Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

overview

Sexual dysfunctions are a heterogeneous group of disorders characterized by a clinically significant disturbance in an individual’s ability to respond sexually or to experience sexual pleasure. Multiple dysfunctions can coexist in the same individual and should be diagnosed separately when present.

DSM Chapter Sections:

• Delayed Ejaculation: Marked delay, infrequency, or absence of ejaculation despite adequate stimulation; causes significant distress.

• Erectile Disorder: Difficulty obtaining or maintaining an erection or marked decrease in rigidity; persistent and distressing.

• Female Orgasmic Disorder: Delay in, infrequency of, or absence of orgasm, or markedly reduced orgasmic sensations in women.

• Female Sexual Interest/Arousal Disorder: Absent or reduced sexual interest, thoughts, initiation of sex, sexual excitement, or genital sensations.

• Genito-Pelvic Pain/Penetration Disorder: Persistent or recurrent vaginal penetration difficulties, pain during intercourse, fear of pain, or pelvic muscle tightening.

• Male Hypoactive Sexual Desire Disorder: Persistently deficient or absent sexual thoughts or desire for sexual activity in men; causes significant distress.

• Premature (Early) Ejaculation: Ejaculation occurring approximately within 1 minute of penetration and before the individual wishes it; persistent and distressing.

• Substance/Medication-Induced Sexual Dysfunction: Significant sexual dysfunction caused by the direct effects of a substance (e.g., medication, alcohol, drugs).

• Other Specified Sexual Dysfunction: Sexual dysfunction symptoms causing distress that don’t meet criteria for a specific disorder, with a specified reason provided.

• Unspecified Sexual Dysfunction: Sexual dysfunction symptoms causing distress that don’t fit specific categories, with no specific reason provided.

Factors to Consider in Assessment:

1. Partner Factors (e.g., partner’s sexual problems, partner health issues)

2. Relationship Factors (e.g., communication issues, mismatched sexual desires)

3. Individual Vulnerability Factors (e.g., poor body image, history of trauma)

4. Psychiatric Comorbidity (e.g., depression, anxiety disorders)

5. Stressors (e.g., bereavement, job loss)

6. Cultural or Religious Factors (e.g., prohibitions against sexual pleasure)

7. Medical Factors (e.g., pelvic nerve damage, hormonal disorders)

Subtypes:

• Onset:

  • Lifelong — Present since the individual’s first sexual experiences.

  • Acquired — Developed after a period of normal sexual functioning.

• Context:

  • Generalized — Not limited to specific situations, partners, or types of stimulation.

  • Situational — Occurs only with certain partners, types of stimulation, or situations.

delayed ejaculation

Delayed ejaculation involves a marked delay or difficulty in reaching ejaculation during partnered sexual activity, despite the individual’s desire to ejaculate and the presence of adequate stimulation. This difficulty must persist for at least six months, occur most of the time during sexual activity, and cause significant distress. The diagnosis requires careful clinical judgment, considering factors like age, health, relationship dynamics, and sexual habits.

Associated Features:

• Important to assess partner factors, relationship dynamics, psychiatric comorbidities (e.g., depression, anxiety), stressors, cultural/religious influences, medical issues (e.g., neurological conditions, hypogonadism), and the effects of medications (e.g., serotonergic drugs).
• Commonly linked to lower sexual satisfaction, reduced subjective arousal, relationship distress, performance anxiety, and general health concerns.
• Some avoid sexual encounters altogether due to repeated difficulty ejaculating.

Criteria:

A. On almost all or all occasions (approximately 75%-100%) of partnered sexual activity, and despite the desire for ejaculation, either:

• Marked delay in ejaculation, OR

• Marked infrequency or absence of ejaculation.

B. Symptoms in Criterion A persist for approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress, other significant stressors, the effects of a substance/medication, or another medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in certain situations/with specific partners.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

erectile disorder

Erectile disorder involves persistent difficulty obtaining or maintaining an erection, or experiencing a significant decrease in erectile rigidity during sexual activity. These issues must occur on almost all occasions of sexual activity, last for at least six months, and cause significant distress. Diagnosis requires careful assessment, taking into account sexual history, health status, relationship factors, and psychosocial stressors.

Associated Features:

• Men may experience low self-esteem, diminished self-confidence, and reduced feelings of masculinity.

• Common emotional responses include guilt, self-blame, anger, and fear of disappointing a partner.

• Fear and avoidance of future sexual encounters may develop.

• Partners may also report decreased sexual satisfaction and reduced desire.

• Important assessment factors include partner health, relationship dynamics, psychological comorbidities (e.g., depression, anxiety), stressors (e.g., job loss), cultural/religious beliefs about sexuality, medical history (e.g., surgeries, hormonal issues, neurological disorders), and substance/medication effects.

Criteria:

A. On almost all or all (approximately 75%-100%) occasions of sexual activity, the individual experiences at least one of the following:

• Marked difficulty obtaining an erection.

• Marked difficulty maintaining an erection until completion of sexual activity.

• Marked decrease in erectile rigidity.

B. Symptoms have persisted for a minimum of approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by a nonsexual mental disorder, severe relationship distress, other significant stressors, the effects of a substance/medication, or another medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in specific situations/with specific partners.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

female orgasmic disorder

Female orgasmic disorder is characterized by a significant delay, infrequency, absence, or markedly reduced intensity of orgasmic sensations during sexual activity. These symptoms must occur on almost all occasions, persist for at least six months, and cause significant distress. The experience and intensity of orgasm vary greatly among women, and diagnosis requires careful evaluation of whether distress is linked to the symptoms rather than simply differences in sexual experience or stimulation patterns.

Associated Features:

• Many women with this disorder experience difficulty communicating about sexual issues.

• Orgasm difficulties often coexist with problems related to sexual interest and arousal.

• Overall sexual satisfaction may remain high, even without frequent orgasms.

• Important factors to assess include partner sexual problems, relationship communication issues, individual vulnerabilities (e.g., poor body image, past trauma), psychiatric comorbidities (e.g., depression, anxiety), stressors (e.g., bereavement, work stress), and cultural/religious attitudes toward sexuality.

Criteria:

A. On almost all or all (approximately 75%-100%) occasions of sexual activity, the individual experiences at least one of the following:

• Marked delay in, marked infrequency of, or absence of orgasm.

• Markedly reduced intensity of orgasmic sensations.

B. Symptoms have persisted for a minimum of approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress (e.g., partner violence), other significant stressors, the effects of a substance/medication, or a medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in specific situations/with specific partners.

Specify if:

• Never experienced orgasm under any situation.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

female sexual interest/arousal disorder

Female sexual interest/arousal disorder involves a persistent or significant reduction in sexual interest, erotic thoughts, initiation of sexual activity, or physical arousal responses. To meet diagnostic criteria, at least three symptoms must be present most of the time, lasting for a minimum of six months and causing significant personal distress. Diagnosis requires distinguishing true dysfunction from normal variations in sexual desire, relationship dynamics, or cultural influences.

Associated Features:

• Women may report a lack of sexual thoughts, fantasies, initiation, responsiveness to cues, or physical arousal.

• This disorder often impacts relationship satisfaction and emotional intimacy.

• Important factors to assess include partner health, communication issues, history of trauma, psychiatric conditions (e.g., depression, anxiety), significant life stressors, and cultural or religious beliefs that affect sexual attitudes.

Criteria:

A. Lack of, or significantly reduced, sexual interest/arousal, shown by at least three of the following:

1. Absent/reduced interest in sexual activity.

2. Absent/reduced sexual or erotic thoughts or fantasies.

3. No/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate.

4. Absent/reduced excitement or pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters.

5. Absent/reduced sexual interest or arousal in response to 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%-100%) sexual encounters.

B. Symptoms have persisted for a minimum of approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress (e.g., partner violence), other significant stressors, the effects of a substance/medication, or a medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in specific situations/with specific partners.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

genito-pelvic pain/penetration disorder

Genito-pelvic pain/penetration disorder involves persistent or recurrent difficulties related to vaginal penetration, vulvovaginal or pelvic pain, fear of pain, or involuntary tensing of pelvic muscles during sexual activity. These symptoms must last at least six months, occur regularly, and cause significant distress. Diagnosis requires careful assessment across physical, emotional, and relational domains, considering both spontaneous and provoked symptoms.

Associated Features:

• Commonly associated with reduced sexual interest and behavioral avoidance of sexual activity.

• Avoidance of gynecological examinations is frequent due to fear or anticipation of pain.

• Feelings of diminished femininity and relationship or marital stress are often reported.

• Relevant assessment areas include partner’s sexual health, relationship dynamics, individual vulnerabilities (e.g., trauma history), psychiatric comorbidities (e.g., anxiety, depression), cultural attitudes toward sexuality, and medical factors like vulvodynia or pelvic floor dysfunction.

Criteria:

A. Persistent or recurrent difficulties with one (or more) of the following:

1. Difficulty with vaginal penetration during intercourse.

2. Marked vulvovaginal or pelvic pain during intercourse or penetration attempts.

3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration.

4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

B. Symptoms have persisted for a minimum of approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress (e.g., partner violence), other significant stressors, the effects of a substance/medication, or a medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

male hypoactive sexual desire disorder

Male hypoactive sexual desire disorder is defined by persistently or recurrently low (or absent) sexual thoughts, fantasies, and desire for sexual activity. The judgment of what constitutes “deficient” is made by the clinician, taking into account the individual’s age, life circumstances, and cultural background. The symptoms must persist for at least six months and cause significant personal distress. Importantly, a mismatch in desire between partners alone does not justify a diagnosis.

Associated Features: 

• Often co-occurs with erectile or ejaculatory difficulties, where performance issues diminish sexual interest.

• Men may rarely initiate sexual activity and may be minimally receptive to a partner’s advances.

• Some may still engage in sexual activity (e.g., masturbation or partnered sex) even in the absence of strong desire.

• Assessment must consider relationship dynamics, cultural expectations, psychological factors (e.g., depression, anxiety), and major life stressors.

• A man’s preference for having a partner initiate sexual activity should not automatically be seen as a symptom unless he shows a lack of receptivity.

Criteria:

A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The clinician must consider age, life context, and cultural factors in judging what is deficient.
B. Symptoms have persisted for a minimum of approximately 6 months.
C. Symptoms cause clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress, other significant stressors, the effects of a substance/medication, or a medical condition.

Specify if:

• Lifelong: Present since first sexual experiences.

• Acquired: Develops after a period of normal functioning.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in specific situations/with specific partners.

Specify severity:

• Mild: Mild distress.

• Moderate: Moderate distress.

• Severe: Severe or extreme distress.

premature (early) ejaculation

Premature (early) ejaculation is defined by a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately one minute of vaginal penetration and before the individual desires it. These symptoms must occur frequently (about 75%-100% of sexual encounters), persist for at least six months, and cause significant personal distress. Diagnosis also applies, with caution, to nonvaginal sexual activities, though specific time thresholds for those activities are less established.

Associated Features:

• Commonly associated with feelings of loss of control over ejaculation.

• Anticipatory anxiety about sexual performance is frequently reported.

• Important assessment factors include partner dynamics, relationship communication, personal vulnerabilities (e.g., trauma history), psychiatric conditions (e.g., anxiety, depression), cultural/religious views on sexuality, and relevant medical conditions.

Criteria:

A. A persistent or recurrent pattern of ejaculation occurring:

• Within approximately 1 minute following vaginal penetration.

• Before the individual wishes it.

Note: While criteria are based on vaginal intercourse, similar patterns are considered in nonvaginal sexual activities, although exact timing criteria are not established.
B. The symptom must have been present for at least 6 months and occur on approximately 75%-100% of sexual encounters.
C. The symptom causes clinically significant distress in the individual.
D. The dysfunction is not better explained by another nonsexual mental disorder, severe relationship distress, other significant stressors, the effects of a substance/medication, or a medical condition.

Specify if:

• Lifelong: Present since the onset of sexual activity.

• Acquired: Develops after a period of normal sexual function.

Specify if:

• Generalized: Occurs across all situations/partners.

• Situational: Occurs only in specific situations/with specific partners.

Specify severity:

• Mild: Ejaculation within approximately 30 seconds to 1 minute of penetration.

• Moderate: Ejaculation within approximately 15–30 seconds of penetration.

• Severe: Ejaculation before sexual activity, at the start of sexual activity, or within approximately 15 seconds of penetration.

Substance/Medication-Induced Sexual Dysfunction

Substance/medication-induced sexual dysfunction involves clinically significant disruptions in sexual function that develop during or shortly after substance use, withdrawal, or medication exposure. The dysfunction must predominate in the clinical picture, persist for at least six months if needed for clarity, and cause significant distress. The symptoms should not be better explained by an independent sexual dysfunction unrelated to substance or medication effects.

Associated Features:

• Can occur with intoxication or withdrawal from substances such as alcohol, opioids, sedatives, stimulants, or unknown substances.
• Common medications involved include antidepressants (especially SSRIs), antipsychotics, hormonal contraceptives, mood stabilizers, and certain cardiovascular or gastrointestinal medications.
• Antidepressants can cause difficulty with orgasm or arousal; bupropion and mirtazapine are linked to fewer sexual side effects.
• Sexual dysfunction can occur independently of depression severity.
• Illicit drug use (e.g., methadone, cocaine) and substances like nicotine and alcohol are associated with decreased sexual desire and performance problems.

Criteria:

A. A clinically significant disturbance in sexual function is the predominant issue.
B. Evidence from history, physical exam, or lab findings shows:

1. Symptoms developed during or soon after intoxication, withdrawal, or exposure to a medication.

2. The involved substance/medication is capable of causing the symptoms.

C. The disturbance is not better explained by an independent sexual dysfunction (e.g., symptoms existed before substance use or persist long after withdrawal).
D. The disturbance does not occur exclusively during delirium.
E. The disturbance causes clinically significant distress in the individual.

Specify:

• With onset during intoxication

• With onset during withdrawal

• With onset after medication use

Specify severity:

• Mild: Occurs on 25%-50% of sexual encounters.

• Moderate: Occurs on 50%-75% of sexual encounters.

• Severe: Occurs on 75% or more of sexual encounters.

other specified sexual dysfunction

Other specified sexual dysfunction applies when symptoms of sexual dysfunction cause clinically significant distress but do not fully meet the criteria for a specific sexual dysfunction diagnosis. In this case, the clinician specifies the reason why the presentation does not fit a specific category (e.g., “sexual aversion”).

The clinician records “Other Specified Sexual Dysfunction” followed by the reason (e.g., “sexual aversion”). Use when the clinical situation warrants diagnosis and description, but established categories don’t fit perfectly.

unspecified sexual dysfunction

Unspecified sexual dysfunction is used when an individual has symptoms characteristic of a sexual dysfunction that cause significant distress, but the clinician either does not specify or cannot determine why the symptoms don’t meet full criteria for a specific diagnosis.

The clinician records “Unspecified Sexual Dysfunction” without needing to specify a reason. Appropriate when information is limited or full diagnostic clarification is not possible.

self-check

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