Sexual dysfunction and paraphilic disorders

Last updated: February 24, 2025

Summary

Sexual dysfunctions are conditions characterized by clinically significant difficulty in experiencing sexual pleasure (e.g., genito-pelvic pain/penetration disorder) or responding to sexual stimuli (e.g., erectile disorder, premature ejaculation). Diagnosis is made using DSM-5 diagnostic criteria. Diagnosis requires exclusion of organic causes, such as dyspareunia in women and erectile dysfunction, both of which are detailed separately. Management of sexual dysfunctions is based on the specific disorder and can include psychotherapy, sex therapy, pelvic floor physical therapy, and/or pharmacological treatment. Congenital conditions affecting sex are covered separately in “Differences (disorders) of sex development.”

Paraphilic disorders are a group of psychiatric disorders characterized by abnormally intense and persistent sexual interests that manifest as urges, fantasies, or behaviors and involve a nonconsenting individual or cause significant distress or functional impairment in the affected individual. These disorders are distinct from paraphilias, which are also characterized by intense and persistent sexual interests but do not cause significant distress or functional impairment.

Sexual dysfunction

DSM-5 diagnostic criteria for sexual dysfunction ^[1]

The symptoms are present for at least 6 months.
The condition causes clinically significant distress in the individual.
The dysfunction is not attributable to another mental disorder (e.g., major depressive disorder, anxiety), severe relationship stress, use of substances/medications, or to any medical conditions (e.g., cardiovascular disease, diabetes mellitus).
Presence of additional condition-specific criteria listed below.

Sexual dysfunction disorders in the DSM-5
Conditions		Additional condition-specific criteria ^[1]	Treatment
Male sexual dysfunction	Male hypoactive sexual desire disorder	Persistent or recurrent deficiency or absence of sexual thoughts and desire for sexual activity	Cognitive-behavioral and psychodynamic therapy Sex therapy Testosterone replacement therapy
	Erectile disorder	≥ 1 of the following occur during ≥ 75% of all sexual encounters: Difficulty developing an erection Difficulty maintaining an erection Reduced rigidity of the erection	Psychodynamic psychotherapy Counseling Sensate focus exercises for performance anxiety Group psychotherapy Pharmacological treatment: see “Treatment of ED.”
	Premature ejaculation (prevalence of up to 30%) ^[2]	Persistent or recurrent ejaculation within ∼ 1 minute of penetration and before the patient wishes to ejaculate Occurs in ≥ 75% of all sexual encounters	Psychotherapy Cognitive-behavioral therapy Pharmacological treatment SSRIs (e.g., paroxetine ) are first-line treatment. Topical anesthetics (e.g., lidocaine-prilocaine spray) can also be used in combination with SSRIs and psychotherapy.
	Delayed ejaculation ^[3]	≥ 1 of the following occur during ≥ 75% of all sexual encounters: Delayed ejaculation Infrequent or absent ejaculation	Psychodynamic psychotherapy Sensate focus exercises Sex therapy
Female sexual dysfunction	Female sexual interest/arousal disorder	Absence of or reduction in ≥ 3 of the following: Interest in sexual activity Sexual thoughts or fantasies Initiation or participation in sexual activities Sexual excitement/pleasure in most (≥ 75%) sexual encounters Sexual arousal to sexual cues Genital or nongenital sexual sensations during most (≥ 75%) sexual encounters	Cognitive-behavioral and psychodynamic therapy Sex therapy Low-dose testosterone and/or vaginal hormone replacement therapy (postmenopausal women)
	Genito-pelvic pain/penetration disorder ^[4]	Persistent or recurrent difficulty with ≥ 1 of the following: Vaginal penetration during sexual intercourse Severe vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration Severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration Severe tightening of pelvic floor muscles during attempted vaginal penetration (historically referred to as vaginismus)	Pelvic floor physical therapy Vaginal dilation Psychotherapy Treatment of any causes of dyspareunia in women (e.g., lubricants and moisturizers for vaginal dryness)
	Female orgasmic disorder	≥ 1 of the following occur during ≥ 75% of all sexual encounters: Severely delayed, infrequent, or absent orgasm (e.g., anorgasmia) Reduced intensity of orgasmic sensation	Psychotherapy Education and exercises to facilitate orgasm through self-stimulation

The most common sexual disorder in men is erectile disorder, followed by premature ejaculation; the two disorders commonly occur concomitantly. In women, the most common disorders are sexual interest/arousal disorder and female orgasmic disorder.

Contributing factors to consider in diagnosis and treatment

Factors in patient history,; e.g., poor body image; , low self-esteem, history of sexual or emotional abuse, stressors, bereavement
Relationship and partner factors, e.g., partner's sexual and medical health, poor communication, discrepancies in sexual interest and arousal
Psychiatric comorbidities, e.g., major depressive disorder, anxiety
Nonpsychiatric conditions and lifestyle factors, e.g., diabetes mellitus, tobacco use, insufficient physical exercise
Cultural or religious factors, e.g., level of sexual education, negative attitudes toward sexuality
Penile hypersensitivity and hyperexcitability of the reflex arc (for premature ejaculation)

Differential diagnoses

Inadequate sexual stimulation
Organic conditions
- Endocrinopathy; (e.g., decreased testosterone levels, diabetes mellitus, hypothyroidism)
- Nerve damage (e.g., damage to the spinal cord due to trauma or pelvic surgery, multiple sclerosis)
- Cardiovascular disease (e.g., ischemia due to atherosclerosis)
Specific differential diagnoses
- Erectile dysfunction due to organic causes (for erectile disorder)
- Dyspareunia in women due to organic causes (for genito-pelvic pain/penetration syndrome)
Other psychiatric disorders
- Major depressive disorder
- Anxiety
Substance and/or medication-induced sexual dysfunction
- Severe disturbance in sexual function that occurs during or soon after substance intoxication, withdrawal, or after exposure to a medication that is capable of causing sexual dysfunction
- Examples: SSRIs, antipsychotics, antihypertensives, opioids, alcohol, cocaine
- Management
  - Reduce dose or discontinue medication
  - See “Substance-related and addictive disorders” for details regarding the management of specific substance intoxication or withdrawal

References:^[1]^[5]

Paraphilic disorders

Definition

A group of psychiatric disorders characterized by abnormally intense and persistent sexual interests and desires; (manifested as urges, fantasies, or behaviors) accompanied by significant distress or functional impairment and/or harm to others
- Paraphilias are variations in sexual preference that may manifest as urges, behaviors, and/or fantasies. Paraphilias are not always pathological, and a paraphilic disorder should only be considered if they interfere negatively with a patient’s life and/or that of others.
Paraphilias and paraphilic disorders are not inherently criminal offenses, but acting on them may constitute sexual assault, rape, or another crime, especially when nonconsenting individuals are involved.

Diagnostic criteria (according to DSM-5)

Presence of abnormally intense and persistent sexual interests occur over a period of at least 6 months as specified by condition below.
Presence of significant distress, impairment in important areas of functioning (e.g., social, occupational), and/or acts directed against nonconsenting individuals
Presence of additional condition-specific criteria listed below

Paraphilic disorders
Condition	Additional disorder-specific criteria
Voyeuristic disorder	Persistent and intense sexual arousal caused by observation of an unsuspecting person who is nude, undressing, or engaging in sexual activity The patient must be ≥ 18 years of age.
Exhibitionistic disorder	Persistent and intense sexual arousal caused by exposure of one's genitals to an unsuspecting person
Frotteuristic disorder	Persistent and intense sexual arousal caused by touching or rubbing against a nonconsenting person
Sexual masochism disorder	Persistent and intense sexual arousal caused by being beaten, bound, humiliated, or made to suffer
Sexual sadism disorder	Persistent and intense sexual arousal caused by inflicting pain, suffering, or humiliation on another person
Pedophilic disorder	Persistent and intense sexual arousal occasioned by prepubescent child or children (≤ 13 years of age) The patient is at least 16 years old and at least 5 years older than the child/children.
Fetishistic disorder	Persistent and intense sexual arousal related to, and a fixation on, nonliving objects (e.g., shoes) or nongenital parts of the body (e.g., feet, hair) Criteria of exclusion: Sexual arousal is limited to sex toys and/or clothing used for crossdressing.
Transvestic disorder	Persistent and intense sexual arousal caused by wearing clothes associated with the opposite gender that cause clinically significant distress and/or functional impairment. Cross-dressing for artistic purposes and in settings where it causes no distress and/or functional impairment to the individual is not a disorder and should not be diagnosed as such. Cross-dressing and transvestic disorder must be distinguished from the practice of transfeminine and transmasculine individuals dressing according to the gender they identify with.

Treatment

Psychotherapy and cognitive behavioral therapy
Group therapy
12-step program (Sexaholics Anonymous) ^[6]
Social skills training
Pharmacological treatment to suppress sex drive (e.g., antiandrogens, antidepressants such as SSRIs, mood stabilizers)