in the oldest cohort (50–59 years old) were three times more
likely to suffer from low desire compared with men in the youngest cohort (18–
29 years old). Predictors of low desire included daily alcohol use, stress,
unmarried status, and poorer health. In a large British survey, complaints of low
interest in sex was the most common problem reported by men (17.1 percent;
Mercer et al., 2003). However, only a small minority (1.8 percent) of the male
sample had low desire for the required 6 month period to qualify for diagnosis.
Most experts believe that male hypoactive sexual desire disorder is acquired or
situational rather than lifelong. Typical situational risk factors include
depression and relationship stress.

Diagnostic Criteria
A. A persistent or recurrent pattern of ejaculation occurring during partnered
sexual activity within approximately 1 minute following vaginal penetration
and before the individual wishes it.
Note: Although the diagnosis of premature (early) ejaculation may be applied to
individuals 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%-1 00%)
occasions of sexual activity (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 attributable to the effects of a substance/medication or
another medical condition.

Specify whether:
Lifelong: The disturbance has been present
since the individual became sexually active.
Acquired : The disturbance began after a period
of relatively normal sexual function.

Specify whether:
Generalized : Not limited to certain types of stimulation,
Situational: Only occu rs with certain types of
stimulation, situations, or partners.
Specify cu rrent severity:
Mild: Ejaculation occurring within approximately 30
seconds to 1 minute of vaginal penetration.
Moderate: Ejaculation occurring within approximately 1
5-30 seconds of vaginal penetration.
Severe: Ejaculation occurring prior to sexual activity, at
the start of sexual activity, or within approximately 1 5
seconds of vaginal penetration .

Prevalence
Estimates of the prevalence of premature (early)
ejaculation vary widely depending on the definition
utilized. Internationally, more than 20%-30% of men
ages 1 8-70 years report concern about how rapidly
they ejaculate. With the new definition of premature
(early) ejaculation (i.e., ejaculation occurring within
approximately 1 minute of vaginal penetration), only 1
%-3% of men would be diagnosed with the disorder.
Prevalence of premature (early) ejaculation may
increase with age.

By definition, lifelong premature (early) ejaculation starts during a male's initial
sexual experiences and persists thereafter. Some men may experience
premature (early) ejaculation during their initial sexual encounters but gain
ejaculatory control over time. It is the persistence of ejaculatory problems for
longer than 6 months that determines the diagnosis of premature (early)
ejaculation. In contrast, some men develop the disorder after a period of having
a normal ejaculatory 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 after the fourth decade of life. Lifelong is
relatively stable throughout life. Little is known about the course of acquired
premature (early) ejaculation. Reversal of medical conditions such as
hyperthyroidism and prostatitis appears to restore ejaculatory latencies to
baseline values. Lifelong premature (early) ejaculation begins with early sexual
experiences and persists throughout an individual's life. In approximately 20%
of men with premature (early) ejaculation, ejaculatory latencies decrease further
with age. Age and relationship length have been found to be negatively
associated with prevalence of premature (early) ejaculation.

Premature (early) ejaculation is a sexual disorder in
males. Males and their sexual partners may differ in
their perception of what constitutes an acceptable
ejaculatory latency. There may be increasing concerns
in females about early ejaculation in their sexual
partners,
which may be a reflection of changing societal
attitudes concerning female sexual activity.

Comorbidity
Premature (early) ejaculation may be associated with
erectile problems. In many cases, it may be difficult to
determine which difficulty preceded the other.
Lifelong premature (early) ejaculation may be
associated with certain anxiety disorders. Acquired
premature (early) ejaculation may be associated with
prostatitis, thyroid disease, or drug withdrawal (e.g.,
during opioid withdrawal).

In DSM-5 “premature ejaculation,” is called early ejaculation
disorder, the persistent and recurrent onset of orgasm and
ejaculation with minimal sexual stimulation. It may occur
before, on, or shortly after penetration and before the man wants
it to (see “DSM-5 Criteria” on p. 432). The average duration of
time to ejaculate in men with this problem is 15 seconds or 15
thrusts of intercourse. The consequences often include failure of
the partner to achieve satisfaction and, often, acute
embarrassment for the early ejaculating man, with disruptive
anxiety about recurrence on future occasions. Men who have had
this problem from their first sexual encounter often try to
diminish sexual excitement by avoiding stimulation, by self-
distracting, and by “spectatoring,” or psychologically taking the
role of an observer rather than a participant (Metz et al., 1997).
Early ejaculation decreases sexual and relationship satisfaction
both in men who have it and their partners (Graziottin & Althof,
2011).

An exact definition of prematurity is necessarily
somewhat arbitrary. For example, the age of a client must
be considered— the alleged “quick trigger” of the
younger man being more than a mere myth (McCarthy,
1989). Indeed, perhaps half of young men complain of
early ejaculation. Not surprisingly, early ejaculation is
most likely after a lengthy abstinence. DSM-5
acknowledges these many factors that may affect time to
ejaculation by noting that the diagnosis is made only if
ejaculation occurs before, on, or shortly after penetration
and before the man wants it to. Early ejaculation is the
most common male sexual dysfunction at least up to age
59 (Meston & Rellini, 2008; Segraves &
Althof, 2002).

In sexually normal men, the ejaculatory reflex is, to a
considerable extent, under voluntary control. They monitor their
sensations during sexual stimulation and are somehow able,
perhaps by judicious use of distraction, to forestall the point of
ejaculatory inevitability until they decide to “let go,” with the
average latency to ejaculation from penetration being 10 minutes
for men with no sexual problems. Men with early ejaculation are
for some reason unable to use this technique effectively.
Explanations have ranged from psychological factors such as
increased anxiety, to physiological factors such as increased
penile sensitivity and higher levels of arousal to sexual stimuli.
Presently, however, no explanation has received much empirical
support, and it is clear that none of these possible explanations
alone can account for all men with the problem (Meston &
Rellini, 2008).

Substance/Medication - Induced
Sexual Dysfunction

Diagnostic Criteria
Substance/Medication – Induced - Sexual Dysfunction
A . A clinically significant disturbance i n sexual function i s 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 Criterion 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 include 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
existence of an independent non-substance/medication-induced sexual dysfunction
(e. g . , a history of recurrent non-substance/medication-related episodes).
D . The disturbance does not occur exclusively during the cou rse of a delirium.
E . The disturbance causes clinically significant distress in the individual.

Specify if (see Table 1 in the chapter "Substance-Related and
Addictive Disorders" for diagnoses
associated with substance class) :
With onset during intoxication : If the criteria are met for
intoxication with the substance 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 medication or after a modification or change in use.
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.

PrevalenceThe prevalence and the incidence of substance/ medication-induced sexual
dysfunction are unclear, likely because of underreporting of treatment-emergent
sexual side effects. Data on substance/ medication-induced sexual dysfunction
typically concern the effects of antidepressant drugs. The prevalence of
antidepressant-induced sexual dysfunction varies in part depending on the
specific agent. Approximately 25%--80% of individuals taking monoamine
oxidase inhibitors, tricyclic antidepressants, serotonergic antidepressants, and
combined serotonergic-adrenergic antidepressants report sexual side effects.
There are differences in the incidence of sexual side effects between some
serotonergic and combined adrenergic-serotonergic antidepressants, although it
is unclear if these differences are clinically significant.
Approximately 50% of individuals taking antipsychotic medications will
experience adverse sexual side effects, including problems with sexual desire,
erection, lubrication, ejaculation, or orgasm. The incidence of these side effects
among different antipsychotic agents is unclear.

Exact prevalence and incidence of sexual dysfunctions among
users of non-psychiatric medications such as cardiovascular,
cytotoxic, gastrointestinal, and hormonal agents are unknown.
Elevated rates of sexual dysfunction have been reported with
methadone or high-dose opioid drugs for pain. There are
increased rates of decreased sexual desire, erectile dysfunction,
and difficulty reaching orgasm associated with illicit substance
use. The prevalence of sexual problems appears related to
chronic drug abuse and appears higher in individuals who abuse
heroin (approximately 60%-70%) than in individuals who abuse
amphetamines or 3,4-methylenedioxymethamphetamine (i.e.,
MDMA, ecstasy). Elevated rates of sexual dysfunction are also
seen in individuals receiving methadone but are seldom
reported by patients receiving buprenorphine. Chronic alcohol
abuse and chronic nicotine abuse are related to higher rates of
erectile problems.

The onset of antidepressant-induced sexual dysfunction may be
as early as 8 days after the agent is first taken. Approximately
30% of individuals with mild to moderate orgasm delay will
experience spontaneous remission of the dysfunction within 6
months. In some cases, serotonin reuptake inhibitor-induced
sexual dysfunction may persist after the agent is discontinued.
The time to onset of sexual dysfunction after initiation of
antipsychotic
drugs or drugs of abuse is unknown. It is probable that the
adverse effects of nicotine and alcohol may not appear until after
years 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.

Some gender differences in sexual side effects
may exist.

Other Specified Sexual Dysfunction

This category applies to presentations in which
symptoms characteristic of a sexual dysfunction that
cause clinically significant distress 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 criteria 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

This category applies to presentations in which
symptoms characteristic of a sexual dysfunction that
cause clinically significant distress 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 dysfunction, and includes presentations
for which there is insufficient information to make a
more specific diagnosis.

Etiology of Sexual Dysfunctions
In their widely acclaimed book Human Sexual Inadequacy, Masters and
Johnson (1970) drew on their case studies to publish a theory of why sexual
dysfunctions develop. Masters and Johnson used a two-tier model of
immediate and distal causes to conceptualize the etiology of human sexual
inadequacy (see Figure 12.5). The immediate causes can be distilled down to
two: fears about performance and the adoption of a spectator role. Fears about
performance involve concerns with how one is “performing” during sex.
Spectator role refers to being an observer rather than a participant in a sexual
experience. Both involve a focus on sexual performancethat impedes the
natural sexual responses. These immediate causes of sexual dysfunctions
were hypothesized to have one or more historical antecedents, such as
sociocultural influences, biological causes, or sexual traumas. Masters and
Johnson’s work set the stage for researchers to begin systematically studying
risk factors for sexual dysfunction. We turn now to research on the causes of
sexual dysfunctions. Figure 12.6 summarizes factors related to sexual
dysfunctions. One thing is clear—sexual functioning is complex and
multifaceted.

Biological Factors
As noted above, a first step in making a diagnosis of sexual dysfunction is to rule out
medical diseases as the cause. The DSM-5 includes separate diagnoses for sexual
dysfunctions that are caused by medical illnesses. Some have criticized this division in
the diagnoses because sexual dysfunctions often have some biological and some
psychological contributions. Biological causes of sexual dysfunctions can include
diseases such as atherosclerosis, diabetes, multiple sclerosis, and spinal cord
injury; low levels of testosterone or estrogen; heavy alcohol use before sex; chronic
alcohol dependence; and heavy cigarette smoking (Bach, Wincze, & Barlow, 2001).
Certain medications, such as antihypertensive drugs and especially selective
serotonin reuptake inhibitor (SSRI) antidepressant drugs like Prozac and Zoloft,
have effects on sexual function, including delayed orgasm, decreased libido, and
diminished lubrication (Segraves, 2003). Among older men who develop erectile
dysfunction, vascular conditions often are involved (Wylie & MacInnes, 2005).
Beyond these general considerations, some biological factors may be specific to
certain sexual dysfunctions. As one example, laboratory-based evidence suggests
that men with premature ejaculation are more sexually responsive to tactile
stimulation than men who don’t have this problem (Rowland et al., 1996). Perhaps,
then, their penises are very sensitive, causing them to ejaculate more quickly.

Psychosocial Factors
Some sexual dysfunctions can be traced to rape, childhood sexual abuse, or
other degrading encounters. Sexual abuse during childhood is associated
with diminished arousal and desire, and, among men, with double the rate
of premature ejaculation (Laumann et al., 1999). See Focus on Discovery
12.3, later in this chapter, for a discussion of childhood sexual abuse and its
repercussions. Beyond the role of traumatic experiences, it is important to
consider the benefits of positive experiences—many people with sexual
problems lack knowledge and skill because they have not had
opportunities to learn about their sexuality (Lopiccolo & Hogan, 1979).
Broader relationship problems often interfere with sexual arousal and
pleasure (Bach et al., 2001). For women, concerns about a partner’s
affection appear particularly correlated with sexual satisfaction (Nobre &
Pinto-Gouveia, 2008). For people who tend to be anxious about their
relationships, sexual problems may exacerbate underlying worries about
relationship security (Birnbaum, Reis, Mikulincer, et al., 2006).

As one might expect, people who are angry with their partners are
less likely to want sex (Beck & Bozman, 1995). Even in couples who
are satisfied in other realms of the relationship, poor communication
can contribute to sexual dysfunction. For any number of reasons,
including embarrassment, worry about the partner’s feelings, or fear,
one lover may not tell the other about preferences even if a partner is
engaging in unstimulating or even aversive behaviors. Depression
and anxiety increase the risk of sexual dysfunctions (Hayes,
Dennerstein, Bennett, et al., 2008). People who are depressed are
more than twice as likely as nondepressed people (62 percent to
26 percent) to have a sexual dysfunction (Angst, 1998). People
with panic disorder, who are often fearful of physical sensations
like rapid heart rate and sweating, are also at risk for sexual
dysfunction (Sbrocco, Weisberg, Barlow, et al., 1997). Anxiety and
depression are particularly comorbid with sexual pain (Meana,
Binik, Khalife, et al., 1998) and with disorders involving low sexual
desire and arousal (Araujo, Durante, Feldman, et al., 1998;
Hartmann, Heiser, Ruffer-Hesse, et al., 2002).

Beyond evidence that depression and anxiety are
detrimental, several studies suggest that low general
physiological arousal can interfere with specific sexual
arousal. Meston and Gorzalka (1995) examined the role
of arousal by assigning women to exercise or no-exercise
conditions, and then asking women to watch erotic films.
Consistent with the positive role of higher arousal,
exercise facilitated sexual arousal. No wonder, then,
that exhausted couples, turning to sex after a full day
of work, parenting, socializing, and other roles, can
encounter problems with sexuality. Too much stress
and exhaustion clearly impede sexual functioning
(Morokoff & Gilliland, 1993).

Negative cognitions, such as worries about pregnancy
or AIDS, negative attitudes about sex, or concerns
about the partner, interfere with sexual functioning
(Reissing, Binik, & Khalife, 1999). But as Masters and
Johnson first suggested, cognitions concerning sexual
performance are particularly important (Carvalho &
Nobre, 2010). Consider the idea that variability in sexual
performance is common; a stressful day, a distracting
context, a relationship concern, or any number of other
issues may diminish sexual responsiveness. The key issue
may be how people think about their diminished physical
response when it happens. One theory is that people who
blame themselves for decreased sexual performance
will be more likely to develop recurrent problems.

In a test of the role of self-blame and erectile
dysfunction, Weisberg and colleagues (2001) asked 52
male participants to watch erotic videos. During the
videos, their sexual arousal (penile circumference) was
measured using a penile plethysmograph (see Figure
12.3). Regardless of their actual arousal, the men
were given false feedback that the size of their
erection was smaller than that typically measured
among aroused men. Men were randomly assigned
to receive two different explanations for this false
feedback. In the first, they were told that the films
did not seem to be working for most men (external
explanation).

In the second, they were told that the pattern of their
responses on questionnaires about sexuality might help
explain the low arousal (internal explanation). After
receiving this feedback, the men were asked to watch one
more film. The men who were given an internal
explanation reported less arousal and also showed less
physiological evidence of arousal during this film than
those given an external explanation. These results,
then, support the idea that people who blame
themselves when their body doesn’t perform will
experience diminished subsequent arousal. Needless to
say, men in this study were carefully debriefed after
the experiment!

Whereas men may worry about their erection,
women can suffer from intrusive thoughts about
their attractiveness. Many women struggle with
negative intrusive thoughts about their weight or
appearance during sex (Pujols, Seal, & Meston,
2010). Beyond concerns about performance and
attractiveness, Masters and Johnson found that
many of their sexually dysfunctional patients had
learned negative views of sexuality from their social
and cultural surroundings. For example, some
religions and cultures may discourage sexuality for the
sake of pleasure, particularly outside marriage.

Other cultures may disapprove of sexual initiative or
behavior among women, other than for the sake of
procreation. One female patient suffering from a
lack of sexual desire, for example, had been taught
as she was growing up not to look at herself naked
in the mirror and that intercourse was reserved for
marriage and then only to be endured for purposes
of having children. Guilt about engaging in sexual
behavior appears to vary by cultural group and can
inhibit sexual desire (Woo, Brotto, & Gorzalka,
2011).

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