Gender- and sexuality-related disorders

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 sexual dysfunction is erectile dysfunction (covered in detail in a separate article), which is characterized by the inability to achieve or sustain an erection sufficient in rigidity or duration for sexual performance. 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-5, is made. Dyspareunia in women is pain that occurs during or after sexual intercourse, affects up to 20% of women, and is detailed separately.

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. This condition is covered in a separate article.

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.

See also “Dyspareunia in women.”

Diagnostic criteria (DSM-5) ^[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.

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 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][4]

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

Treatment

• Psychotherapy and cognitive behavioral therapy
• Group therapy
• 12-step program (Sexaholics Anonymous) ^[5]
• Social skills training
• Pharmacological treatment to suppress sex drive (e.g., antiandrogens, antidepressants such as SSRIs, mood stabilizers)

References:^[1][4]