Gender- and sexuality-related disorders

Last updated: April 8, 2022

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Sexual dysfunctions are a group of physical and psychiatric disorders 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). To diagnose psychosexual dysfunctions, the dysfunction must persist for at least 6 months, cause clinically significant distress in the individual, and not be 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). The most common organic sexual dysfunction is erectile dysfunction, which is characterized by the inability to achieve or sustain an erection sufficient in rigidity or duration for sexual intercourse. Organic causes are diverse and include vascular, neurological, and hormonal conditions. If the dysfunction is not attributable to substances/medications, severe relationship stress, or an organic cause, the psychiatric diagnosis of erectile disorder, described in the DSM-V, is made. Dyspareunia is pain that occurs during or after sexual intercourse, affects up to 20% of women, and is associated with various organic conditions.

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, however, they do not cause significant distress or functional impairment.

Gender dysphoria is diagnosed in patients who experience significant distress caused by an incongruity between their experienced gender and their sex assigned at birth. Gender diverse identities (e.g., transgender, bigender, agender) are not disorders, but individuals may experience distress in the processes of affirming their identity, leading up to gender dysphoria.

For congential conditions affecting sex, see “Differences (disorders) of sex development.”

Sexual dysfunctions are a group of physical and psychiatric disorders characterized by clinically significant difficulty in experiencing sexual pleasure, responding to sexual stimuli, and/or performing sexually. The etiology is often complex, involving organic and psychological factors. See “Sexual response cycle” in “Sexuality and sexual medicine” for details on the physiological sexual response.

Diagnostic criteria (DSM-V) [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.
Psychosexual dysfunction (DSM-V)
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
Erectile disorder
  • ≥ 1 of the following occur during ≥ 75% of all sexual encounters:

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
Delayed ejaculation [3]
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

Genito-pelvic pain/penetration disorder

  • 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: considered best initial treatment option ; consists of a combination of modalities, such as patient education, internal manual techniques, dilatation exercises, local tissue desensitization, and home exercises (e.g., Kegel exercises).
  • Psychotherapy
  • Anxiolytic drugs: in conjunction with other therapeutic modalities
  • Local botox injections for refractory cases
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

References:[1][4]

Definition

A condition characterized by a persistent or recurrent inability to acquire or maintain an erection of sufficient rigidity or duration for sexual intercourse due to substances/medications, organic, and/or psychogenic causes.

Epidemiology

  • The most common form of sexual dysfunction in men
  • Affects 10–25% of men
  • Becomes more common with age

Etiology

Often involves a combination of organic and psychogenic risk factors.

PENIS: most common causes of erectile dysfunction are Psychological, Endocrine, Neurogenic, Insufficient blood flow, Substance use.

Clinical features

  • Failure to initiate, failure to fill, or failure to maintain an erection during sexual intercourse
  • A sudden onset generally indicates psychogenic etiology (e.g., performance anxiety with a new sexual partner).
  • The difficulty can be generalized or situation-specific (e.g, with one partner)

Diagnosis [1]

Treatment [7]

Definition

  • Dyspareunia: pain that occurs during or after sexual intercourse and is due to organic and/or psychogenic factors [8]
  • Genito-pelvic pain/penetration disorder (defined by the American Psychiatric Association in the DSM-V): an umbrella term for female sexual pain (pelvic or vulvovaginal pain that is precipitated or exacerbated by sexual contact) that is not attributable to another mental disorder, severe relationship stress, use of substances/medications, or to any medical conditions.

Etiology [8][9]

Clinical features [8][9]

  • Superficial or deep pain before, during, or after sexual intercourse
  • Pain is often reproducible e.g., during any sexual activity involving the genitals, gynecologic exams (e.g., speculum insertion), insertion of a tampon or menstrual cup
  • Chronic vulvar pain, burning, and irritation may indicate an underlying vulvovaginal condition e.g., vulvodynia, vulvovaginal atrophy

Diagnosis

Diagnostic criteria

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

Management

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-V)

  • 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

References:[1][4]

Definition

  • Gender dysphoria refers to the distress caused by the incongruity between gender identity and gender assigned at birth and not the experience of incongruity itself.
  • Gender dysphoria should not be confused with a transgender identity, the affirmation of which may require psychiatric treatment for associated distress (e.g, due to discrimination) and medical treatment in the course of gender transition but is not considered a disorder in its own right.

Diagnostic criteria

Diagnostic criteria (DSM-V)
Gender dysphoria in children Gender dysphoria in adolescents and adults
An incongruence between a child's gender identity and gender assigned at birth over a period of at least 6 months, as manifested in ≥ 6 of the following:

An incongruence between an adolescent's/adult's gender identity and gender assigned at birth over a period of at least 6 months, as manifested in ≥ 2 of the following:

  • Strong desire to be the other gender (self-identification as another gender)
  • In boys, a strong desire to wear typical girls' clothing; in girls, a strong desire to wear typical boys' clothing
  • Strong desire for cross-gender roles during make-believe play
  • Strong preference for toys and activities typically associated with the other gender
  • Strong preference for playmates of the other gender
  • Strong rejection of typically masculine toys and activities in boys; rejection of typically feminine toys and activities in girls
  • Strong dislike of one's own sexual anatomy
  • Strong desire for the primary and/or secondary sex characteristics that correspond with the desired gender
  • Clinically significant distress/impairment in important areas of functioning (e.g., occupation, school)

Treatment [11]

A transgender or gender diverse identity is not a mental disorder but may cause distress potentially leading to psychiatric disorders due to stigma, discrimination, and/or a sense of mismatch between gender assigned at birth and gender identity (e.g., gender dysphoria).

References:[1][4][12]

  1. Sexaholics Anonymous. https://www.sa.org/. . Accessed: December 20, 2021.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  3. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. Wolters Kluwer Health ; 2014
  4. Coleman E, Bockting W, Botzer M, et al.. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. International Journal of Transgenderism. 2012 . doi: 10.1080/15532739. 2011.700873 . | Open in Read by QxMD
  5. Practice Guidelines for LGB Clients - Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. http://www.apa.org/pi/lgbt/resources/guidelines.aspx. Updated: February 20, 2011. Accessed: June 3, 2017.
  6. Carson C, Gunn K. Premature ejaculation: definition and prevalence.. Int J Impot Res. undefined; 18 Suppl 1 : p.S5-13. doi: 10.1038/sj.ijir.3901507 . | Open in Read by QxMD
  7. Di Sante S, Mollaioli D, Gravina GL, et al. Epidemiology of delayed ejaculation.. Translational andrology and urology. 2016; 5 (4): p.541-8. doi: 10.21037/tau.2016.05.10 . | Open in Read by QxMD
  8. Rosen RC, Riley A, Wagner G. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997 . doi: 10.1016/s0090-4295(97)00238-0 . | Open in Read by QxMD
  9. Elhanbly S, Elkholy A, Elbayomy Y, Elsaid M, Abdel-gaber S. Nocturnal penile erections: the diagnostic value of tumescence and rigidity activity units. Int J Impot Res. 2009; 21 (6): p.376-381. doi: 10.1038/ijir.2009.49 . | Open in Read by QxMD
  10. Erectile Dysfunction: AUA Guideline (2018).
  11. Hill DA, et al.. Dyspareunia in women. Am Fam Physician. 2021 .
  12. Heim, LJ. Evaluation and Differential Diagnosis of Dyspareunia. Am Fam Physician. 2001 .

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