Workshop on “Sexual Dysfunction: A Hidden Chapter in Psychiatry”. Organized by: Psychiatric Sex Clinic Department of Psychiatry, BSMMU.

1. Workshop on
“Sexual Dysfunction: A Hidden Chapter in
Psychiatry”
Organized by: Psychiatric Sex Clinic
Department of Psychiatry, BSMMU.

2. Classification and Diagnosis of Sexual Dysfunctions
Presented by:
Dr. S.M. Yasir Arafat
Phase B Resident, Psychiatry, BSMMU
Editorial Member: Int J Psych, J Behav Health, EC Psy
& Psych & Int J Percept in Public Health
November 06, 2016.

3. Content
Changes in classification
DSM-IV classifications
DSM-5 classifications
DSM diagnostic criteria
Question & Answer
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4. Introduction
Sexual dysfunction is one of the most common psychiatric disorders,
but it is often ignored in assessment
It can be primary or secondary (a result of psychiatric disorder or
medication)
Sexuality is a hidden topic and not talked much in countries like
Bangladesh with strong cultural & religious myths and
Having health seeking behavior of availing traditional healers and lack
of specialized service center
One of the basic challenges is about defining what makes a sexual
problem become a dysfunction or disorder
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5. Evolution
DSM-I: 1952, 102 Diagnostic Criteria, Freudian Paradigm
Sexual Deviations and Psychophysiological Genitourinary Disorders
Frigidity: the condition as the inability of a woman to have a vaginal orgasm
DSM-II: 1968, 182 Diagnostic Criteria, Psychodynamic Paradigm
dyspareunia and impotence
DSM-III: 1980, 265 Diagnostic Criteria, Biological Paradigm
Psychosexual Disorders’: Gender identity disorders, paraphilias, psychosexual
dysfunctions
Inhibited sexual desire, Inhibited sexual excitement, Inhibited (female) orgasm,
Functional dyspareunia, F vaginismus
The DSM-III-R of 1987 changed ‘Psychosexual Dysfunctions’ to ‘Sexual
Dysfunctions’,
DSM-IV: 1994, 297 Diagnostic Criteria Biopsychosocial Approach
DSM-5: 2013 arafatdmc62@gmail.com; 01713272917

6. ICD-10 Classification
Desire, Arousal, Orgasm, Pain
Lack/loss of sexual desire
Sexual aversion/lack of sexual enjoyment
Excessive sexual drive
Failure of genital response
Orgasmic dysfunction
Premature ejaculation
Non-organic dyspareunia
Non-organic vaginismus
Other sexual dysfunction

7. DSM-IV TR Classifications
Hypoactive Sexual Desire Disorder
Sexual Aversion Disorder
Female Sexual Arousal Disorder
Male Erectile Disorder
Female Orgasmic Disorder
Male Orgasmic Disorder
Premature Ejaculation
Dyspareunia
Vaginismus
Sexual Dysfunction Due to GMC, Substance-Induced, NOS

8. DSM-5 Classifications
Male Hypoactive Sexual Desire Disorder
Erectile Disorder
Premature (Early) Ejaculation
Delayed Ejaculation
Female Sexual Interest/Arousal Disorder
Female Orgasmic Disorder
Genito-Pelvic Pain/Penetration Disorder
Substance/ Medication-Induced, Other Specified, & Unspecified
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9. DSM-IV TR & DSM-5 Classifications
Female hypoactive desire disorder
Female arousal disorder
Female sexual interest/arousal
disorder
Dyspareunia
Vaginismus
Male erectile disorder
Hypoactive sexual desire disorder
Premature ejaculation
Male orgasmic disorder
Female orgasmic disorder
Genito-pelvic pain/penetration
disorder
Erectile disorder
Male Hypoactive sexual desire disorder
Premature (Early) ejaculation
Delayed Ejaculation
Unchanged
Sexual aversion disorder Deleted
GMC, Substance, Unspecified Combined, Unspecified, Other Specified

10. Male Hypoactive Sexual Desire Disorder
The mono-symptomatic criterion
Low desire for sex and absent sexual thoughts or fantasies
Duration 6 months
The disease causes marked distress
No 75-100% criterion, clinician judgement
The disease is not a result of medical illness, another psychological
disorder, or the effects of a drug
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11. Erectile Disorder
At least one of three symptoms 75% to 100% of the time
Struggle to achieve an erection
Struggle maintaining an erection until the completion of sexual activity
Noticeable decrease in erectile rigidity
Six months
The symptoms produce marked distress in the individual
Other factors arafatdmc62@gmail.com; 01713272917

12. Premature (Early) Ejaculation
Four criterions
A. Consistently ejaculating within one minute or less of vaginal
penetration or before penetration.
B. Criterion A has persisted for at least six months, and has been
experienced 75%-100% of the time
C. Symptom results in clinically significant distress
D. Other arafatdmc62@gmail.com; 01713272917

13. Delayed Ejaculation
Defined by four symptoms with a choice of seven specifiers.
Inability to climax during sex with a partner about 75-100% of the time,
with either a delay in ejaculation or infrequent or absent ejaculation
The symptoms described above have persisted for at least six months
The symptoms produce marked distress in the individual
The delayed ejaculation is not better accounted for by another mental
disorder, use of a medication known for causing ejaculatory delay or failure,
or due to stressors within or external to the relationship.
Not due to a deliberate effort to prolong sexual activity

14. Female Sexual Interest/Arousal Disorder
A complete lack of or significant reduction in sexual interest or arousal
Three or more of the following symptoms
Absence of an interest in sexual activity; absence of fantasizing or even
thinking sexual or erotic thoughts; disinclined to initiate sexual
encounters; and exhibits no sense of pleasure during sexual acts; no
interest in sexual cues; present in 75-100% situations
These symptoms persisted for six months and result in distress
Not explained by other conditions
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15. Female Orgasmic Disorder
Female orgasmic disorder is marked by a significant change in orgasm
in 75-100% situations
Changes can be reduced intensity, delay, infrequency or absence of
orgasm and reduced orgasmic sensation
The symptom last for six months; produce marked distress
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16. Genito-Pelvic Pain or Penetration Disorder
Experiences of persistent or recurrent difficulties towards vaginal
penetration
Intense fear/anxiety in anticipation of, during, or as a result of vaginal
intercourse
Actual pain experienced in pelvis or vulvovaginal area during attempted
or as a result of vaginal penetration
Marked tensing or tightening of the lower pelvic/inner-abdominal
muscles during attempted vaginal penetration
 The symptom last for six months; produce marked distress
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17. Other Sexual Dysfunctions
Substance/ Medication-Induced Sexual Dysfunction
Other Specified Sexual Dysfunction
Unspecified Sexual Dysfunction
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18. Specifiers
Lifelong: The disorder is lifelong, commencing at the onset of sexual
activity
Acquired: starting after a period of normal sexual function
Generalized: in which ejaculating is delayed or not possible in either
solitary or partnered sexual activity
Situational: in which a man can ejaculate while masturbating, but not with
a partner, or during specific sex acts- e.g., oral copulation but not vaginal
intercourse
Degrees of severity which include: mild, moderate, severe
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19. Instruments for Research
Condition Instrument Gender
Sexual desire
Arizona Sexual Experiences Scale (McGahuey 2000) Both
Changes in Sexual Functioning Questionnaire (Clayton 1997) Both
Female Sexual Function Index (Rosen 2000) Female
Derogatis Interview for Sexual Functioning (Derogatis 1997) Both
Sexual arousal Profile of Female Sexual Function (Derogatis 2004; McHorney 2004) Female
Sexual Function Questionnaire (Quirk 2002) Female
Orgasm
Index of Premature Ejaculation (Althof 2006) Male
International Index of Erectile Function (Rosen 1997) Male
Sexual distress Female Sexual Distress Scale (Derogatis 2002, 2008) Female
Overall ratings
Golombok–Rust Inventory of Sexual Satisfaction (Golombok 1985) Both
Golombok–Rust Inventory of Marital State (Rust 1989) Both
Sexual Interest and Desire Inventory – Female (Clayton 2006) Female
Short Personal Experiences Questionnaire (Dennerstein 2001) Female

20. Conclusion
Diagnostic criteria is ever evolving and constantly changing
Existing criteria helps to classify and hope to explore
We have ample opportunity to shape the criteria by cementing sound
evidences
There is still room for further research evidence to conclude about
diagnostic criteria, and some debates are likely to continue for a long
time arafatdmc62@gmail.com; 01713272917

21. References
1. Ahsan MS, Arafat SMY, Ali R, Rahman SMA, Ahmed S, Rahman MM. Sexual History Taking Competency: A Survey among the Clinicians in Bangladesh. Int
J Psychiatry. 2016;1(1):4.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Washington DC: American Psychiatric Association,
2013; pp-483.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision. Washington DC: American
Psychiatric Association, 2000.
4. World Health Organization. International Classification of Diseases, Behavioral and mental disorder, 10th Ed. Geneva: World Health Organization, 1992.
5. Sungur MZ, Gündüz A. A comparison of DSM-IV-TR and DSM-5 definitions for sexual dysfunctions: Critiques and challenges. J Sex Med. 2014;11(2):364–
73.
6. Kawa S, Giordano J. A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon
and practice. Philos Ethics, Humanit Med. 2012;7(1):2.
7. IsHak WW, Tobia G. DSM-5 Changes in Diagnostic Criteria of Sexual Dysfunctions. Reprod Syst Sex Disord. 2013;2(2):2–4.
8. Hatzimouratidis K. Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation. Eur Assoc Urol. 2015;
9. Ehret AM, Berking M. From DSM-IV to DSM-5: What Has Changed in the New Edition? Verhaltenstherapie. 2013;23(4):258–66.
10. Damjanović A, Duišin D, Barišić J. The Evolution of the Female Sexual Response Concept: Treatment Implications. Srp Arh Celok Lek. 2013;141.
11. Bhugra D, Colombini G. Sexual dysfunction: classification and assessment. Adv Psychiatr Treat. 2013;19(1):48–55.

22. Questions
“The scientist is not a person who gives the right answers, he's one who
asks the right questions.”
― Claude Lévi-Strauss
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