Sexual Dysfunctions

CHAPTER 12

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Sexual Dysfunctions

Quick Guide to the Sexual Dysfunctions

DSM-5 addresses three sorts of issues directly tied to sexual functioning. In DSM-IV and before, they were all included in the same chapter; now the sexual dysfunctions, gender dysphoria, and paraphilic disorders are spread out over three different chapters. As with most other diagnoses, patients can have problems in multiple areas, which can in turn coexist with other mental diagnoses.

With the exception of substance-induced sexual dysfunction, the sexual dysfunctions are gender-specific. DSM-5’s organization is alphabetical; I’ve grouped these disorders by gender and stage in an act of sex at which the dysfunction occurs. The link indicates where a more detailed discussion begins.

Sexual Dysfunctions

Male hypoactive sexual desire disorder . The patient isn’t much interested in sex, though his performance may be adequate once sexual activity has been initiated.

Erectile disorder . A man’s erection isn’t sufficient to begin or complete sexual relations.

Premature (early) ejaculation . A man experiences repeated instances of climax before, during, or just after penetration.

Delayed ejaculation . Despite a normal period of sexual excitement, a man’s climax is either delayed or does not occur at all.

Female sexual interest/arousal disorder . A woman lacks interest in sex or does not become aroused enough.

Genito-pelvic pain/penetration disorder . Genital pain occurs (only in women) during sexual intercourse, often during insertion.

Female orgasmic disorder . Despite a normal period of sexual excitement, a woman’s climax either is delayed or does not occur at all.

Substance/medication-induced sexual dysfunction . Many of these problems can also be caused by intoxication or withdrawal from alcohol or other substances.

Other specified, or unspecified, sexual dysfunction . These are catch-all categories for sexual problems that do not meet the criteria for any of the foregoing sexual dysfunctions.

Other Causes of Sexual Difficulties

Paraphilic disorders . These include a variety of behaviors that most people regard as distasteful, unusual, or abnormal. Nearly all are practiced almost exclusively by males.

Gender dysphoria . Some people strongly identify so strongly with the opposite gender that they are uncomfortable with their assigned gender roles.

Nonsexual mental disorders. Many patients develop sexual dysfunctions as a result of other mental disorders. Lack of interest in sex may be encountered especially in somatic symptom disordermajor depressive disorder, and schizophrenia.

INTRODUCTION

The sexual dysfunctions usually begin in early adulthood, though some may not appear until later in life—whenever the opportunity for sexual experience arises. Most of them are quite common. Any of them can be caused by psychological or biological factors or by a combination of these. Ordinarily, we wouldn’t use one of these diagnoses if the behavior occurs only in the course of another mental disorder.

Also, any of these dysfunctions can be lifelong or acquired. Lifelong (also called primary) means that this dysfunction has been present since the beginning of active sexual functioning. Acquired means that at some time the patient has been able to have sex without that particular dysfunction. As you might imagine, lifelong dysfunctions are vastly more resistant to therapy.

Furthermore, most sexual dysfunctions may be either generalized or situational (that is, limited to specific situations). For example, a man may experience premature ejaculation with his wife but not with another woman. Some dysfunctions may not even require that the patient have a partner; they can occur during masturbation, for example. (Generalized and situational don’t apply to genito-pelvic pain/penetration disorder.)

DSM-5 has tightened its advice on how much dysfunction is required for diagnosis. The patient must have the symptoms on the majority of occasions (in criteria sets, it is phrased as “almost all or all”) of sexual activity over a 6-month period—and those phrases have been explicitly, and confusingly, defined as meaning 75% or more. However, the criteria also specify that they must cause “clinically significant distress,” leaving some room for clinician judgment based on how long the problem has existed and the degree to which the problem affects patient and partner. This judgment will be influenced by the circumstances surrounding the particular sex activity—such as degree of sexual stimulation, the amount of that activity, and with whom it occurs. For example, female sexual interest/arousal disorder should not be diagnosed if it occurs only when intercourse is attempted after little or no foreplay.

In addition to these considerations, here are some additional factors to take into account. (Note that in DSM-IV they were subtypes that we added to the official title of each sexual disorder; DSM-5 has in essence demoted them to an advisory capacity.)

•  Partner factors (such as partner’s sexual problems or health status)

•  Relationship factors (such as poor communication, relationship discord, discrepancies in desire for sexual activity)

•  Individual vulnerability factors (such as a history of abuse or poor body image)

•  Cultural/religious factors (for example, inhibitions related to prohibitions against sexual activity)

•  Medical factors relevant to prognosis, course, or treatment (any chronic illness could be an example)

Although common, the sexual dysfunctions tend to be ignored by clinicians who don’t specialize in their evaluation and treatment; too often, we simply fail to ask. An alert clinician may be able to make a diagnosis of one or more of these conditions in a patient who comes for consultation regarding unrelated mental health problems.

F52.0 [302.71] Male Hypoactive Sexual Desire Disorder

Relatively little is known about low sex interest and desire in men, compared to women. This has partly resulted from the unfounded assumption that it is uncommon. Yet, in a 1994 survey of over 1,400 men, 16% agreed that they had had a period of several months when they were not interested in sex (compared with 33% for women.) These men tended to be older, never married, not highly educated, black, and poor. Compared to other men, they were more likely to have been inappropriately “touched” before puberty, to have experienced homosexual activity at some time in their lives, and to use alcohol daily. Even a few percent of young men (in their 20s) will admit to relative lack of sexual desire, though it seldom rises to the level of male hypoactive sexual desire disorder (MHSDD).

MHSDD can be primary or acquired. The (relatively less common) primary type has been associated with some sort of sexual secret (such as shame about sexual orientation, past sexual trauma, perhaps a preference for masturbation over sex with a partner). Such a man’s low sex desire may be masked by the effect of a new romance; this glow typically persists for only a matter of months before frustration and heartache (and more secrecy) set in, for patient and partner alike.

Acquired MHSDD is the more common pattern. It often develops as a consequence of dysfunctions of erection or ejaculation (early or delayed). These in turn can stem from a variety of causes: diabetes, hypertension, substance use, mood or anxiety disorders, sometimes a lack of intimacy with a partner. Whatever the origin, the man’s confidence in his ability to achieve or maintain an erection (or to satisfy his partner) yields to a pattern of anticipatory anxiety and failure. He has trouble admitting that his sexual relationship is less than perfect, and so he retires from the fray, so to speak, defeated and uncommunicative.

Such a pattern can begin at almost any stage of life, though about two out of three couples stop having sex by their mid-70s. At any age, when this happens to heterosexual couples, it is overwhelmingly (90%) likely to be at the man’s initiative.

Essential Features of Male Hypoactive Sexual Desire Disorder

A man lacks erotic thoughts or wishes for sexual activity.

The Fine Print

The clinician must judge the deficiency in light of age and other factors that can affect sexual function.

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, relationship problems, other mental disorders)

Coding Notes

Specify:

{Lifelong}{Acquired}

Specify severity of distress over the symptoms: {Mild}{Moderate}{Severe}

Nigel O’Neil

“She’s not your typical trophy wife,” Nigel O’Neil told the therapist in confidence. “I love Gemma because she’s so competent, so organized—and such a nice person,” he added, almost as an afterthought. “But she just doesn’t turn me on the way Bea used to.”

At age 53, Nigel was well into his second marriage, solemnized 3 years after his first wife died of malignant melanoma. For several years, Gemma had been his personal assistant in the office where he worked for a large publisher. Around the time of Bea’s death, he had turned to her for more than his morning mug of Darjeeling. During his first session, he admitted that he still felt guilty about that.

Born in London, Nigel had been reared a strict Catholic. “That operationalized to the fact that, before we were married, Bea and I hadn’t done much more than a little fooling around. We were very young and inexperienced.” Afterwards, he had been able to obtain and maintain an erection satisfactory for intercourse “most of the time, though even then we had our problems, Bea and I.” He declined to elaborate, stating only that they seemed minor in comparison.

Gemma was 15 years younger than Nigel. For several months, they had pursued an active sex life—“something else she organized.” At the office, he had appreciated the way she managed his schedule. “At home, not so much.” In the last 6 months, when she approached him for sex, he usually fobbed her off with the excuse that he was too tired or preoccupied. On the few occasions she could persuade him to try, he couldn’t maintain an erection long enough to achieve penetration. The one time they did have intercourse, his attention had “wandered off to the office,” and he withdrew before either of them climaxed.

Nigel’s internist had checked his testosterone level, which was within normal range. On his second visit, Gemma tagged along. She and Nigel agreed that they drank little and had never used drugs or tobacco. Gemma added that a few months earlier, in desperation, she had subscribed to Playboy for him. “He’s the only man I know who really does just read the articles,” she commented.

Nigel hadn’t seen other women; he didn’t even masturbate. “For months, the magazine’s the only thing I’ve put to bed. I don’t even have randy fantasies any more.” The issue didn’t distress Nigel for himself (“It’s just not something I ever think about!”), but he became almost tearful as he talked about how deeply he cared for Gemma, how he longed that she be happy—that she not abandon him for someone else.

One session when Nigel was in the room, Gemma explained, “Besides books and magazines, our company makes films, mostly about love and lovemaking. Nigel thinks that’s a total irony, but I don’t think we’ve finished shooting yet.”

Evaluation of Nigel O’Neil

Nigel’s history is loaded with indicators of a persistent sexual disorder, including multiple failures of his erection, his interest, his response (to invitations from Gemma), and even his fantasy life (criterion A). His interest in work was good and he denied feeling depressed, so a mood disorder seems unlikely (D), but a thorough review to identify any possible anxiety disorder would seem a good idea. The history appears to rule out an etiological role for drugs or alcohol (also D); there wasn’t any apparent relationship distress—yet, at any rate. The duration met the 6-month requirement (B), and Nigel’s distress was palpable (C).

In addition, Nigel would probably qualify for the diagnosis of erectile disorder. If so, it should also be made (other sexual disorders can coexist with MHSDD). It’s just one more issue he and his clinician would need to explore.

Once the principal diagnosis was nailed down, the clinician’s real work would begin—examining the possible causes of Nigel’s lack of sexual interest. Each of these could indicate a therapeutic avenue to explore. Multiple possible contributing factors must be considered:

Relationship factors—did Nigel resent Gemma’s overmanagement of their lives?

Medical factors—did Nigel have, say, diabetes or a cardiovascular condition? (If medical factors were the exclusive cause of Nigel’s current sexual problems, we wouldn’t make this diagnosis at all; see criterion D.)

Cultural/religious concerns—sex with Gemma while Nigel was still married to Bea could play a role.

Though there’s no information for partner factors or for any individual vulnerability factors such as depression, further exploratory interviews of both Nigel and Gemma would clearly be in order.

Nigel’s still unelaborated sexual problems with Bea even make us wonder whether his problem could have been lifelong, rather than acquired. Had his sex interest been on the low side with her, too? Had she complained? Did he fantasize about other women? Men? How affectionate were they as a couple?

In its bare-bones form, Nigel’s diagnosis would read as given below, but there’s much more work to be done. Despite his difficulties with sex, I’d put his GAF score at a relatively healthy 70.

F52.0 [302.71] Male hypoactive sexual desire disorder, acquired, generalized, severe

F52.21 [302.72] Erectile Disorder

Erectile disorder (ED), otherwise known as impotence, can be partial or complete. In either case, the erection is inadequate for satisfactory sex. Impotence can also be situational, in which case the patient can achieve an erection only under certain circumstances (for example, with prostitutes). ED is probably the most prevalent male sexual disorder, occurring at least occasionally in perhaps 2% of young men; that number does not improve with age. Of all the sexual dysfunctions, this is the one most likely to occur for the first time later in life.

A variety of emotions can play a role in the development or maintenance of ED. These include fear, anxiety, anger, guilt, and distrust of the sexual partner. Any of these feelings can so preoccupy a man’s attention that he cannot focus adequately on feeling sexual pleasure. Even a single failure may lead to anticipatory anxiety, which then precipitates another round in the circle of failure. The prominent sex researchers Masters and Johnson also talked about a factor they called spectatoring, in which the patient evaluates his performance so constantly that he cannot concentrate on the enjoyment of sex. Such a patient might have an erection with foreplay but lose it upon penetration.

ED should not be diagnosed if biological factors are the principal or only cause. This is unlikely if erections occur spontaneously, with masturbation, or with other partners. Some authorities now estimate that half or more of patients who complain of impotence have a biological cause for it, such as prostatectomy for cancer. When psychological factors are judged to be a part of the cause, as is often the case, the diagnosis can be made.

Like the other sexual dysfunctions, ED can be either lifelong or acquired; the former is rare and hard to treat.

Essential Features of Erectile Disorder

The patient almost always has marked trouble achieving or maintaining an erection adequate to consummate sex.

The Fine Print

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, relationship problems, other mental disorders)

Coding Notes

Specify:

{Lifelong}{Acquired}

{Generalized}{Situational}

Specify severity of distress over the symptoms: {Mild}{Moderate}{Severe}

Parker Flynn

“I think I must be over the hill.”

If you didn’t count the three counseling sessions he had had while sifting through the wreckage of his first marriage, this was Parker Flynn’s first visit ever to a mental health professional. At age 45 he had been a bridegroom for only 7 months, and he was afraid he was losing his sexual potency.

Everything had been fine before the wedding, but the first evening of their honeymoon, Parker had been unable to get enough of an erection to do either him or his wife much good. He supposed he’d had too much champagne—normally he didn’t touch alcohol. His wife had also been married before and knew a thing or two about men. She hadn’t criticized; she’d even said it would be all right. But she was attractive and 10 years younger than Parker, and he was worried: Most of the time since, he’d been unable to perform.

“Some of the guys warned me, it’s what happens when you get older,” Parker insisted. “That which should be easy is hard, and that which should be hard isn’t.”

Before he popped the question, he had undergone a complete physical examination. Other than being a few pounds overweight—Parker was devoted to chocolate ice cream—he was given a clean bill of health. Besides the ice cream, he denied any other addictions, including alcohol, drugs, and tobacco.

“I get so nervous when it’s time to make love,” Parker explained. “I can get a pretty good erection when we’re fooling around, but when it’s time to get serious, I lose it. Her first husband was something of a stud, and I keep wondering how my performance measures up to his.”

Evaluation of Parker Flynn

Parker’s interest in sex seemed to be just fine; he gave every indication (normal erections) that there was nothing wrong with the excitatory phase. But because he worried about maintaining his erection, he did have difficulty maintaining an erection (criterion A2) stressful enough that he sought care (C). His problem was exacerbated by the phenomenon of spectatoring (see above), in which his performance was affected by wondering how well he was doing while he was doing it. His problem had been present for 7 months—just qualifying for the DSM-5 time requirement (B, though in obvious cases I’d be a little relaxed about this requirement; it does say “approximately,” after all).

Parker’s physical condition was good, pretty much ruling out a causative physical illness (D). Some patients with impotence may suffer from sleep apnea; of course, it is vital to explore this possibility, because of the potentially lethal nature of that disorder. He had no previous mental health problems that would preclude the diagnosis of ED. His difficulty may have begun with an alcohol-related incident, but from his history, substance use played no role in its maintenance. Also note that, as they age, men may require more stimulation to achieve erection than they did when they were younger; such a physiological change should not constitute evidence of ED. Sporadic erectile problems that don’t cause important distress also should not be given this diagnosis.

Parker’s problem was not lifelong but acquired; the vignette provides no evidence that it applied only in specific situations, so neither situational nor generalized type would be specified. With no other obvious specifiers to note (and a GAF score of 70), his diagnosis would read:

F52.21 [302.72] Erectile disorder, acquired

F52.4 [302.75] Premature (Early) Ejaculation

As the disorder’s name implies, the man climaxes before he wants to—sometimes just as he and his partner reach the point of insertion. However, different studies use widely varying standards of how many minutes actually constitutes early: Is it 7 minutes? Is it 1? Both standards have been proposed. Whatever the duration, the climax yields disappointment and a sense of failure for both partners; secondary impotence sometimes follows. Stress in a relationship can exacerbate the condition, which of course promotes even greater loss of control. However, some women may value premature ejaculation (PE) because it decreases their exposure to unwanted sexual activity or pregnancy.

PE is a commonplace disorder; it accounts for nearly half the men treated for sexual disorders. It is especially frequent among men with more education—presumably because their social group is especially sensitive to the issue of partner satisfaction. Whereas anxiety is often a factor, physical illness or abnormalities rarely cause this problem.

Essential Features of Premature (Early) Ejaculation

The patient almost always ejaculates before he wants to, within moments of penetration.

The Fine Print

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders)

Coding Notes

Specify:

{Lifelong}{Acquired}

{Generalized}{Situational}

Specify severity:

Mild. The patient ejaculates 30–60 seconds after penetration.

Moderate. 15–30 seconds after penetration.

Severe. 15 seconds after penetration or less (perhaps before penetration).

Let’s be practical. And honest. The official criteria state two time standards for the patient with premature ejaculation, which boil down to “about a minute” and “too early.” DSM-5 claims that men can pretty accurately estimate time as long as it’s a minute or less, and in the heat of the moment, it seems unlikely in the extreme that anyone is going to clap a stopwatch on the activity. Therefore, for the vast majority of our patients, we will eschew the clock and accept the statement that “I just flat-out come too soon.”

Claude Campbell

Claude Campbell could remember, in embarrassing detail, the first time it ever happened. He had been a very young Marine second lieutenant stationed in Vietnam in the last year of the war. Suddenly granted leave to go to town, he had had to borrow a pair of Class A uniform trousers from the battalion chaplain.

Claude and two friends were seated at a sidewalk table, drinking a mixture that the military called a “Bombs Away,” when a prostitute sat down next to him. When she set to work warming her hand between his thighs, it only took a few moments before Claude felt himself lose control. A crimson blush spread across his face as a stain darkened the front of the chaplain’s khaki trousers.

“That was one of the worst times, but it sure wasn’t the last,” said Claude. After he left the Marines, he finished college and got a job selling computers. He soon married a girl he had dated during high school. Their wedding night, and most of their other nights, were never quite the disaster of the Vietnam bar, but he could never last longer than a minute or so after insertion.

“Not that it bothered her,” commented Claude ruefully. “She never enjoyed sex much, anyway. She was always glad to get it over with in a hurry. I know now why she insisted on ‘saving it’ for after we were married. She never wanted to spend it in the first place.”

Claude always hoped that his problems had been largely due to his first wife’s prudery and disapproval, but several months into his new marriage, things hadn’t improved much. “She’s being very patient,” he said, “but we’re both beginning to get desperate.”

Evaluation of Claude Campbell

Claude’s difficulty had been with him ever since his sex life began, and it occurred every time (criterion B). Although a few such incidents might be dismissed in a youngster or in any man with a new partner, in a mature adult (we don’t know Claude’s age at evaluation) who has been in a lasting relationship with frequent sexual activity, it must be considered pathological (A). Claude’s difficulty was clearly causing him distress (C); we’d have to enquire further about substance use (D). As noted earlier, physical illness does not play a significant role in the development of PE.

Claude’s problem was not situational (it had occurred with both of his wives and with the prostitute). As far as we’re aware, he’d had it forever. I’d place his GAF score at 70.

F52.4 [302.75] Premature ejaculation, generalized, lifelong, moderate

F52.32 [302.74] Delayed Ejaculation

Men with delayed ejaculation (DE) achieve erection without difficulty, but have problems reaching orgasm. Some only take a long time; others may not be able to ejaculate into a partner at all. Prolonged friction may cause the partners of these patients to complain of soreness. Anxiety about performance may cause secondary impotence in the patients themselves.

Even when it has been present lifelong, a man can usually ejaculate by masturbating (alone or with the help of his sex partner). The personalities of patients with lifelong DE have been described as rigid and puritanical; some seem to equate sex with sin. Or the disorder may be acquired from interpersonal difficulties, fear of pregnancy, or a partner’s lack of sexual allure. DE is somewhat more common in patients with anxiety disorders.

DE is probably uncommon. When men do have problems with delayed (or absent) climax, there is often a medical cause; examples include hyperglycemia, prostatectomy, abdominal aortic surgery, Parkinson’s disease, and spinal cord tumors. Some men have a physical abnormality that, upon orgasm, causes semen to be expelled into the urinary bladder (retrograde ejaculation). Drugs like alphamethyldopa (an antihypertensive) and thioridazine (a neuroleptic), as well as alcohol, have also been implicated. If any of these factors is the sole cause, it cannot be regarded as an example of DE.

The drug thioridazine, which can inhibit a man’s ability to have orgasm, is sometimes used to treat patients with premature ejaculation (see the previous diagnosis).

Essential Features of Delayed Ejaculation

The man experiences pronounced delay or infrequency of climax.

The Fine Print

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, relationship problems)

Coding Notes

Specify:

{Lifelong}{Acquired}

{Generalized}{Situational}

Specify severity: {Mild}{Moderate}{Severe}

Rodney Stensrud

Rodney Stensrud and his girlfriend, Frannie, had come to the clinic seeking relief for Rodney’s “performance problem.” They had been together for nearly a year, and they disagreed as to the extent of the problem.

Rodney was frankly worried. It had always taken him a long time to have a climax, and now, after 40 minutes or so of vigorous intercourse, he sometimes found himself wilting under pressure. Frannie was more sanguine. Her previous boyfriend had never been able to last longer than 5 minutes, and that often left her feeling frustrated.

“Now I almost always come more than once,” she said with an air of satisfaction. Recently Rodney had been taking even longer, and she admitted that she was getting pretty sore. “Maybe if we could get it back down to about half an hour,” she suggested.

Rodney’s parents had reared him strictly. Throughout his childhood, he had attended parochial school, so that he was “pretty clear on the concept of good versus evil.” He admitted that he felt guilty that he and Frannie were living together without benefit of clergy, but she wasn’t ready to take that step yet. She used to laugh and tell him that she wanted to “save something for after the baby came.”

Before meeting Frannie, Rodney’s only experience had been with two prostitutes he had encountered while he was in the Navy. It had taken him hardly any time at all with either of them. In fact, he felt that the one with the mouth had rather shortchanged him. “There sure wasn’t any delay involved,” he said. Neither had he experienced any particular problem masturbating, either when he was an adolescent or more recently when Frannie was gone on an extended business trip.

Rodney had been referred by a urologist, who had found nothing physically wrong. The couple’s only drinking was an occasional glass of white wine. At one time Rodney had occasionally used marijuana at parties, but Frannie was death on drugs, so he had given it up a year ago.

Evaluation of Rodney Stensrud

After apparently normal desire and excitation phases, Rodney always took an inordinately long time to reach climax (criterion A1). From the vignette, this does not appear to have been a lifelong problem, though it had now lasted for many months (B). The problem was causing him enough distress to seek help (C); already he seemed headed down the road to secondary impotence.

Rodney’s problem was situational; he had experienced no ejaculatory delay when with a prostitute or when masturbating. His referring physician had noted no physical illnesses that might account for his disorder, and there was no significant substance use; with no evidence of any other mental disorder that might be diagnosed instead, we’ve exhausted the possibilities of criterion D. His upbringing was puritanical, reinforcing the impression that the basis of his disorder was psychological, not physical.

Frannie’s reaction to Rodney’s disorder was perhaps somewhat atypical. Female partners sometimes complain of discomfort from prolonged intercourse necessary to achieve climax. Would the fact that Frannie found value in Rodney’s disorder present a possible problem for therapy? When working with the couple, Rodney’s clinician should keep this factor in mind—along with the possibility that he could have an anxiety disorder.

Rodney’s GAF score would be about 70. His diagnosis would be as follows:

F52.32 [302.74] Delayed ejaculation, acquired, situational, moderate

F52.22 [302.72] Female Sexual Interest/Arousal Disorder

Female sexual interest/arousal disorder (FSIAD) represents the fusion of two older diagnoses: hypoactive sexual desire disorder and female sexual arousal disorder. DSM-5 has combined them for several reasons. Especially in women, there is a high overlap between desire and arousal; some authorities think of desire as just the cognitive component of arousal. Moreover, one phase doesn’t always precede the other; their relationship really depends on the individual. And treating low desire also improves arousal.

Sexual desire depends upon a number of factors, including the patient’s inherent drive and self-esteem, previous sexual satisfaction, an available partner, and a good relationship with the partner in areas other than sex. Sexual desire may be suppressed by long abstinence. It may present as infrequent sexual activity, or as a perception that the partner is unattractive. Some patients actually become averse to sex, expressing loathing of any genital contact or of aspects of genital sexual contact.

Lack of interest in sex is the most common complaint of women coming to treatment. About 30% of women ages 18–59 will admit to having a period of at least several months when they’ve lacked sexual desire. As a result, perhaps half feel distress, which can affect the individuals or their relationships. Low desire is greater for women who are postmenopausal (either naturally or after surgery). There may be a history of painful intercourse, feelings of guilt, or rape or other sexual trauma occurring in childhood or in a patient’s earlier sexual life.

Don’t diagnose FSIAD if the problem occurs only in the context of another mental condition, such as major depressive disorder or a substance use disorder. (Among the medications that can contribute are antihistamines and anticholinergics.) Also note that postmenopausal females may need more foreplay to lubricate to the same degree than they did when they were younger. However, FSIAD often coexists with another sexual condition, such as female orgasmic disorder. A woman who doesn’t express interest in sex but does respond to sexual activity with excitement would not qualify for a diagnosis of FSIAD. Neither would someone who identifies herself as having been “asexual” her whole life.

Essential Features of Female Sexual Interest/Arousal Disorder

A woman’s low sexual interest or arousal is indicated by minimal interest in sexual activity, erotic thoughts, response to partner overtures, and enjoyment during sex. She will generally not initiate sexual activity and doesn’t “turn on” to erotic literature, movies, and the like.

The Fine Print

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, relationship problems)

Coding Notes

Specify:

{Lifelong}{Acquired}

{Generalized}{Situational}

Specify severity: {Mild}{Moderate}{Severe}

Ernestine Paget

“She hardly ever wants to do it,” James Paget told the marriage therapist.

“That’s not quite accurate,” Ernestine responded. “The truth is, I never want to do it. It’s disgusting.”

When they got married 3 years earlier, Ernestine had been uninterested in sex, though receptive to the idea of it. “It seemed to mean a lot to him, so I put up with it,” she explained. “But he was never satisfied. No matter how often we made love, a few days later there he was, wanting more. It got old fast.”

“It is the usual expectation,” her husband remarked dryly, “and it’s not my fault how she was brought up.”

In Ernestine’s family, sex was never discussed and nudity wasn’t allowed. Ernestine could never remember having much curiosity about sex, let alone interest. She had been an only child. “I assume her parents only did it once,” offered James.

For the first few months, Ernestine would simply lie still and think about other things, enduring what was for her a basically boring activity because it was important to her new husband. Her gynecologist had assured her that as far as her anatomy and hormones were concerned, she was completely normal. Unless she was figuring out whether it was time to start taking her new prescription of birth control pills, she never thought about sex.

“God knows, I never dream about it,” Ernestine said. “Maybe if he’d led up to it more, it would have helped. His idea of foreplay is half an hour of David Letterman and a slap on the butt.” She had once tried to explain this to James, but he had only called her “frigid.” That was the last word they had exchanged on the subject until now.

Now James pretty much ignored Ernestine. She undressed in the closet; they slept on the two edges of their king-sized bed. She didn’t know where he was getting his sex these days, but it wasn’t at home and she said she didn’t care.

“At least he doesn’t have to worry that I’d try to cut it off, like that Bobbitt woman,” Ernestine said. “I don’t even like to look at it, let alone touch it with a 10-inch knife.”

Evaluation of Ernestine Paget

Ernestine’s low sex interest was shown not just by absent interest (criterion A1); she denied even fantasizing (A2) about what was for her a boring activity (A4). This is an important point: Some patients may reject the idea of sex with a current (or with any) partner, yet may still harbor an abstract interest in sex or in sex with some hypothetical person. When Ernestine began her sexual life with her husband 3 years earlier (B), she was merely uninterested in sex. It was only with experience that she became intolerant of the very idea of sexual contact, from which we can infer criterion A3. (Three of the six criterion A requirements for FSIAD must be met.) Although she could face the prospect of no sex with equanimity, her husband couldn’t, and that disparity was causing distress for them both; criterion C was thus satisfied.

Ernestine’s clinician needed to ascertain that she had no other major disorder—such as major depressive disordersomatic symptom disorder, or obsessive–compulsive disorder—that could explain her antipathy to sex (D). In the presence of any of these, she’d only receive the additional diagnosis of FSIAD if her sexual symptoms remained once the other pathology had been eliminated. Similar arguments would hold for substance use or another medical condition.

The Pagets were also having severe problems with other aspects of their marriage—enough to warrant mention as a spousal relationship problem. Her abhorrence of sexual contact could also meet the criteria for specific phobia; under the circumstances, however, no such additional diagnosis is necessary. In DSM-IV, Ernestine would have qualified for a diagnosis of sexual aversion disorder, but DSM-5 has eliminated it.

Ernestine’s condition appears to have lasted throughout her sexual life. With our current information, we couldn’t determine whether her disorder was generalized or situational. Although we suspect that something in her upbringing may lie at its roots, in DSM-5 we have no way to code this putative etiology. With a current GAF score of 61, her diagnosis would be as follows:

F52.22 [302.72] Female sexual interest/arousal disorder, lifelong, severe
Z63.0 [V61.10] Relationship distress with husband (emotional withdrawal)

Disorders of female sexual arousal and orgasm are often highly correlated. Among health care clinicians, you may encounter less than slavish adherence to the criteria used for these disorders.

F52.6 [302.76] Genito-Pelvic Pain/Penetration Disorder

Genito-pelvic pain/penetration disorder (GPD), new in DSM-5, subsumes the DSM-IV categories of dyspareunia and vaginismus, which were combined because they couldn’t be discriminated reliably. The old terms will probably retain some currency as descriptors of particular types of discomfort.

Some women experience marked discomfort when attempting to have sexual intercourse. The pain may be experienced as a cramping contraction of the vaginal muscles (vaginismus) that may be described as an ache, a twinge, or a sharp pain. Anxiety can produce tension in the pelvic floor, with resulting pain severe enough to prevent consummation of a relationship (sometimes for years). Soon anxiety comes to replace sexual enjoyment. Some patients can’t even use a tampon; a vaginal exam may require anesthesia.

Nearly a third of women who have had gynecological surgery will experience some degree of pain with intercourse. Infections, scars, and pelvic inflammatory disease have also been reported as causes. Don’t diagnose GPD when pain is only a symptom of another medical condition or is due to substance misuse. What percentage of women will qualify for GPD remains unknown.

Two examples of this somewhat clumsily named condition follow.

Essential Features of Genito-Pelvic Pain/Penetration Disorder

A patient has major, repeated pain or other problems with efforts at vaginal intercourse; she may experience anxiety, fear, or pelvic muscle tension.

The Fine Print

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, relationship problems)

Coding Notes

Specify:

{Lifelong}{Acquired}

Specify severity: {Mild}{Moderate}{Severe}

Mildred Frank

Mildred Frank and her twin sister, Maxine Whalen (see next vignette), had been having problems with pain during intercourse. Their symptoms were different and quite personal, but they had always discussed everything with each other. Now they had made the joint decision to seek help. The gynecologist had referred them both to the mental health clinic.

“It’s sort of a burning,” was how Mildred described her difficulty. “When it’s bad, it feels like your hands do if you’re sliding down a rope. It’s awful! Even if I use Vaseline, it still bothers me.”

The referral letter noted that she’d had surgery for a prolapsed uterus but was otherwise healthy. “I could have told you that,” she said. “I’ve never even been to a doctor, except to have my babies.”

On close questioning, Mildred admitted that the pain didn’t occur often. But during the past year or two she had always been afraid it would hurt, and that made her invariably tense up when she was having intercourse with her husband. She’d had some vaginal infections, but these had been largely under control during the last few months; the gynecologist didn’t think that they caused the pain she complained of. The letter also noted that her physical exam had been completed easily, with no evidence of vaginal spasm.

“Maybe I do overreact,” she said. “At least that’s what my husband tells me. He says I’m too excitable, that I should just relax.”

Evaluation of Mildred Frank

Many women have sporadic pain with intercourse, in which case diagnosis is usually not warranted. But for a couple of years (criterion B) Mildred had experienced pain, tensing, and fear; each was enough to qualify her for the form of GPD that was once known as dyspareunia (A2, A4, A3). Her distress was evident (C); as ever, the real problem is to rule out other causes first.

Mildred described herself as otherwise healthy, and her gynecologist made no mention of other medical problems. Although she had had some vaginal infections, the doctor felt that they couldn’t completely account for her pain. Her clinician would have to determine that there was no substance-induced disorder, though this would seem unlikely. Sexual dysfunctions can be expected with a number of mental conditions (anxiety, mood, and psychotic disorders), but her history supports none of them as a possible cause. Painful intercourse famously occurs in patients with somatic symptom disorder, but Mildred claimed that she was otherwise healthy, which would greatly reduce the likelihood of this diagnosis. All of the foregoing factors should lay to rest our concern about other causes (D).

Although Mildred’s pain with intercourse was acquired fairly recently and only occurred occasionally, it did cause her to seek treatment. She had had no partners other than her husband, though nothing in the vignette suggests that she would have fared better with someone else. Although insufficient symptoms were noted to warrant a personality disorder, her clinician should note in the chart any behaviors that seem to justify further investigation. I’d give her GAF score as 71.

F52.6 [302.76] Genito-pelvic pain/penetration disorder, acquired, mild to moderate

In men, the symptom of painful intercourse is rare and almost always associated with some physical illnesses, such as Peyronie’s disease (a lateral bend in an erect penis), prostatitis, or infections (for example, gonorrhea and herpes). It can cause an inability to complete penetration during sex—or fear that pain will occur. However, at least one study has reported that, contrary to expectation, men with a pelvic pain syndrome experience minimal impact on their interpersonal relationships; indeed, pain levels and good relationship adjustment were directly proportional. Such a situation would obviate a diagnosis of GPD, even if DSM-5 had been disposed to allow it in a man.

Maxine Whalen

Maxine Whalen and her twin sister, Mildred Frank (see preceding vignette), had both been having problems with pain during intercourse; as noted above, they made a joint decision to seek help. Finding no anatomical causes for either of them, the gynecologist had referred both to the mental health clinic.

Maxine wasn’t married yet, and she didn’t think she wanted to be. “It’s not that I don’t get horny,” she explained. “And I love foreplay. I could do it all night. But every time a man has tried to enter me, something inside me clamps down like a trap. I couldn’t even get a pencil inside, let alone a penis. I can’t even use a tampon.”

Maxine usually relieved her frustration by masturbating, which reliably produced a climax. Oral sex had also worked. “Not many men are likely to be satisfied with that for long,” she remarked. “It makes me feel like a freak.”

The spasms that contracted Maxine’s vaginal muscles produced severe, cramping pain. They were so extreme that her gynecologist had to insert the speculum under general anesthesia. The exam revealed no physical abnormalities.

On her second visit, Maxine remembered something that Mildred apparently hadn’t known. When the girls were 4, they had been molested in some way. Even Maxine wasn’t sure exactly what had happened. She only knew that some man—she thought it might be the Uncle Max for whom she had been named—had taken the girls to a tavern, stood them on the bar, and allowed the other patrons to “play” with them.

Evaluation of Maxine Whalen

Maxine’s lifelong (criterion B) history of severe pain and obstructed penetration (A1, A2—only one required) suggests the diagnosis. The fact that the spasm was reproduced by the attempted introduction of the gynecologist’s speculum was diagnostic. Unless a patient is both unattached and content to refrain from intercourse, it is axiomatic that vaginal spasms will produce distress or interpersonal difficulty (C).

Maxine’s history did not indicate that there had ever been a time since she became sexually active when she was free of vaginal spasm (B); therefore, we’d call it lifelong. Her gynecologist found no physical cause (no surprise there, since none are usually reported—D). Her GAF score would be 65.

In DSM-IV-TR, Maxine’s diagnosis would have been vaginismus.

F52.6 [302.76] Genito-pelvic pain/penetration disorder, lifelong, generalized, severe

F52.31 [302.73] Female Orgasmic Disorder

Achieving climax is a problem for a lot of women, though studies have been persistently inconsistent as to just what that means. Perhaps 30% of women report significant difficulties; 10% never learn the trick. A few physical illnesses, including hypothyroidism, diabetes, and structural damage to the vagina, can contribute to the condition; if judged to be exclusively the cause, they obviate the diagnosis of female orgasmic disorder (FOD). Orgasm can also be inhibited by medications such as antihypertensives, central nervous system stimulants, tricyclic antidepressants, and monoamine oxidase inhibitors. Possible psychological factors include fear of pregnancy, hostility of the patient toward her partner, and feeling guilty about sex in general. Age, previous sexual experience, and the adequacy of foreplay must also be considered in diagnosing FOD.

Once learned, a woman’s ability to achieve orgasm persists, often improving throughout life. But women just don’t complain of having premature orgasms, the way men do. Although it occurs (shown by surveys), it often doesn’t pose a problem. Many women are able to enjoy sex without experiencing climax on a frequent basis. FOD is often comorbid with other sexual dysfunctions, especially female sexual interest/arousal disorder.

Essential Features of Female Orgasmic Disorder

A woman has been troubled by orgasms that are too slow, too rare, or too weak.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Duration (6+ months) • Distress to the patient • Differential diagnosis (substance use and physical disorders, problems in partner relationship)

Coding Notes

Specify if: Never experienced an orgasm under any situation

Specify:

{Lifelong}{Acquired}

{Generalized}{Situational}

Specify severity: {Mild}{Moderate}{Severe}

Rachel Atkins

“I don’t think anyone has quite the understanding of frustrating that I do,” Rachel Atkins said to her gynecologist.

Her early history was “a sociological nightmare.” She was born to a 16-year-old high school dropout who had gone on to a lifetime of serial marriages and alcoholism. Beginning when she was in middle school, a series of stepfathers had molested Rachel until, when she was 16, she’d bolted—into prostitution.

“How ironic is that, escaping from sex by going on the game?” she asked. But she was lucky enough to avoid AIDS and, when she was 22, smart enough to jump at a chance at college, financed by a conscience-stricken former client.

As a sex worker, Rachel had experienced hundreds of men. “It wasn’t as bad as you might think,” she explained. “I could pick my own johns, and some of them I rather liked—not at all like Mom’s collection of rats.” One possible victim of her experiences was her orgasm, which had always been missing in action. “I always figured it’d be there when I really wanted it. Only it never was.”

Now a university graduate solidly planted in the academic world (she taught anthropology at a college in her community), Rachel was nearing 30 and had a boyfriend who wanted to marry her. “He knows all about my past, and he’s OK with it. But he wants me to come when we have sex. I think it would reassure him that he’s different from all those others. I desperately want to please him, but there’s just something missing in me. It’s beyond distressing!”

Rachel loved the closeness she felt with Henry, and she lubricated well. “I just never quite get over the top. It’s like when you think you’re going to sneeze, you know? And instead, it just dissolves in your nose.” She’d tried mood music, alcohol, marijuana, erotic literature, and clitoral stimulation. “But I could be digging pottery shards, for all the good any of it does.”

Apart from the usual teenage experimentation and the brief “therapeutic” flirtation with white wine and marijuana, Rachel had used no drugs. Her general health was excellent, she said.

“I promised Henry I’d always be truthful with him, and I intend to keep that promise. So I refuse to fake it. I could, though—I’ve sure had practice!”

Just why women have orgasms isn’t actually known. Of course, the reason for the male counterpart is obvious: Its absence would leave us bereft of males or females. One of the more popular theories is that it developed in parallel with the male orgasm, and there’s just been no evolutionary pressure for it to go away. The author of that theory must have been a guy.

Discussion of Rachel Atkins

Rachel’s problem wasn’t lack of interest in sex—she looked forward to it with her boyfriend, and she lubricated normally during foreplay. Her difficulty was solely her inability to climax—ever (criterion B). If she had had occasional orgasms, or if she climaxed only with masturbation, she could still receive this diagnosis, according to DSM-5’s criterion A1; low intensity of orgasm would also qualify (A2). There was no evidence that other medical or mental conditions or substance use contributed in the slightest (D). What she did have in abundance was distress (C).

Because she’d never experienced a climax, we should add that verbiage to her diagnosis (which obviates the other possible specifiers). Her GAF score would be rated very high (95) for any patient, because of her overall excellent adjustment. I would rate the severity of her FOD as only moderate, largely because of the composure and well-balanced approach to her life she showed during the discussion with her clinician.

F52.31 [302.73] Female orgasmic disorder, never experienced an orgasm under any situation, moderate

Substance/Medication-Induced Sexual Dysfunction

As with physical illness, a variety of psychoactive substances can affect the sexual abilities of men and women. Note that you would substitute the diagnosis of substance/medication-induced sexual dysfunction for a specific substance intoxication diagnosis only when the patient’s problems in that area exceed those you would expect in the usual course of substance intoxication.

On average, perhaps half of patients taking antipsychotic and antidepressant drugs will report sexual side effects, though these will not always reach the level of clinical significance. Users of street drugs also often have sexual side effects, though they may complain less, since they may value their drug of choice more highly than sex.

The vast number of possible expressions has persuaded me not to include a vignette for this section.

Essential Features of Substance/Medication-Induced Sexual Dysfunction

Substance use appears to have caused sexual dysfunction.

The Fine Print

The D’s: • Distress to the patient • Differential diagnosis (physical disorders, delirium, primary sexual disorders)

You’d only make this diagnosis when the symptoms are serious enough to warrant clinical attention and they are worse than you’d expect from ordinary intoxication or withdrawal.

Coding Notes

When writing down the diagnosis, use the exact substance in the title: For example, alcohol-induced sexual dysfunction.

ICD-9 kept coding simple: 292.89 for alcohol, 292.89 for all other substances. For coding in ICD-10, refer to Table 15.2 in Chapter 15.

Specify if:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers.

Specify severity:

Mild. Dysfunction in 25–50% of sexual encounters.

Moderate. 50–75% of encounters.

Severe. 75% or more.

F52.8 [302.79] Other Specified Sexual Dysfunction

F52.9 [302.70] Unspecified Sexual Dysfunction

Use one or the other of these categories for patients whose sexual dysfunctions don’t qualify for any of the specific sets of criteria spelled out above. Such conditions would include those for whom you conclude that there is a sexual problem, but one of the following obtains:

Atypical symptoms. The symptoms are mixed, atypical, or below threshold for a defined sexual disorder.

Uncertain cause.

Insufficient information.

As usual, the other specified designation should be used in cases where you choose to state the reasons for not assigning one of the other diagnoses described in this chapter; the unspecified designation should be used when you do not so choose.

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