Sexual Dysfunction Disorders

• Sexual dysfunctions involve significant disturbances in sexual response or pleasure, forming a heterogeneous group of disorders.
• Disorders include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, and male hypoactive sexual desire disorder.
• Multiple dysfunctions can occur simultaneously and must each be diagnosed accordingly.

Diagnostic Criteria and Subtypes

• Symptoms must persist for approximately 6 months to be considered a sexual dysfunction.
• Symptoms must cause clinically significant distress or impairment.
• Lifelong onset occurs when the dysfunction is present from the individual's first sexual experiences.
• Acquired onset develops after a period of normal sexual functioning.
• Generalized occurrence patterns happen across all contexts, stimulation types, or partners.
• Situational occurrence is limited to specific contexts, situations, or partners.

Assessment Considerations

• Distinguishing between dysfunction and inadequate sexual stimulation relies on knowledge and experience.
• Evaluating the impact of psychosocial, cultural, and medical factors is important in assessment.
• Ruling out nonsexual mental disorders, substance/medication effects or other medical conditions helps in differential diagnosis.
• Consider relationship distress, partner violence, or significant stressors that might mimic sexual dysfunction.

Influential Factors in Sexual Functioning

• A partner's own sexual problems or health status can affect sexual functioning.
• Relationship dynamics, such as poor communication, desire discrepancies, and relationship distress, are critical factors.
• Individual vulnerability factors include: poor body image, history of sexual or emotional abuse, psychiatric comorbidity (depression, anxiety)
• Stressors like job loss or bereavement are also influential factors.
• Cultural norms and religious beliefs may create prohibitions against sexual activity or shape attitudes toward sexual pleasure.
• These cultural factors influence both the presentation of dysfunction and help-seeking behavior.
• Underlying medical conditions like neurological or endocrine disorders, and the effects of medications (e.g., SSRIs, antihypertensives) can contribute to sexual dysfunction.
• Age-related changes like decreased androgen levels or loss of peripheral nerve function affect sexual performance.

Detailed Disorder-Specific Information

• Delayed ejaculation is characterized by marked delay or infrequent ejaculation despite adequate sexual stimulation and desire.
• Delayed ejaculation is often associated with psychological factors, specific medical conditions, requiring different interventions based on whether it's lifelong or acquired.
• Erectile disorder is defined by difficulties obtaining or maintaining an erection or decreased erectile rigidity on almost all occasions.
• Requires a careful sexual history to determine if erectile disorder is situational or generalized and to assess its duration (minimum 6 months).
• Erectile disorder is associated with psychological distress, low self-esteem, relationship issues, and often co-occurs with others sexual dysfunctions.
• Female orgasmic disorder involves marked delay, infrequency, or reduced intensity of orgasmic sensations.
• Female orgasmic disorder is diagnosed only when the symptoms are persistent, distressing, and not attributable to insufficient stimulation.
• Female orgasmic disorder recognizes the variability in how women experience orgasm, with many requiring clitoral stimulation for orgasm that may not occur during penile-vaginal intercourse.
• Female sexual interest/arousal disorder is characterized by a significant reduction in sexual interest and arousal, including decreased initiation, low erotic thoughts, and diminished physical arousal.
• Female sexual interest/arousal disorder requires the presence of at least three specific indicators, and the symptoms must persist for at least 6 months.
• Female sexual interest/arousal disorder must be distinguished from normal variations in sexual desire, especially when considering relationship dynamics and cultural expectations.
• Genito-pelvic pain/penetration disorder encompasses difficulties with vaginal penetration, which may be due to pain, fear or anxiety about pain, and involuntary pelvic floor muscle tightening.
• Genito-pelvic pain/penetration disorder can manifest as superficial (vulvovaginal) or deep (pelvic) pain.
• Genito-pelvic pain/penetration disorder can lead to avoidance of sexual and even necessary medical procedures (like gynecological exams).
• Genito-pelvic pain/penetration disorder often coexists with other sexual dysfunctions, particularly low sexual desire.
• Male hypoactive sexual desire disorder is defined by a persistent deficiency or absence of sexual desire and erotic thoughts.
• It requires both low desire and diminished sexual fantasy over a minimum period of 6 months.
• Factors such as relationship issues, psychological stress, and medical conditions are carefully evaluated, and the disorder should not be diagnosed solely based on desire discrepancies with a partner.

Gender-Diverse Considerations

• Clinicians should assess based on individual's current anatomy rather than by sex assigned at birth for diagnoses linked to reproductive anatomy (e.g., erectile dysfunction or premature ejaculation).
• Acknowledging that more research is needed, clinicians should use their best judgement, especially regarding gender-diverse populations.
• Gender-diverse persons may not fit traditional sex-based diagnostic categories.

Prevalence, Impact, and Functional Consequences

• Functional consequences extend beyond sexual activity, affecting fertility, intimate relationships, and overall quality of life.
• Prevalence rates for sexual dysfunctions vary widely by disorder, age group, and cultural context.
• Dysfunctions have significant psychological, relational, and even broader societal impacts, including depression, relationship distress, decreased self-esteem, and increased risk of mental health issues like suicide.

General Features of Paraphilic Disorders

• A paraphilia requires clinically significant distress or social, occupational impairment, or involve non-consenting individuals, or cause harm/risk of harm to others to be diagnosed as a paraphilic disorder.
• A paraphilia is an intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with physically mature, consenting partners.
• Paraphilic fantasies, urges, or behaviors must persist for at least 6 months.
• Clinically significant distress can manifest as guilt, shame, anxiety or significant social/occupational consequences.
• If the paraphilia involves non-consenting persons or exploitation, it is classified as a disorder, it is automatically considered a disorder, even if the individual does not experience personal distress.
• Paraphilic disorders must be differentiated from nonpathological sexual interests, especially if they do not cause distress or harm.
• Consider substance-induced or other medical/psychiatric conditions that could influence sexual behavior.
• Paraphilic disorders commonly co-occur with other psychiatric conditions (e.g., mood disorders, anxiety disorders, substance use disorders) and sometimes with multiple paraphilic interests.

Specific Paraphilic Disorders

• Each of the eight paraphilic disorders have unique focal sexual interests
• Voyeuristic disorder is defined by sexual arousal from observing an unsuspecting, non-consenting person who is naked, disrobing, or engaging in sexual activity.
• Voyeuristic disorder requires at least 6 months of recurrent and intense sexual arousal, the individual either acts on these urges with a non-consenting person or experiences clinically significant distress/impairment.
• The voyeur must be at least 18 years old and differentiates from curiosity in adolescents.
• Exhibitionistic disorder is defined by sexual arousal from exposing one's genitals to an unsuspecting, non-consenting person.
• Exhibitionistic disorder requires over at least 6 months, recurrent, intense sexual arousal from the act of exposing genitals to an unsuspecting person, where the indivudal either acts on urges or experiences distress/impairment.
• Exposure can be to prepubertal children, physically mature individuals, or both.
• May seek the "shock value" or fear in the victim as part of arousal with the presence of risk-taking and impulsivity.
• Frotteuristic disorder is defined by sexual arousal from touching or rubbing against a non-consenting person.
• At least 6 months of recurrent, intense sexual arousal from rubbing/touching a non-consenting individual, where the individual acts on these urges or experiences marked distress/impairment.
• Often occurs in crowded public spaces (e.g., public transportation) and typically begins in late adolescence or early adulthood.
• Sexual masochism disorder is defined by sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer.
• Requires at least 6 months of recurrent, intense sexual arousal from undergoing physical or psychological suffering.
• Causes distress/impairment, or the individual engages in practices that pose risk of serious harm (e.g., asphyxiation).
• With asphyxiophilia: If the practice involves restriction of breathing.
• Consenting bondage-discipline/sadomasochism (BDSM) does not automatically indicate a disorder and must cause distress/impairment or dangerous beyond typical risk.
• Sexual sadism disorder is defined by sexual arousal from the physical or psychological suffering of another person.
• Inflicting suffering on a non-consenting person, or from fantasies causing distress/impairment for at least 6 months.
• If the acts are carried out with a non-consenting partner, it meets the disorder criteria regardless of the perpetrator's personal distress.
• There may be an association with antisocial personality traits or lack of empathy.
• Severe disorder can lead to criminal offenses.
• Pedophilic disorder is defined by sexual arousal involving sexual activity with a prepubescent child (generally 13 years or younger).
• Recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexual activity with a prepubescent child.
• Individual must be at least 16 years old and at least 5 years older than the child.
• There is an act on urges or experiences marked distress/interpersonal difficulty.
• Can be exclusive (attracted only to children) vs. nonexclusive (also attracted to adults), with a sexually attracted focus to males, females, or both.
• There is typically a high risk of legal and social consequences.
• Individuals may attempt to rationalize or minimize behavior.
• Fetishistic disorder is defined by sexual arousal from either nonliving objects or a highly specific focus on non-genital body parts (e.g., feet).
• Requires at least 6 months of recurrent, intense sexual arousal from the use of nonliving objects (e.g., shoes, underwear) or a focus on a body part (e.g., feet, hair).
• There is a cause distress/impairment or involves non-consenting contexts.
• This does not include clothing used for cross-dressing (transvestic disorder) or sex toys intended for sexual stimulation.
• Onset typically develops in adolescence and may be linked to classical conditioning experiences.
• Transvestic disorder is defined by sexual arousal from cross-dressing (in a heterosexual male, typically).
• Over at least 6 months, recurrent, intense sexual arousal from cross-dressing is required.
• Cause distress/impairment or involves non-consenting contexts.
• Can occur with fetishism if there is sexual arousal by fabrics/materials.
• Can occur with autogynephilia if arousal is linked to thoughts/images of oneself as a female.
• This is distinct from gender dysphoria or transgender identity; transvestic disorder specifically involves erotic cross-dressing and associated distress or functional problems.

Additional Considerations

• Paraphilic disorders severity ranges from mild (occasional fantasies causing some distress) to severe (compulsive behaviors that may lead to legal, social, or personal harm).
• Onset and course often begins around puberty or adolescence when sexual fantasies first emerge.
• Can become chronic if not addressed, though some individuals show fluctuating intensity over time.
• Treatment and management may include psychotherapy, behavioral interventions, pharmacotherapy, motivation and insight into harm caused, and consideration of ethical considerations for legal mandates.
• Risk of harm to others: Certain paraphilic disorders inherently involve victims and can require careful risk assessment and lead to legal consequences.
• In cultural context, definitions of what is considered "deviant" sexual behavior can vary, but the DSM criteria focus on distress, impairment, and lack of consent, transcending cultural differences.