Sexual and Gender Identity Disorders



The Sexual and Gender Identity Disorders are categorized into the following three types: Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders. Sexual Dysfunctions are marked by inhibited sexual desire, social difficulties, and constant, debilitating feelings of distress. People with sexual dysfunctions may avoid sexual opportunities for fear of failure. They also may feel inadequate which can diminish their self-esteem. There are four categories of Sexual Dysfunctions: Sexual desire disorders, Sexual arousal disorders, Orgasmic disorders, and Sexual pain disorders. Paraphilias are sexual urges relating to objects, behaviors, or circumstances not normally associated with sexual activity. People with paraphilias usually feel that their urges are demanding, or compulsory. A psychiatric diagnosis of paraphilia requires that the person have acted on the urges or be distinctly distressed by them. Gender Identity Disorders are marked by intense cross-gender identification with persistent discomfort pertaining to the persons biologically determined sex. These individuals have the anatomic sex of one sex, but feel that they are members of the other.




2. Voyeurism (302.82)

    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
      • B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
      • C. These activities have caused distress, impaired work, social or personal functioning.
    • Associated features
      • Voyeurism, a form of paraphilias, refers to the achievement of sexual gratification by observing or spying on unsuspecting people, especially while they dress, undress, or engage in sexual activity. The observers, often known as "Peeping Tom's", may not feel guilt or remorse when intruding upon other individuals' privacy. Voyeuristic individuals may rationalize their behavior, claiming "no harm, no foul." Voyeurism is considered a crime in several states, but the definition of voyeurism varies from state to state.
      • This clip shows the story of when a person is caught acting on voyeurism.

  • Some are harmless sexual variation in physical appearance, but can cause people to become innocent victims. Voyeurism is like scopophilia (love of watching) and is the impulse to spy on other people which are almost always strangers. The voyeur is subject to repetitive and irresistible urges to spy on others through windows, doors, in public toilets, parks, or beaches. They may fantasize about engaging in sexual acts with their victims, but these acts are rarely gratified. Voyeurist may also listen to erotic conversations between unsuspecting individuals.
  • The voyeur may wait outside their victims window and masturbate to the subject undressing, taking a shower, or even a couple having sex. They also may wait until afterwards to masturbate while replaying the incident in their mind.
  • The voyeur may risk injury by assuming precarious positions to catch a preferred view of their target.
    • Child vs. adult presentation
      • Lack of maturity and understanding prevents children from being diagnosed with Voyeurism.
    • Gender and cultural differences in presentation
      • Men are much more likely to be diagnosed with Voyeurism than women. There does not seem to be any differences with cultural presentation of Voyeurism. However, with the social nature of the prohibited activity it appears to be an important facctor in the sexual arousal pertaining to Voyeurism.
      • Voyeurs tend to harbor feelings of inadequacy and to lack social and sexual skills.
    • Epidemiology
      • The onset for the disorder is normally before the age of 15 years.
      • Some studies have shown that men express voyeuristic tendencies more often than women, but the disorder is not unique to males (American Psychiatric Association). The prevalence rate of this abnormality is not known. Some research suggests that people in the U.S. are showing more voyeuristic characteristics due to the increase in reality television shows being aired.
    • Etiology
      • There are some differing opinions on the origins of voyeuristic behavior. One opinion is derived from Freudian psychoanalytic studies; this theory places an emphasis on child abuse and the harboring of traumatic childhood memories. Voyeuristic tendencies may be rooted in childhood. (Lane, R.). A different approach to voyeurism is expressed in the cognitive-behavioral approach. An Orgasm is labeled as a reinforcer that can lead to voyeuristic or exhibitionistic behaviors. An orgasm is defined as "The peak of sexual excitement, characterized by strong feelings of pleasure and by a series of involuntary contractions of the muscles of the genitals, usually accompanied by the ejaculation of semen by the male." The nature of the orgasm teaches, reinforces, and conditions some individuals to the point that they acquire a desire to engage in voyeuristic activities. (Schwartz, M.).
    • Empirically supported treatments
      • Successful treatment requires a desire from the individual to change his/her voyeuristic tendencies. Behavioral therapy is most commonly used for voyeurs. The person is instructed in ways to control the impulses that cause these actions (Schwartz, M.). The physician may suggest alternative means of sexual gratification to help change patterns of thinking that lead to voyeurism. Other treatment options would include psychoanalytic therapy (Lane, R.). The therapist would help to uncover the underlying thoughts that are causing the voyeuristic thoughts or tendencies. Support groups and the use of SSRIs and Antiandrogens are also a common treatment for individuals suffering from voyeurism.
    • Prognosis
      • Once voyeurism behaviors take place, they typically do not stop. Over time, it may become the main form of sexual gratification for the voyeur. The course of voyeurism tends to be chronic.
      • The prognosis for eliminating voyeurism tends to be poor because individuals with this disorder typically have no desire to change their patterns of behavior.
      • Since voyeurism involves non-consenting partners and is against the law in many jurisdictions, the possibility of embarrassment may deter some individuals.

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3. Transvestic Fetishism (302.3)


    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
      • B. The fantasies, sexual urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning. It involves using nonliving objects to obtain sexual arousal.
      • Specify if :
        • With Gender Dysphoria: if the person has persistent discomfort with gender role or identity
    • Associated features
      • Common symptoms associated with this psychological disorder do not seem to vary greatly, but these symptoms do vary in severity. Transvestic Festishism is defined as a paraphilia by the DSM and usually occurs in patients as one of several paraphilias. These disorders, known as paraphilias, are a group of mental disorders characterized by several types of obsessions involving sexual practices or activities that incorporate sexual practices involving non-consenting or inappropriate partners, or unusual means of arousal. The main feature of this disorder is recurring sexual urges or sexual desires involving dressing in clothing normally worn by the opposite sex. This is often also referred to as cross-dressing. A diagnosis of this disorder is usually made only if an individual has acted out on these urges or if the urges seem to interfere with everyday activities for the individual. The frequency at which the urges occur is the deciding factor in the severity of cases. For some individuals, the urge occurs often and is necessary for sexual arousal, while in some individuals they may not be necessary or present unless triggered by outside influences (e.g. stress). When these outside influences are absent, individuals with less severe cases are typically able to function in a normal sexual manner. Participation in transvestism is usually gradual, over time the sufferer begins to assume the identity of a member of the opposite sex based on his or her perceptions of that sex. Transvestic behavior in patients is closely associated with achieving some sort of sexual gratification. A person that practices transvestic fetishism often finds it difficult to distinguish from the opposite gender. They have often adopted many qualities specific to that gender (e.g. mannerisms, clothing, materials, and other items associated with the opposite gender). In extreme cases some individuals undergo hormonal or surgical procedures to change their appearance to that of the opposite sex (gender reassignment surgery.) The DSM states that one should not be considered homosexual in nature just because of transvestism, although some do occasionally have homosexual encounters. Some individuals with transvestic behavior appear to be motivated by autogynephilia which is a condition in which the individual is sexually stimulated by fantasies that their own bodies are female.
      • The ICD-10 adds the additional exclusion criteria that the disorder is not a symptom of another mental disorder such as schizophrenia. It also includes a separate diagnosis of Dual-role Transvestitism characterized by non-erotic cross-dressing and the absence of desire toward permanent sex reassignment.
    • Child vs. adult presentation
      • It is difficult to determine differences in the presentation of this disorder between children and adults because the disorder typically begins during childhood and progresses further into adulthood if untreated.
    • Gender and cultural differences in presentation
      • Individuals diagnosed with this disorder are typically male; females are rarely diagnosed. A few cases have been reported, but virtually no information is available on female occurrences of the disorder. This may be due to the fact that, in Western cultures, women may dress in a number of socially accepted ways, while men are more limited in socially accepted attire. It should be noted, however, that in current times, there are fewer diagnoses of this disorder. Today there is a greater degree of acceptance regarding this condition and the disorder is generally seen as harmless to others.
      • Some Dutch studies suggest adult transsexualism ratios of 1:11,900 in males and 1:30,400 in females. In adults transsexualism is difficult to estimate or diagnose. In children there have been reports of 10-16%.
    • Epidemiology
      • Estimation is difficult in adults but probably less than 2% to 5% in the general population, but is difficult to estimate or diagnose.Transvestic Fetishism is slightly more prevalent in the child population because that is where it usually begins.
    • Etiology
      • Some individuals may be unaware of the root causes of the disorder in their cases. Possible causes of this disorder could be adolescent curiosity or factors stemming from encounters in childhood as simple as dressing up in the clothes of one's mothers or sister if the individual in question is male. In adults, many of these individuals will steal their relatives/or girlfriends undergarmets and hide them when they are not around. They will wait for the opportune time to wear these things when alone for fear their "little secret" will come out. The activity is found enjoyable and therefore repeated, but the reasoning behind the enjoyment is unconscious. It has been suggested that the disorder can sometimes be caused by mothers' creating gender confusion by dressing the boy as if he were a girl. This behavior is sometimes related to the mother's anger towards men or anger at the fact that she had a son rather than a daughter. Such occurrences are rare and support for this notion is lacking.
      • Ray Blanchard has suggested an etiological association between transvestic fetishism and "non-homosexual gender identity disorders" (i.e., FTMs sexually attracted to men, both men and women, or neither, and MTFs attracted to women, both men and women, or neither). This is based on retrospective studies of transvestic male fetishists and MTFs where Blanchard has identified a common element of "autogynephilia"--which Blanchard defines as a man's eroticization of himself as being or dressing as a female.
    • Empirically supported treatments
      • The most common diagnosing practice is taking a history or by engaging in direct observation. A diagnosis is only made if a patient is markedly distressed by an inability to dress as they desire or if the disorder interferes with normal activities in daily life. Known treatments for the disorder were developed when the disorder was less accepted. These treatments often utilized aversion therapy involving electrical shocks, but these treatments were largely unsuccessful.
      • Another type of treatment referred to as orgasmic reorientation has also been tried with little success. The goal in this type of therapy was to attempt to help people learn to respond sexually to generally accepted stimuli. With the view of the disorder changing with the times there is less focus on treatment of the disorder and more encouragement for societal acceptance.
    • Prognosis
      • The prognosis for treatment of transvestic fetishism is poor, as most persons with this disorder do not desire to change. Most cases in which treatment was demanded by a spouse as a condition of continuing in a marriage have not been successful.

  • The video below is an interview with Eddie Izzard who is a stand-up comedian, but also has a fetish for cross-dressing. Most people with this disorder are able to lead normal lives and most of them "dress up" in their own privacy; however, it is clearly seen in this interview that Eddie Izzard mixes his fetish in with his every day life.


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4. Frotteurism (302.89)


    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a non-consenting person.
      • B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
      • Frotteurism is the paraphilic focus that involves touching and/or rubbing against a non-consenting person. This particular behavior usually occurs in crowded places, such as public transportation facilitates and concerts, from which the individual can more easily escape arrest. The most common form of Frotteurism is when he or she rubs his or her genitals against the victim’s thighs and buttocks or with women, fondles her genitalia or breasts with his hands. Individuals with Frotteurism will often fantasize that they have an exclusive and caring relationship with their victim at the moment of contact. While doing this when he or she usually recognizes what has happened and to avoid possible prosecution, he or she must escape detection after touching his victim.
    • Associated features
      • A person who is suffering from Frotteurism usually experiences symptoms such as intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a non-consenting person for over a period of at least six months. These fantasies, urges, and behaviors can cause distress and problems associated with work, social atmospheres, and other important daily activities. Frotteurism is a derivative of the French word "frotter" meaning "to rub."
      • Frotteurism is also known as "mashing". Mashing has been reported exclusively among males (DSM, 2000). Mashing usually takes place in crowded places, such as buses, elevators, or subway cars. The man usually incorporates images of his mashing within his masturbation fantasies. Mashing is related to "toucherism", which is the fondling of nonconsenting strangers. Mashing can be so furtive and fleeting that the victim may not realize what has happened.
    • Child vs. adult presentation
      • Typically, children under the age of 12 do not have Frotteurism due to lack of understanding and maturity. Most individuals who participate in frotteurism are between the ages of 15 and 25.Tendencies typically increase the age of 15 and decrease after the age of 25.
    • Gender and cultural differences in presentation
      • Activities related to this disorder have been well-documented, particularly during historic periods in which they were considered more appropriate in certain less-established areas.
      • Men are more likely to engage in frotteurism than women. Women are most likely to be the victims of the acts of frotteurism.
    • Epidemiology
      • Currently, there is no information on the epidemiology of Frotteurism available. Frotteurism is associated with paraphilic fantasies, but it occurs most commonly in adolescents. This disorder is not associated with traumatic experiences in either adolescent or adult life.
    • Etiology
      • Research has been unable to uncover a direct cause for Frotteurism; however, some possible causes have been suggested. One theory that experts agree on is that there are underlying issues related to one's childhood that plays a major role. Other experts say that when a person accidentally and randomly touches or rubs on another person’s genitals or other body parts in public and finds sexual arousal from that contact, the person's feelings act as a reinforcer that perpetuates the behavior. Sometimes the sexual arousal and excitement become too much for one to bear and the person succumbs to these urges.
    • Empirically supported treatments
      • To treat paraphilias, one generally uses either medication and/or behavioral therapy. This behavioral therapy or psychotherapy is focused on uncovering and establishing the cause and reason for taking part in frotteurism. The most successful treatment is Cognitive-behavioral therapy (CBT). Other therapies include biofeedback therapy, and covert sensitization. In biofeedback therapy, an individual is connected to a machine that displays light and/or sound. The individual must attempt to keep the light or sound within a certain range while he or she is exposed to sexually-enticing objects or material. Covert sensitization is a therapy in which an individual is relaxed and then asked to picture things in her or his mind that excite them. The individual is then instructed to picture something negative. The goal behind this therapy is to link the sexually pleasing cognitions to negative cognitions in order to suppress them. In order for treatment to be successful, the individual must learn how to control the temptations and impulses to touch other non-consenting individuals for sexual gratification. An example of a medication that can be given to help females who suffer from Frotteurism is Medroxyprogesterone, which is a female hormone that is credited to decrease sexual desire. Antiandrogens are a type of medication given to males suffering from Frotteurism. The medicine fluoxetine, or Prozac, is commonly given to people who suffer from Frotteurism to increase the chemical serotonin in the brain, which would reduce obsessive thoughts and behaviors that are compulsive.
    • Prognosis
      • The prognosis for eliminating frotteurism is poor as most "frotteurs" have no desire to change their behavior. Since frotteurism involves nonconsenting partners and is against the law in many jurisdictions, the possibility of embarrassment may deter some individuals.





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5. Sexual Masochism (302.83)


    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.
      • B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Associated features
      • Sexually masochistic behaviors are usually evident by early adulthood and often begin with masochistic or sadistic play during childhood. The masochist experiences sexual excitement from physically or psychologically receiving pain, suffering, and/or humiliation. Fantasies, sexual urges, or behaviors through which the individual is beaten, bound, humiliated, or subjected to pain in some ways characterize this disorder. Some that suffer from sexual masochism may be uncomfortable with or bothered by these fantasies and sexual urges, so they may not act on them when engaged in sexual activity with other people but may carry them out in private. There is a dangerous and potentially fatal form of masochism called hypoxyphilia, in which individual’s experience sexual pleasure or arousal by way of oxygen deprivation, such as choking with hands or other materials. Hypoxyphilia is a dangerous act, where the victim achieves sexual arousal and attempts to enhance his or her experience of an orgasm by oxygen deprivation; to this occurs via strangulation, using a plastic bag or a mask. Mistakes while engaging in hypoxyphila can result in serious injury, brain damage, or death. Paraphilic Infantilism, another form of Sexual Masochism involves the victim's desire to be treated as an infant. Such individuals often wear diapers in these situations. The majority of Infantilists are heterosexual males. This may be due to the feeling of freedom and loss of responsibility some attempt to achieve through Infantilism.
      • Sexual masochism is a paraphilia, where a sexual sadist will have a partner who willingly acts with him or her. Sexual masochists have a desire or need for pain or humiliation to enhance sexual arousal so that gratification may be attained. During sexual excitation or sexual contact, the individual is humiliated, beaten, or receives some type of pain or suffering. For the masochist, she or he is typically bound to increase the feeling of helplessness. Like sexual sadism, some masochists are bothered by their fantasies, and they may appear, but not acted on, during sexual activity. This situation usually involves a fantasy rape without any possibility of escape. Some act on fantasies in private; usually these would include self-mutilation, sticking themselves with pins, or giving themselves electric shocks. If the partner is involved, the acts might include blindfolding, restraint, spanking, whipping, cutting, and some form or humiliation.
      • Sexual masochism is very different from Sexual Sadism, yet oftentimes the two are linked. Sexual masochism tends to be chronic once it appears, and the acts may increase in severity, eventually leading to serious injury or to death. Sexual Sadism is also chronic and the behaviors can increase in severity. Also, there is a term known as sadomasochism which is used to illustrate the occasion where sadism and masochism are both present in one person but portrayed as different disorders, or according to which theory is used, it can also be used as a replacement for both terms.However, Masochism, like Sadism, is formed from a proper name. The term is derived from an Australian novelist, Leopold von Sacher-Masoch, who explains this disorder in his novels.
    • Hitler as a Masochist
      • Otto Strasser told the OSS officials during interviews on May 13, 1943 that Hitler’s niece, Geli Raubal, had confided in him a story about Hitler’s perversion. She had told him that “Hitler made her undress… He would lie down on the floor. Then she would have to squat over his face where he could examine her at close range and this made him very excited. When the excitement reached it’s peak, he demanded that she urinate on him and that gave him his sexual pleasure. Geli said the whole performance was extremely disgusting to her and … it gave her no gratification.” This leads many to believe that Hitler may have been a masochist. A personal friend to Hitler, Father Bernard Stempfle, supported this claim along with the claim of Geli Raubal. He said that there was a compromising letter written to Geli from Hitler that fortunately for Hitler Geli never received. The letter was said to contain Hitler’s mention of his masochistic and coprophilic inclinations. Another accusation of his masochism came from the German film star, Renaté Mueller. She had been invited to join Hitler for the night in his Chanceller, where after they had reached the undressing point Hitler “lay on the floor… condemned himself as unworthy, heaped all kinds of accusations on his own head, and just groveled around in an agonizing manner. The scene became intolerable to her, and she finally acceded to his wishes to kick him. This excited him greatly; He became more and more excited” (
Waite, R. G. L. (1977). The Psychopathic God Adolf Hitler. New York: Basic Books, Inc., Publishers.).
    • Child vs. adult presentation
      • Masochistic sexual fantasies often begin in childhood, but children are not diagnosed with this disorder. Sexual masochism is generally diagnosed by early adulthood. This disorder takes on a chronic course which can vary by person in severity and in dangerousness. For some, the dangerousness will rise to a level and plateau, for others it could become so severe or dangerous it could lead to permanent damage or even death. Private acts may include: self mutilation, sticking with pins, electric shocks, cutting, burning, and choking. Partnered acts may include: spanking, whipping, handcuffing, chaining, blindfolding, and humiliation in the form of defecation, urination, cross dressing, and mocking animal behavior (such as dogs or cats).
    • Gender and cultural differences in presentation
      • Males are more commonly diagnosed with sexual masochism than females. Cultures may differ on how the individuals satisfy their sexual urges toward this disorder, but all cultures that have been examined are similar in presentation.
    • Epidemiology
      • Approximately thirty percent of masochists also participate in sadistic behaviors (sadism). There are less than 2 people per million in the U.S. and other countries that die from hypoxyphilia, oxygen deprivation. There is no significant difference between the prevalence of Sexual Masochism in heterosexuals and homosexuals.
    • Etiology
      • The causes of sexual masochism are unclear; however, there a handful of theories that attempt to shed some light on the etiology of SM. Some theories attempt to explain the presence of sexual paraphilias in a general sense. Paraphilias involve sexual sadism and masochism with unusual masturbatory behaviors and with the use of special sexual devices and props. Most urges are acted upon alone and, though they may seem highly unusual to the average person, they usually cause no harm to the primary individual or to others. In some cases, such behaviors can indeed cause harm and can be serious in some cases. Unusual sexual practices stem from boredom of traditional sex or out of curiosity. This theory uses learning theory to back up its assertion that paraphilias develop because inappropriate sexual fantasies are suppressed and become stronger when forbidden. When the individual can finally act on them, they are in distress or arousal and so the paraphilia becomes associated with the arousal. Another theory explains this behavior as a form of escape (from old routine). Theories that stem from the psychoanalytic camp suggest that childhood trauma plays a role in the development of sexual masochism or sadism. This disorder is incompletely understood, and the etiology remains unclear.
    • Empirically supported treatments
      • Behavioral treatment is used to treat paraphilias and focuses on correcting and maintaining healthy arousal patterns and masturbation. Other behavioral therapies may include social skills training and cognitive restructuring. Medications can also be used treatment to reduce fantasies and behaviors relating to paraphilias. The goal of medication treatment is to reduce the sex drive so the number of sexual fantasies, erections, and sexual behaviors such as masturbation and sexual intercourse, diminishes.
    • Prognosis
      • Because of the chronic course of sexual masochism and the uncertainty of its causes, treatment is often difficult. The fact that many masochistic fantasies are socially unacceptable or unusual leads some people who may have the disorder not to seek or continue treatment.
      • Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual masochism should be referred to professionals who have experience treating such cases.

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6. Sexual Sadism (302.84)

    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
      • B. The person has acted on these sexual urges with non consenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
      • C. Sexual Sadism is severe and is associated with Antisocial Personality Disorder. The sexually sadistic individual may either seriously injure or kill the victim or partner.
    • Associated features
      • The paraphilic focus of Sexual Sadism involves acts in which the individual derives sexual excitement from psychological or physical suffering (including humiliation) of the non-consenting victim. It is the suffering of the victim that is sexually arousing. Sadistic fantasies or acts may involve activities that indicate the dominance of the person, such as forcing the victim to crawl or keeping the victim confined. Such fantasies may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Some individuals with this Paraphilia feel empowered by their sadistic fantasies; this feeling may be invoked during sexual activity but not otherwise acted upon. Some individuals with SS may engage in sexual acts for many years without the need to increase the potential for inflicting serious physical damage; however, usually the severity of their sadistic acts increases over time. When SS is severe, or when it is associated with Antisocial Personality Disorder, the individual with SS may seriously injure or kill the victim.
      • The urges must have been recurrent for at least six months for a diagnosis to be made or attempted. Achieving sexual excitation or orgasm is dependent on the other individual's being humiliated or receiving pain. Some individuals are bothered by these fantasies, which may occur during the sexual excitation and activity but are otherwise not carried out; thus, they remain fantasies. The partner (victim) may very well be terrified of the anticipated act, especially if the behavior involves total control or domination. In other instances, the sexual sadist will have a partner who willingly acts with him or her; she or he may suffer from sexual masochism. Some individuals with SS may act out their fantasies on unwilling partners or victims. Typical sadistic fantasies involve dominance over the partner/victim, and the fantasies were most likely present during the individual's childhood.
      • Sexual Sadism is often linked with Sexual Masochism.
    • Child vs. adult presentation
      • Sadistic sexual fantasies are likely to have been present during childhood and it is likely that individuals with SS were abused as children, both sexually and physically. Adult presentation is usually expressed in early adulthood about the time that the sexually sadistic activities appear, and the disorder is usually chronic in its course. Generally the sadistic acts increase in severity over the sufferer's lifespan.
    • Gender and cultural differences in presentation
      • Sexual Sadism presents itself in males in over 95% of known cases researched worldwide. Sexual Sadism will present itself in much the same manner throughout different cultures. Although this disorder can be obtained by males or females, it is more common for males to behave with more non-consenting partners even if it is considered rare.
    • Epidemiology
      • Sexual Sadism is found in only 1 to 2% of the population in the United States.
      • Age of onset varies greatly, but it typically has developed by early adulthood.
    • Etiology
      • There is no universally accepted cause or theory explaining the origin of Sexual Sadism. Some researchers explain it as the result of biological factors. Evidence for this theory comes from abnormal findings from neuropsychological and neurological tests from offenders. Others believe it is caused from brain injury or mental disorders such as Schizophrenia.
    • Empirically supported treatments
      • Behavior therapy is often used to treat Sexual Sadism. This psychological treatment includes management and conditioning of arousal patterns and masturbation as well as cognitive restructuring and social skills training.
      • Medication is especially recommended for individuals with SS who exhibit behaviors dangerous to others. The medications that are used are female hormones, which speed up the clearance of testosterone from the bloodstream, and Antiandrogen medications, which block the body's uptake of testosterone. SSRIs may also be used.
    • Prognosis
      • Because of the chronic course of sexual sadism and the uncertainty of its causes, treatment is often difficult. The fact that many sadistic fantasies are socially unacceptable or unusual leads many people who may have the disorder to avoid or drop out of treatment. Treating a paraphilia is often a sensitive subject for many mental health professionals. Severe or difficult cases of sexual sadism should be referred to a specialized clinic for the treatment of sexual disorders or to professionals with experience in treating such cases.

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7. Gender Identity Disorder in Adolescents or Adults (302.85)

    • DSM-IV-TR criteria
      • A. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the opposite sex, frequent dressing as the opposite sex, desire to live or be treated as the opposite sex, or the conviction that he or she has the typical feelings and reactions of the opposite sex.
      • B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of their sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
      • C. The disturbance is not concurrent with a physical intersex condition.
      • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      • Specify if (for sexually mature individuals): Sexually attracted to males, Sexually attracted to females, Sexually attracted to both, Sexually attracted to neither
    • Associated features
      • Differentiation of sex vs. gender – The terms sex and gender are commonly, mistakenly, considered interchangeable. Stoller (1968) defines sex as the sum of overt anatomical and physiological differences between male and female. Gender, separate from sex, refers to the sum of behavioral or psychological differences between the sexes.
      • General descriptive features – Individuals with GID experience strong, persistent desires to live as the opposite sex. These desires lead to pervasive distress over their assigned sex. Adults, often independent of immediate familial pressures, may seek hormonal treatment or gender reassignment surgery in order to pass as the opposite sex. This appearance is further enhanced by cross-dressing. Tension may exist between individuals with GID and their families; tension is typically greater when the subject is male, though generally neither males nor females are supported by their families in matters relating to their dissatisfaction with their assigned sex. In extreme cases, individuals with GID may resort to mutilation of, or self-removal of, their genitalia.
      • Physical examination findings – individuals with GID generally have normal, rather than ambiguous, genitalia, which debunks the notion that GID onset may be related to ambiguous genitalia. Hormonal treatments may result in noticeable increases in breast size in males. Individuals with GID may also resort to plastic surgery or surgical reduction of the Adam’s apple in order to complete their desired appearances.
    • Adolescent vs adult presentation
      • Adolescent presentation – Adolescents with GID are at a greater risk for depression, thoughts relating to suicide, and suicide attempts. In adolescents, GID presentation may resemble child or adult presentation depending on the level of development. Criteria are applied accordingly, but assessment of developmental levels may take considerable time in order to assure the valid application of said criteria. Younger adolescents may be difficult to diagnose because lack of cooperation from the child to discuss their feelings, particularly if they are concerned with how their families may react. Subjects may be referred to a clinic for issues concerning poor social integration with peers.
      • Adult presentation – Adults with GID commonly experience anxiety and depressive symptoms. Adult individuals with GID experience frustrations with their biological sex and frequently cross-dress in the privacy of their homes. Through hormonal treatment and skillful cross-dressing techniques, many adults can convincingly pass for members of the opposite sex. Unless gender reassignment surgery has been performed, sexual activity is typically limited by individuals’ insistence that partners abstain from touching or seeing their genitalia.
    • Gender and cultural differences in presentation
      • Gender – Typically, females with GID are more accepted than males with GID, this is because men are often ostracized (with considerable severity). Females generally experience less peer rejection and ridicule. In clinical settings, males outnumber females at a ratio as high as 3:1, and males are at a higher risk for associated Personality Disorders.
      • Culture – GID seems to be more present in males than females across cultures, but cultural acceptance is highly varied. In Western culture, GID is pathologized and individuals with the disorder, particularly males, are heavily stigmatized. In Native American cultures, such individuals are received differently; individuals who assume the roles of the opposite sex are known as the Two-Spirit. As the name suggests, the two-spirited are those who have both male and female spirits. Two-Spirits perform the work of the opposite sex and don garments appropriate for their new roles. This concept appears to be consistent across contemporary Native American cultures.
    • Epidemiology
      • Prevalence – Due to the stigma associated with GID, epidemiologists have encountered great difficulties in determining its prevalence; it is considered relatively rare even when accounting for under reporting due to the fear of stigmatization. The Meyer-Bahlburg (1985) study suggests a 1 in 30,000 occurrence in men and a 1 in 100,000 occurrence in women. Another study (Bakker, van Kesteren, Gooren, & Bezemer, 1993) suggests higher rates based on the prevalence of hormonal treatments for persons suffering from gender-identity-related problems in the Netherlands.
      • Course – Typically, gender dysphoria in childhood subsides before adulthood is reached, but some studies suggest that its previous presence may influence sexual orientation. Individuals with gender dysphoria in childhood sometimes reconcile their issues by identifying themselves as homosexual during adolescence. GID can follow two courses in adulthood. The first course is a continuation of GID that has persisted through childhood. The second course is characterized by a gradual onset beginning in early to mid-adulthood that follows, or is co-morbid with, Transvestic Fetishism. Both forms of GID present in adulthood are persistent, but spontaneous remissions have been noted.
    • Etiology
      • Biological factors – A great deal of research has been dedicated to assessing the effects of biological factors in determining risk for GID. Current research is inconsistent and exiguous, and much of it concerns the sensitive topic of homosexuality rather than GID directly. Some studies attempt to link GID with prenatal hormone environments; it has been posited that DES (diethylstilbesterol), a drug thought to prevent miscarriages that has the side effect of exposing the fetus to abnormally high levels of testosterone, results in masculine behavioral patterns in females. This hypothesis is not well supported, due to there being few differences between subjects exposed to this drug and control subjects. Other studies suggest physical attractiveness as a factor in GID. Typically, males with GID are rated as more physically attractive, while females with GID are rated as less physically attractive. It has been hypothesized that parental behavior may influence notions of gender identity in children. For example, a boy with a feminine appearance may be dressed in non-masculine accoutrement; the imaged imposed upon him by his parents may influence his notions of appropriate masculine behavior in later life. Limited research studying GID and twins has shown that if one twin has GID, the other is more likely to have it as well. This would provide good support for biological theories, but very small sample sizes have made it difficult to examine this hypothesis thoroughly.
      • Psychosocial factors – Sex assignment at birth has been hypothesized as a determining factor of GID. Infants born with ambiguous genitalia who are assigned sex roles typically develop gender identities consistent with their assigned roles; however, supporters of said hypothesis maintain that if these roles are not decisively reinforced, subjects may develop GID. Social reinforcement is also considered a deciding factor in the development of GID. A lack of corrective measures taken when observing play patterns inconsistent with that of an individual’s sex has been associated with the development of GID. The quality of parenting as a factor has been examined; Zucker & Bradley (1995) suggested that mothers diagnosed with mental illnesses may be less capable in their parenting, which may increase the likelihood of GID onset. Similarly, Coates (1985) and Green (1987) suggested that distant or absent fathering may be linked to GID onset.
    • Empirically supported treatments
      • Psychotherapy – Psychotherapy has proven useful in interventions, though its effectiveness is dependent upon how early it is administered. The purpose of this treatment is to help individuals cope with their biologically determined sex and reinforce the behavioral patterns associated with those roles. This method may reduce transsexual behavior in later life.
      • Hormonal treatment and surgery – Adults with GID may request surgical reassignment of sex. Individuals who desire this treatment have typically experienced hormonal therapy to reduce undesired secondary sex characteristics and to develop those present in the opposite sex. Hormonal treatment causes breast growth and reductions of facial hair in males and cessation of menstruation, increases in body hair, and voice deepening effects in females. Subjects are typically required to live as the opposite sex with hormonal treatment for a year or more before surgery is considered an option.
      • Past treatments have included various behavioral therapies targeted toward changing the individual's social and sexual behaviors to be more stereotypically masculine or feminine, including behavioral modification of vocal characteristics, sexual fantasies, patterns of sexual arousal, even movements and posture.
      • In contrast, current treatment, as outlined by the Standards of Care, includes three principal elements comprising a " triadic therapy." These elements include living as the desired gender, hormone therapy, and sex reassignment surgery- although not all individuals will desire, or complete, all three steps.
    • Prognosis
      • If gender identity disorder persists into adolescence, it tends to be chronic in nature. There may be periods of remission. However, adoption of characteristics and activities appropriate for one's birth sex is unlikely to occur.
    • Link:





Two Spirits clip from Frameline on Vimeo.



Journal article: Is the gap more than gender?


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8. Exhibitionism (302.4)


    • DSM-IV-TR criteria
      • A. Over a period of at least 6 months, recurring, intense sexually arousing fantasies, urges, or behaviors involving the exposure of one’s genitals to unsuspecting strangers
      • B. The person has acted on said urges, or the urges or fantasies cause marked distress or interpersonal difficulty
    • Associated features
      • Exhibitionists in some cases masturbate while exposing themselves (or while fantasizing that he/she is exposing himself/herself) to another person. There is a pattern in which males exhibit themselves and there are three characteristic features of the exhibition: 1) It is performed for unknown women. 2) It takes place where sexual intercourse is impossible (e.g. a crowded shopping center). 3) It seems designed to surprise and shock the woman. The male exhibitionist usually exposes his erect penis, but it is not necessarily essential for the activity. Ejaculation may occur at the moment of exposure or develop later with masturbatory stimulation. Some exhibitionists are aware of a conscious desire to shock or upset their target; while others fantasize that the target will become sexually aroused by their display.
    • Child vs. adult presentation
      • Generally, society accepts exhibitionism in children as a natural curiosity, not a disorder, however if the behaviors continue a paraphilia is probable. Disorder appears to develop before the age of 18, and rarely is found in people over the age of 50.
    • Gender and cultural differences in presentation
      • Most reported cases of exhibitionism involve males. Some scientists argue that women who undress in front of windows (as to invite a person to watch), or who wear low cut gowns are exhibitionists in a sense. Exhibitionism generally appears in Western society and is believed to be almost absent in such countries as Japan, Burma, and India. Additionally, in the American society it can be a crime when committed by a male, but when women expose themselves, excluding total nudity, they are often seen as victims of male voyeurism.
    • Epidemiology
      • Prevalence and incidence are not easily defined because people with this disorder usually do not seek treatment voluntarily. Exhibitionism is one of the three most common sexual offenses, the other two being voyeurism and pedophilia. It is rarely diagnosed in general mental health clinics, but most professionals believe that it is probably under-diagnosed and under-reported.
    • Etiology
      • People with these types of paraphilia tend to have personalities accompanied by social isolation, low self-esteem, and, usually, feelings of sexual inadequacy. They are not generally comfortable with normal heterosexual relationships and they are not willing to risk the rejection of their attempts to create willing sexual relationships, so they resort to abnormal sexual activity. They suggest that sexual abuse as children or other traumatic childhood situations may be the cause. According to Freudian theory, during the phases of psychosexual development, fixations rooted at one level of sexual adjustment prevent normal progress to the next stage of development. Some behavioral theories state that sexual arousal has been linked with the activity of exposure through either a Pavlovian-type conditioning process or operant conditioning. Some documented cases have shown that some men become exhibitionists after traumatic brain injuries (TBIs).
      • Several theories have attempted to explain the etiology of exhibitionism.
        • Biological theories - these theories hold that testosterone increases the susceptibility of males to develop deviant sexual behaviors.
        • Learning theories - these theories assert that emotional abuse in childhood and family history are both risk factors.
        • Psychoanalytical theories - these theories posit that male gender identity requires separation from his mother psychologically so that he does not identify with her as a member of the same sex.
    • Empirically supported treatments
      • Cognitive-behavioral therapy is the most effective form of treatment for exhibitionism. Under C-B treatments, patients are encouraged to recognize and address the irrational justifications and possible punishments for their behaviors and thinking patterns.
      • Psychotherapy is typically aimed at finding the hidden or underlying cause of such behavior.
      • Group Couples Therapy is usually helpful for those who are married and whose family ties have been strained by exhibitionism. Orgasmic reconditioning has the patient replace the exhibitionist fantasies with more socially acceptable sexual behaviors while masturbating.
      • Group Therapy- is typically used to get people past the " denial" stage that is frequently associated with paraphilias, and acts a form of relapse prevention.
      • Twelve-Step programs for sexual addicts. Exhibitionists who feel guilty and anxious about their behavior are opten helped by social support and emphasis on a healthy spirituality found in these groups, as well as cognitive restructuring that is built into the twelve steps.
    • Prognosis
      • The prognosis for people with exhibition disorder depends on a number of factors, including the age of onset, the reasons for the patient's referral to psychiatric care, degree of his cooperation with the therapist, and comorbidity with other paraphilias or other mental disorders. For some patients, exhibitionism is a temporary disorder related to sexual experimentation during their adolescence. For others, however, it is a lifelong problem with potentially serious legal, interpersonal, financial, educational, and occupational consequences. People with exhibition disorder have the highest recidivism rate of all the paraphilias; between 20% and 50% of men arrested for exhibitionism are re-arrested within two years.

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9. Sexual Aversion Disorder (302.79)

    • DSM-IV-TR criteria
      • A. Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.
      • B. The disturbance causes marked distress or interpersonal difficulty.
      • C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction).
      • Subtypes: To indicate onset (Lifelong versus Acquired) and Context (Generalized versus Situational)
    • Associated features
      • Some individuals faced with severe sexual aversion disorder may experience panic attacks with extreme anxiety, dizziness, nausea, faintness, heart palpitations, and breathing difficulties. There may be noticeable changes in interpersonal relations (such as marriage). Individuals with sexual aversion disorder (SAD) may avoid sexual situations or potential sexual partners by subtle diversion strategies like falling asleep early, traveling, neglecting their appearance, substance abuse, or burying themselves in work, school, or other activities.Sexual aversion disorder is characterized not only by a lack of desire, but also by fear, revulsion, disgust, or similar emotions when the person with the disorder engages in genital contact with a partner. The aversions may take several different forms, it may be related to specific aspects of sexual intercourse, such as the sight of the partner's genitals, or the smell of his or her body secretions, but it may also include kissing, hugging, and petting as well as intercourse itself.
    • Child vs. adult presentation
      • This disorder manifests itself in early adulthood, so there is no information regarding symptom presentation in children.
    • Gender and cultural differences in presentation
      • There are few statistics on the number of people with SAD because it is often confused with other disorders. Many people find sex a hard subject to talk about even with a doctor; consequently, the number of people with SAD is greater than the number of people who seek treatment.
    • Epidemiology
      • Because SAD is a subcategory of the Hypoactive Sexual Desire Disorders, the prevalence of SAD is currently unknown. The prevalence is higher in women than in men.
    • Etiology
      • In women Sexual aversion disorder is normally caused by a traumatic experience of the past, such as rape, incest, molestation, and other forms of sexual abuse. In men the disorder is associated with performance anxiety. Evidence suggests that past sexual trauma and/or relationship issues may be an underlying cause in the development of SAD.
    • Empirically supported treatments
      • Sexual aversion disorder is treated most often with the help of a psychiatrist and psychotherapy. If the disorder also concerns a partner or a spouse, marriage counseling is often used. Pharmacotherapy is typically used for patients with sexual aversion disorder only if they are experiencing panic attacks severe enough to cause additional distress not normally for the disorder itself. Behavioral counseling would be of use in finding out and resolving the underlying issue of this conflict.
    • Prognosis
      • When sexual aversion disorder is addressed as a psychological disorder, treatment can be very successful. Psychotherapy to treat the underlying psychological problems can be successful as long as the patient is willing to attend counseling sessions regularly. For sexual aversion disorder that is situational or acquired, psychotherapy for both the patient and his or her partner may help to resolve interpersonal conflicts that may be contributing to the disorder. Panic attacks caused by or associated with the disorder can be treated successfully by medication if the doctor considers this form of treatment necessary.
      • If sexual aversion disorder is not diagnosed, discussed, or treated, the result may be infidelity, divorce, or chronic unhappiness in the relationship or marriage.
    • Additional Information

Sexual Aversion Disorder
Sexual Aversion Disorder
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10. Pedophilia (302.2)

    • DSM-IV-TR criteria
      • Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving sexual activity with a pre-pubescent child or children (generally age 13 or younger)
      • The fantasies, sexual urges, or behaviors case clinically significant distress or impairment in social, occupation, or other important areas of functioning.
      • The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.
        • Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old
      • The person must state whether they are:
        • Sexually attracted to males
        • Sexually attracted to females
        • Sexually attracted to both males and female
      • Must specify if:
        • Limited to incest
      • Must state whether:
        • Exclusive Type (aroused only by children)
        • Nonexclusive Type
    • Associated features
      • Recurring sexual dreams, behaviors, or urges concerning children that are 13 years old or younger. These urges may be directed toward children of the same sex as the pedophiles, or the other sex. Some pedophiles are attracted to both boys and girls. Some are attracted to to only children, while others are attracted to children as well as adults. These issues must be persistent for at least 6 months and must cause impairment to everyday functioning to be considered symptoms. If an individuals is 16 years old and exhibits these behaviors with someone that is at least 5 years younger, he would be considered for this disorder.
      • To be diagnosed as having Pedophilia, the individual must be at least 16 years of age. The disorder typically begins in adolescence, although some individuals with Pedophilia report that they did not become sexually aroused by children until middle adulthood.
      • Pedophiles may limit their activity to exposing themselves to the child (sometimes known as flashing), touching and fondling the child gently, undressing the child and looking at him or her, or masturbating in front of the child.
    • Gender and cultural differences in presentation
      • The word "Pedophilia" is derived from the Greek words "paidos" (child) and "philia" (love). Until recently, pedophilic individuals had found it relatively easy to gain access to unattended children. Awareness of Pedophilia has been raised in the past two decades, and it has become more difficult for these individuals to find children with whom to act out their fantasies. In response to the scarcity of vulnerable children, many pedophiles have turned to chatrooms and child pornography.
      • Males are more often diagnosed with this disorder than women. Pedophilia is more prevalent among Caucasians than among other ethnicities. It is also known that if a male prefers males, it is more likely that he will repeat his pedophilic actions. This has led certain religious or otherwise radical activists to suggest that pedophilia and homosexuality are "one and the same," resulting in further media attention to an already well-covered topic.
      • One of the biggest issues in assessing behavior as pedophilic or normal is the criteria for Pedophilia; by Western standards, certain cultures (e.g. Islamic) would have higher prevalence of Pedophilia. Some cultures allow "child weddings," or unions between mature males and prepubescent females. In some tribal societies in Africa, pedophilic behavior is considered perfectly normal; men often take "boy-wives" in addition to wives. The men engage in sexual activity with these boy-wives until it is deemed time for the young boy to choose a wife of his own. At this point, the boy's "husband" will then aid him in choosing a wife, and the boy will be allowed to leave to start a family of his own. Clearly, it is important to note any religious or cultural backgrounds in individuals being examined as having Pedophilia. This is a very difficult situation, as some groups have voiced the concern that any pedophile can simply convert to a belief system that accommodates and excuses his behaviors
      • Islamic Sharia law
    • Epidemiology
      • There is very little known about the prevalence of Pedophilia at this time because, due to the severely negative stigma associated with having Pedophila, many people with Pedophilia rarely seek help from a mental health professional. The ratio of sex offenders against female children and sex offenders against male children is about 2:1. According to data in a (1987; 1988) study, sexual offenders against males have many more victims than those against females. Sexual offenses against female children have a rate of 19.8, while sexual offenses against male children are at a rate of 150.2. Since there is a higher rate of sexual offenders against male children, this may suggest that this group has a greater number of true pedophiles.
      • Note: The large commercial market in pedophiliac pornography suggests a much higher prevalence than the limited medical data indicates
    • Etiology
      • Some researchers feel that it is due to biological factors, that one of the male sex hormones predisposes men to be more sexually deviant; however, according to a 2002 study there is no evidence of any link between genetics and Pedophilia. Others suggest that pedophilia results from certain psychosocial factors (e.g. being sexually abused as a child, or the nature of one's familial interactions). Still others invoke factors such as the following: anomalies in psychological development, the desire to overpower sexual partners, and the belief that sex is a necessary requisite for affection.
    • Empirically supported treatment
      • There are multiple treatment options for those individuals that are considered to have Pedophilia. The first one is cognitive behavioral therapy. This is a relapse prevention program that has been shown to reduce recidivism.
      • Another option is behavioral interventions. This helps suppress sexual arousal of children and turn it more toward adult arousal. However, it is currently not known if the method changes sexual interest or if it just changes the ability to control erections during testing.
      • Medication is also used in some cases. The three classes of medications most often used to treat pedophilia (and other paraphilias) are: female hormones, particularly medroxyprogesterone acetate, or MPA; luteinizing hormone-releasing hormone (LHRH) agonists, which include such drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate; and anti-androgens, which block the uptake and metabolism of testosterone as well as reducing blood levels of this hormone. These hormones are sometimes prescribed to divert intrusive sexual thoughts, urges, or abnormally frequent sexual behavior. Although medication may seem like a good option, it almost always must be long term to be fully and completely effective.
      • Relapse- Pedophilia is typically chronic in nature, but the fantasies and behaviors associated with Pedophilia tend to decrease with age (as is the case with any sexual activity).
      • Surgical castration is sometimes offered as a treatment to pedophiles who are repeat offenders or who have pleaded guilty to violent rape.
    • Prognosis
      • The prognosis of successfully ending pedophilic habits among people who practice pedophilia is not favorable. Pedophiles have a high rate of recidivism; that is, they tend to repeat their acts often over time.
      • The rate of prosecution for pedophiles through the criminal justice system has increased in recent years. Pedophiles are at high risk of being beaten or killed by other prison inmates. For this reason, they must often be kept isolated from other members of a prison population. Knowledge of the likelihood of abuse by prison personnel and inmates is not, however, an effective deterrent for most pedophiles.


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11. Female Orgasmic Disorder (302.73)


    • DSM-IV-TR criteria
      • A. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of Female Orgasmic Disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
      • B. The disturbance causes marked distress or interpersonal difficulty.
      • C. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.
      • Specify type:
        • Lifelong Type
        • Acquired Type
      • Specify type:
        • Generalized Type
        • Situational Type
      • Specify:
        • Due to Psychological Factors
        • Due to Combined Factors
    • Associated Features
      • The disorder may affect body image, self-esteem, or her relationship satisfaction. Chronic general medical conditions such as diabetes or pelvic cancer have a more likely reason to impair the arousal phase of the sexual response.
    • Child vs Adult Presentation
      • There is little information on how this affects children since children are typically not sexually active or mature. It mostly begins in early adulthood. Younger women seem to have this disorder because the ability increases with age.
    • Gender and Cultural Differences in Presentation
      • This certain disorder only affects females, although there is a Male Orgasmic Disorder as well. Cultural presentation will be the same as western cultures.
    • Epidemiology
      • The epidemiology of Female Orgasmic Disorder varies extensively. Some examples are 10-15% of women had never had an orgasm, 10-15% hardly ever had experienced an orgasm, 50% of women had experienced an orgasm during intercourse, and 10-15% had experienced orgasm difficulty.
    • Etiology
      • There is evidence that a traumatic experience likely leads to this disorder. It can also be related to problems in a relationship. Another cause is a pelvic floor prolapse. This is the loosening of the muscles that support the organs. It can be caused by surgery or childbirth.
    • Empirically Supported Treatments
      • Some treatments for Female Orgasmic Disorder are as follows: Developing proper communication skills, sexual aides, behavioral and cognitive therapy, directed masturbation training, and body awareness. These can be developed through sex counseling and therapy.
      • There are substance-induced (drug related) sexual dysfunctions for which inhibited orgasm can be the result.
    • Prognosis
      • Many women with FOD can be helped to achieve orgasm through a combination of psychotherapy and guided sexual exercises. However, this does not mean that they will be able to achieve an orgasm all of the time or in every situation, or that they will always be satisfied with the strength or quality of the climax. Couples often need to work through relationship issues that have either caused or resulted from FOD before they can see improvement. Working through the problems take time, and commitment from both parties.


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12. Male Orgasmic Disorder (302.74)


  • DSM-IV-TR Criteria
    • A. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration.
    • B. The disturbance causes marked distress or interpersonal difficulty.
    • C. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.
      • Specific type:
        • Lifelong Type
        • Acquired Type
      • Specify type:
        • Generalized Type
        • Situational Type
      • Specify:
        • Due to Psychological Factors
        • Due to Combined Factors
    • Associated Features
      • Male orgasmic disorder refers to a delay in or absence of orgasm following a normal phase of excitement and an adequate degree of stimulation. Male orgasmic disorder is most often situational. The male may have an issue reaching orgasm with a certain partner, but not through masturbation.
      • Male orgasmic disorder has also been termed delayed ejaculation, ejaculatory incompetence, and retarded ejaculation.
    • Child vs. Adult Presentation
      • This disorder occurs once the individual has become sexual active and is not seen in children.
    • Gender and Cultural Differences in Presentation
      • Research shows that this occurs in every race and ethnic group. This disorder is more commonly found in women.
      • In Lifelong Type manifestations will occur around the age of puberty
      • In certain genetic hypogonadism disorders such as Klinefelter's syndrome, certain body signs and symptoms may alert the physician
      • In acquired Type of Male orgasmic disorder, the patient will have had the previous experience of normal sexual function. In these cases, it is usually a situational factor that precipitates the disorder.
    • Epidemiology
      • It is rare for males to have a lifelong form of the disorder. Research shows that about 8% of males have experienced this at one time or another.
    • Etiology
      • The causes are mostly psychological.
      • The psychological causes can be intrinsic or extrinsic. Intrinsic factors include the fear of getting the partner pregnant, depression, low self-esteem, stress, bad relationships, and traumatic experiences with sex. The extrinsic factors may include the absence of a private location to perform, or perhaps, fatigue from other parts of life.
      • Although male orgasmic disorders are generally psychological, there are cases where the causes are organic. The disorder could be caused by hypogadism, in which enough testosterone is not produced. Pituitary conditions, thyroid disorders, and diseases of the body or penis may also cause orgasmic disorder. Additionally, medications such as as blood pressure medication or antidepressants or substance abuse- narcotic or alcohol- can cause this disorder.
      • The most common causes of the male orgasmic syndrome are psychological in nature. The responsible psychological mechanisms may be "intrinsic" (due to basic internal factors), or "extrinsic" (due to external or environmental factors).
      • The disorder can result from trauma but can also be acquired through problems within relationships.
    • Empirically Supported Treatments
      • The most effective treatment is psychotherapy. This might require the partner to be actively involved with the therapy as well.
      • Before the orgasmic disorder can be treated, the cause of the condition must be discovered, then the treatment will follow accordingly. If the condition is caused by a physical problem, treatment for the physical problem is sought. However, if the condition is caused by a psychological problem, psychotherapy and sex therapy are commonly used. In couples sex therapy, the couple is often taught to focus on relaxation, exploration, decreasing inhibitions, and improving sexual communication. Sex therapy focuses on increasing sexual stimulation and reducing performance anxiety.
    • Prognosis
      • The prognosis of a male with males orgasmic disorder is dependent on whether the condition is lifelong or acquired and the conditions causes.Prognosis is best when it can be demonstrated that the condition is related to some extrinsic or environmental factor that can be correlated. The prognosis is also favorable in those cases that are due to a organic disorder such as thyroid disorder or hypogonadism. The prognosis is a grimmer when the disorder is found to be a secondary to a deeper and chronic psychological or psychiatric problem that it in itself carries an unforgivable prognosis.
    • Additional Information
Male orgasmic disorder



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13. Hypoactive Sexual Desire Disorder (302.71)


  • DSM-IV-TR criteria
      • A. Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and context of the person’s life.
      • B. The disturbance causes marked distress or interpersonal difficulty.
      • C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
    • Specify type:
      • Lifelong Type
      • Acquired Type
    • Specify type:
      • Generalized Type
      • Situational Type
    • Specify:
      • Due to Psychological Factors
      • Due to Combined Factors
  • Associated Features
      • Hypoactive Sexual Desire Disorder affects women’s sexual desires, and contributes too many sexual dysfunctions. HSDD is a common reason for women’s sexual dissatisfaction. HSDD causes a lack in sexual desire, and usually leads to relationship problems, involving lack of communication, distrust, anger, and lack of a connection. Women will experience sexual aversion, sexual apathy, and sexual desire. The person will usually not initiate sex, and will be unresponsive to another person’s initiations. In extreme cases of HSDD some patients may have never felt sexual desire, and if they did at one time, but no longer have an interest, could be due to some traumatic event, such as incest,sexual abuse, or rape. However, if sexual trauma is absent it could be due to rigid religious training. Another possibility is that the initial attempts at sexual intercourse resulted in pain or sexual failure. Rarely, HSDD in both males and females may result from insufficient levels of the male sex hormone, testosterone.
      • Low sexual interest is frequently associated with problems of sexual arousal or with orgasm difficulties. The deficiency in sexual desire may be the primary dysfunction or may be the consequence of emotional distress induced by disturbances in excitement or orgasm. General medical conditions may have a nonspecific effect on sexual desire due to weakness, pain, problems with body image, or concerns about survival. Depressive disorders are often present with low sexual desire, and the onset of depression may precede, co-occur with, or be the consequence of the deficient sexual desire. Individuals with Hypoactive Sexual Desire Disorder may have difficulties developing stable sexual relationships and may have marital dissatisfaction and disruption.
      • Acquired HSDD- is acquired, situational HSDD in the adult is commonly associated wit the boredom in the relationship with the sexual partner. Depression, the use of psychoactive or antihypertensive medication, and hormonal deficiencies may contribute to the problem. HSDD may also result from impairment of sexual function, particularly erectile dysfunction in the male, or vaginismus in the female. Vaginismus is defined as a conditioned voluntary contraction or spasm of the lower vaginal muscles resulting from an unconscious desire to prevent vaginal penetration. An incompatibility in sexual interest between the sexual partners may result in relative HSDD in teh less sexually active member. This usually occurs in the presence of a sexually demanding partner.
      • Painful Intercourse- (dyspareunia) is more common in women than in men, but may be a deterrent to genital sexual activities in both sexes. The causes are usually physical in nature and related to an infection of the prostate gland, urethra, or testes. Occasionally, an allergic reaction to a spermicide preparation or condom may interfere with sexual intercourse. Painful erections may be a consequence of Peyronie's disease, which is characterized by fibrotic changes in the shaft of the penis that prevent attainment of a normal erection. In the female, dyspareunia may be caused by vaginismus or local urogenital trauma or inflammatory conditions such as hymenal tears, labial lacerations, urethral bruising, or inflammatory conditions of the labial or vaginal glands.
      • Priapism- the occurrence of any persistent erection of more than four hours duration occurring in the absence of sexual stimulation. It is not associated with sexual excitement and erection does not subside after ejaculation. Priapism can occur at any age, by is more common between the ages of five to ten years and between ages twenty to fifty. In children, priapism is commonly associated with leukemia and sickle cell disease, or occurs following trauma. The most common cause in adults is the intrapenile injection of agents to correct erectile dysfunction.
      • Prolactinoma- is a rare but important case of HSDD, it is a functioning prolactin-secreting tumor of the pituitary gland. Men who have this condition typically state that ehy can achieve an erection, but they have no interest in sexual relations with their partner. In females, prolactinomas are is associated with galactorrhea (lactation in the absence of pregnancy), amenorrhea, systems of estrogen deficiency, and dyspareunia.
      • Delayed maturation- is a potential cause of HSDD. It is present in boys if there is not testicular enlargement by age thirteen and a half or if there are more than five years between the initial and complete growth of the genitalia. In girls, delayed sexual maturation is characterized by a lack of breast enlargement by age thirteen or by a period greater than five years between the beginning of breast growth and the onset of menstruation. Delayed puberty may be the result of familial constructional disorders, genetic defects, such as turner's syndrome in females and Klinefelter's syndrome in males, central nervous system disorders such as pituitary conditions that interfere with the secretions of gonadotropic hormones, and chronic illness such as diabetes mellitus, chronic renal failure, and cystic fibrosis.
      • Sexual Anhedonia-s is a rare variant of HSDD seen in males, in which the patient experiences erection and ejaculation but no pleasure from orgasm. The cause is attributed to penile anesthesia, due to psychological or emotional factors in a hysterical obsessive person. Psychiatric referral is indicated unless there is evidence of spinal cord injuries or peripheral neuropathy. Loss of tactile sensation of the penis is unlikely to be organic in cause unless there is associated anesthetic areas in the vicinity of the anus or scrotum.
  • Child vs. Adult presentation
      • Hypoactive Sexual Desire Disorder is not common in children. The typical age of onset for Lifelong forms of Hypoactive Sexual Desire Disorder is puberty. More frequently though, the disorder develops in adulthood, after a period of adequate sexual interest, in association with psychological distress, stressful life events, or interpersonal difficulties.
  • Gender and cultural differences in presentation
      • Across cultures, there is a higher prevalence of HSSD among men from the Middle East ( 21.6%) and South East Asia (28.0%) compared to European, North American, and South American men.
      • The prevalence of low sexual desire in American and Swedish women ranges from 27% to 34% of the population. HSDD is reported by 43% of women from the Middle East and Southeast Asia.
  • Epidemiology
      • Sexual desire decreases with age, relationship duration, and children. Nearly half of all women will have some sexual dysfunction during their life, and HSDD accounts for a large portion of those dysfunctions. Approximately 33% of women in the United States and Canada reported having little sexual desire. This number represents the number of women who periodically have little sexual desire. Only 7.9% of women reported that they frequently lack sexual desire.
      • Because of a lack of normative age- or gender- related data on frequency or degree of sexual desire, the diagnosis must rely on clinical judgment based on the individual's characteristics, the interpersonal determinants, the life context, and the cultural setting.
      • Low desire occurs in approximately 15% of men aged 19 to 59. In men, operationalized low sexual desire as reduced thoughts, fantasises, and sexual dreams. Reduced sexual behavior with a partner, and reduced sexual behavior through masturbation. Men in the 50 to 59 age category were three times as likely to experience low desire as men in the 18 to 29 age category.
  • Etiology
      • In some cases Hypoactive Sexual Desire Disorder is considered lifelong, or begining in adolescence. Most cases of HSDD can be linked to a point in life when libido decreased. Social problems, like marital problems or depression, may cause HSDD. Anorexia nervosa and Bulimia nervosa can also be a determining factor for HSDD. Hormonal deficiencies such as low estrogen lead to vaginal dryness and can promote HSDD. Physical ailments like endometriosis and pelvic inflammatory disease can cause the disorder too (West et al., 2008). This disorder can also be due to a general medical condition which causes pain (dyspareunia) or discomfort during intercourse.
  • Empirically supported treatments
      • Sex therapy is very common for people with this disorder. Typically, the therapist tries to find a psychological or biological cause of the HSDD. It is very common for both partners to join in therapy, but women generally accept sex therapy more readily.Therapy treatment generally focuses more on relationship and communication issues, improved communication (verbal and nonverbal), working on non-sexual intimacy, or education about sexuality may all be possible parts of treatment. Counseling/Sex therapy can open each partner up to the other's point of view, and is often seen as the best chance to make improvements in sexual desire.
      • Psychotherapy may involve exploration of interpersonal issues, including anger, trust, exploration of an affair, and feelings of attractiveness. Treatment might also encourage men to use fantasies, erotic stimuli, and include forms of sexual activities besides intercourse.
      • Among the pharmacological treatments for HSSD, bupropion is a norepinephrine and dopamine agonist with an efficacy rate of approximately 86% in nondepressed men.
      • Testosterone replacement has been the primary hormonal treatment and is administered as an injection, a patch, or as a gel. Testosterone treatment in women is recomended against, due to increased risk of cardiovascular disease and/or breast cancer. If testosterone treatment is considered in men with low desire, close consultation with an endocrinologist is essential because of possible negative side effects on prostate size and gynecomastia (males).
      • The synthetic hormone, tibolone, which has estrogenic, androgenic, and progestogenic effects while not stimulating the uterus lining is licensed for the treatment of menopausal symptoms in Europe. Tibolone was found to significantly increase sexual desire, the frequency of sexual fantasies, and sexual arousability relative to control (woman).
  • Prognosis
      • The prognosis for HSDD depends primarily on the underlying cause or causes. In certain medical conditions, the prognosis for development, or recovery of sexual interest, is good.


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14. Substance-Induced Sexual Dysfunction


  • DSM-IV-TR criteria
      • A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.
      • B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2):
        1. the symptoms in Criterion A developed during, or within a month of, Substance Intoxication
        2. medication use is etiologically related to the disturbance
      • C. The disturbance is not better accounted for by a Sexual Dysfunction that is not substance induced. Evidence that the symptoms are better accounted for by a Sexual Dysfunction that is not substance induced might include the following: the symptoms precede the onset of the substance use or dependence (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Sexual Dysfunction (e.g., a history of recurrent non-substance-related episodes).
      • NOTE: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.
      • Code [Specific Substance]-Induced Sexual Dysfunction:
        • 291.89 Alcohol
        • 292.89 Amphetamine [or Amphetamine-Like Substance]
        • 292.89 Cocaine
      • With Impaired Desire
      • With Impaired Arousal
      • With Impaired Orgasm
      • With Sexual Pain

With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
  • Associated Features
  • Child vs. adult presentation
  • Gender and cultural differences in presentation
  • Epidemiology
  • Etiology
  • Empirically supported treatments

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15. Male Erectile Disorder (302.72)


      • DSM-IV-TR criteria
        • A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.
        • B. The disturbance causes marked distress or interpersonal difficulty.
        • C. The erectile dysfunction is not better accounted for by another Axis I disorder (other than a Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition
        • Specify if:
          • Lifelong Type
          • Acquired Type
        • Specify if:
          • Generalized Type
          • Situational Type
        • Specify:
          • Due to Psychological Factors
          • Due to Combined Factors
      • Associated Features
        • It is normal for older men to need more stimulation to gain an erection, and they may require more time in between erections too. However, older men should still be able to achieve erection and enjoy sex. When a man of any age, younger or older, cannot achieve an erection or maintain one long enough for sexual satisfaction for both partners, it is considered Erectile Dysfunction (ED).
      • Child vs. adult presentation
        • Premature ejaculation one form of ED can occur at any age, and it is a common disorder. The occurrence of Premature Ejaculation in men aged 18-30 is common, it but may also occur in conjunction secondary to impotence in men aged 45-65. The inability to achieve an erection and ED, in general, is more commonly seen in older men, and sexual function drastically declines after one reaches the age of 50. This disorder only occurs in men.
      • Gender and cultural differences in presentation
        • There is no significant data that supports major differences in premature ejaculation between races, however, recent surveys suggest some racial variation. An analysis by Laumann et al (1999), found that premature ejaculation was more prevalent in African American men (34%) than white men (29%) or Hispanics (27%).
      • Epidemiology
        • Approximately 5-20% of men have moderate-to-severe ED.
      • Etiology
        • The majority of these cases with this disorder have an organic etiology, most commonly vascular disease that decreases blood flow into the penis. Diabetes, Hypertension, and Artherosclerosis are associated and linked to causal explanations for ED. If a persons hormones are imbalanced, it can result in ED as well. A few physical causes of ED are: excessive alcohol and tobacco use, fatigue, brain and spinal-cord injuries, Hypogonadism, liver or kidney failure, Multiple Scleroisis, Parkinson's Disease, radiation therapy to the testicles, stroke, or some types of prostrate or bladder surgeries. Emotions or feelings which can lead to ED are similar to those associated with Male Orgasmic Disorder and include: nervousness due to previous bad sexual experiences or prior episodes of impotence, stress from external situations (ie. work, school, or family), depression, crowding insecurities, being preoccupied, and thinking the partner is displaying negative reactions. Values and conceptions regarding what is perceived as a normal duration should be considered. Age is an important factor as well; as individuals age, they typically engage in less sexual activity for shorter durations. Some evolutionary theorists have posited that ED in older individuals may serve an evolutionary function; ED may reduce the chances that a genetically degenerated sperm will couple with an ovum (egg cell). Hence, ED may be a natural mechanism that, to an extent, safeguards the species from genetic anomalies.
      • Empirically supported treatments
        • Testosterone supplements may be used for cases due to hormonal deficiency.
        • The cause is usually due to lack of adequate penile blood supply as a result of damage to inner walls of blood vessels. This damage is more frequent in older men, and often associated with disease, for example, diabetes.
        • ED can, in many cases, be treated by drugs which are taken orally, injected, or as penile suppositories.
        • Exercise, particularly aerobic exercise is an effective cheap treatment for erectile dysfunction.
        • Alprostadil can be injected into the penis or inserted using a special applicator - usually just before sexual intercourse.
        • A purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it.
        • Often, as a last resort if other treatments have failed, the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis.
        • One medication used to treat this disorder is Viazil. See how it works by clicking here.

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16. Premature Ejaculation (302.75)

      • DSM-IV-TR criteria
        • A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.
        • B. The disturbance causes marked distress or interpersonal difficulty.
        • C. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids).
        • Specify type:
          • Lifelong Type
          • Acquired Type
        • Specify type:
          • Generalized Type
          • Situational Type
        • Specify:
          • Due to Psychological Factors
          • Due to Combined Factors
      • Associated Features
        • Premature Ejaculation can be categorized as one of two types - Primary PE and Secondary PE. Primary PE refers to the type that has been present in an individual since becoming sexually functional. Secondary PE refers to the type that is acquired later in life in individuals who have had normal levels of sexual function. Both forms of PE are categorized as psychological conditions, as physiological factors such as organic diseases and brain lesions cannot be implicated.
        • Individuals suffering from Premature Ejaculation display symptoms included but not limited to abdominal pain, involuntary movements of the eyes, accentuated fall in systolic pressure, and urinary problems.
      • Child vs. adult presentation
        • Premature ejaculation can happen at any point during a man's life but is more common in young men aged 18-30. It may also occur in conjunction with secondary impotence in men aged 45-65.
      • Gender and cultural differences in presentation
        • Premature Ejaculation is limited to the male sex, though its effects can pose problems for both sexes..
        • Research shows that only men suffer from this disorder and it is common. Although all races can have premature ejaculation, there is some evidence that it occurs more in African Americans than in Hispanic and white men. In an analysis by Laumann et al (1999), they found that premature ejaculation occured more among African American men (34%) and white men (29%) than in Hispanic men (27%).
        • Rates are relatively uniform around the world except in the Middle East, where the rate is approximately 12.4%
      • Epidemiology
        • This disorder affects 25%-40% of men in the U.S.
        • According to the NHSLS, PE affects approximately 30% of men aged 18 to 59, making it the most prevalent male sexual dysfunction.
      • Etiology
        • There is no clear cause for premature ejaculation. It is believed that some psychological factors such as anxiety, guilt, or depression may be causing premature ejaculation. It may also be caused by medical conditions, such as hormonal problems, history of injuries, or side effect from certain medications. It has been suggested that PE may have conferred males an evolutionary advantage; males who were able to ejaculate faster would have been able, potentially, to impregnate females more efficiently. The cultural shift of sexual activity to a more recreational function has largely eliminated whatever potential benefits PE may have conferred evolutionarily.
      • Empirically supported treatments
        • Treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control.
        • In clinical cases, various medications are being tested to help slow down the speed of the arousal response.
        • Serotonergic medications, such as SSRIs, can delay ejaculation. Clinical trials indicate that Paroxetine gives the largest increase in intravaginal ejaculation latency time.
        • Clomipramine often helps with serious cases that are related to the central nervous system (as opposed to psychological factors). Tramadol has also been shown to be effective in delaying ejaculation.
        • The stop-start method requires the men to provide direct feedback to his partner for when the ejaculatory urge nears. At this point, sexual stimulation stops, allowing for his arousal to subside before stimulation is resumed. The efficacy of the stop-squeeze technique is approximately 60%.
        • The squeeze technique is where the woman teases her partner to erection and prior to his ejaculation, she squeezes the tip of the penis, which temporarily prevents ejaculation. This process is repeated three or four times in a 15-20 minute session before the man purposely ejaculates.

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Sexual Pain Disorders


1. Dyspareunia (302.76)

      • DSM-IV-TR criteria
        • A. Recurrent or persistent genital pain associated with sexual intercourse in either a male or female
        • B. The disturbance causes marked distress or interpersonal difficulty.
        • C. The disturbance is not caused exclusively by Vaginismus or lack of lubrication, is not better accounted for by another Axis I disorder (except another Sexual Dysfunction), and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
        • Specify type:
          • Lifelong Type
          • Acquired Type
        • Specify type:
          • Generalized Type
          • Situational Type
        • Specify:
          • Due to Psychological Factors
          • Due to Combined Factors
      • Associated Features
        • A person with dyspareunia experiences pain in the genital area before, during or after sexual intercourse. The nature, duration, and intensity of the pain may vary across individuals, but is most often experienced during sexual intercourse.
        • The most reported type of pain is superficial pain which occurs upon penetration.
      • Child vs. adult presentation
        • This occurs in sexually active individuals and is not normally seen in children.
      • Gender and cultural differences in presentation
        • Men can have this disorder, however, it is very rare. When men do have it, it is almost always due to a medical condition.
        • Estimates of the prevalence of male dyspareunia are sparse but appear to affect 3% to 5% of men in Western countries and 10% to 12% of men in the Middle East and Southeast Asia.
        • A study of 404 gay men reported a prevalence rate of approximately 14% anodyspareunia from receptive anal sex, with the majority experiencing it lifelong. A significant proportion of men found it highly distressing, and, as a result, it led to avoidance of sexual activity or restricting activity to insertive anal sex.
      • Epidemiology
        • In a survey of 329 women in 1993 at a gynecological clinic it was found that 7.7% of women experienced painful intercourse on most or all occasions. There is very little data on the prevalence of this disorder in men. However, studies have shown that when this disorder exists in men, it is usually caused by a medical problem.
        • 60% of women experience genital pain before, during, or after intercourse at some point. However, the location and frequency varies among women.
      • Etiology
        • There are several causes of dyspareunia. There are entry pain causes. These would include inadequate lubrication, injury, trauma, or irritation. This could be due to a pelvic surgery or a female circumcision. Another cause could be inflammation, infection, or skin disorder, such as eczema. Also, allergic reactions to birth control products, such as latex could be the cause. Also, an improper fit of a diaphragm can cause pain. Vaginismus can also be a cause, which is involuntary muscle spasms of the vagina. Finally, vestibulitis is unexplained stinging or burning around opening of vagina can cause entry pains associated with dsypareunia. There are also deep pains that are causes by illnesses, infections and surgeries or medical treatments. These could include pelvic inflammatory disease, uterine prolapse, infections in the uterus or Fallopian tubes, and complications from hysterectomies. There are also emotional causes that could include psychological factors, stress, and history of sexual abuse. Specifically, these could include fear of intimacy and depression. Also, pelvic floor muscles are very sensitive to stress, so this could be a factor. This being caused by a history of sexual abuse is not very common although it can be a factor.
      • Empirically supported treatments
        • Carefully examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain.
        • Clearly explaining to the patient what has happened, including identifying the sites and causes of pain. Making clear that the pain will, in almost all cases, disappear over the time or at least will be greatly reduced. If there is a partner, explaining him also the causes and treatment and encouraging him to be supportive.
        • Encouraging the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), mutual caressing without intercourse, and using sexual books and pictures.
        • Prescribing very large amounts of water-soluble sexual or surgical lubricant during intercourse.
        • A manual physical therapy (Wurn Technique) which treats pelvic and vaginal adhesions and microadhesions may decrease or eliminate intercourse pain.
        • Reducing use of scented bath products can help, because they can irritate the genital area.
        • Kegal exercises for relaxation of the vaginal muscles also can help.
        • Instructing the receiving partner to take thte phallus of the penetrating partner in their hand and control insertion themselves, so that they are in control.

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2. Vaginismus (306.51)

      • DSM-IV-TR criteria
        • A. Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.
        • B. The disturbance causes marked distress or interpersonal difficulty.
        • C. The disturbance is not better accounted for by another Axis I disorder (e.g., Somatization Disorder) and is not due exclusively to the direct physiological effects of a general medical condition.
        • Specify type:
          • Lifelong Type
          • Acquired Type
        • Specify type:
          • Generalized Type
          • Situational Type
        • Specify:
          • Due to Psychological Factors
          • Due to Combined Factors
      • Associated Features
        • Vaginismus, or spasm of the muscle surrounding the vagina often occurs in response to attempted intercourse, but can also occur in response to penetration by a finger, tampon, or speculum. Although this disorder is listed as a pain disorder, pain is not a necessary condition for the diagnosis. Vaginismus may be best defined as a phobic/aversive response to vaginal penetration.
        • There are two types of vaginismus: Primary and Secondary. Primary vaginismus occurs in women who have never been able to have pain-free intercourse. Secondary vaginismus is due to a medical condition, surgery, traumatic event, childbirth, or menopause.
        • Individuals suffering from Vaginismus disorder display symptoms such as trouble or impossibilities with sexual penetration and pelvic examination.
      • Child vs. adult presentation
        • Vaginismus is a disorder that occurs in women. Children do not have to worry about it, although, Vaginismus could be linked to sexual trauma as a child, or teen.
      • Gender and cultural differences in presentation
        • Vaginismus is only present in females.
        • Research shows that 0.17% of women in the United Kingdom have this disorder. Also, 5 out of 1000 marriages in Ireland reported having this problem.
        • The problem occurs in 1% to 6% of women and is highly comorbid with dyspareunia.
      • Epidemiology
        • A study in 1993 by Rosen and colleagues estimate that the rates of vaginismus range from 5% to 17%.
        • 2 out of 1000 women have this. However, it could be higher, because women are embarrassed and it is not commonly known about and often misdiagnosed.
        • In the United States, 47% of women with this disorder are single or dating, while 53% are married.
        • The majority (53%) are ages 26 to 35. Next, women aged 36-50 make up 26% of those with the disorder. 18% are 25 or younger and 9% are 51 or older.
      • Etiology
        • Non-physical causes are fears, anxiety, stress, traumatic event, childhood experiences, and partner issues. Sometimes, there is no known cause at all. Physical causes are medical conditions, childbirth, abuse, menopause, pelvic trauma, and temporary discomfort.
        • Most common causes are fears and anxiety about intercourse and pain. Anxiety due to performance pressures and negativity towards sex can also cause a woman to experience this. Partner issues such as abuse, distrust, and fear of commitment are causes as well. Childhood experiences like overly rigid parenting, inadequate sex education, and exposure to shocking sexual imagery can lead to vaginismus.
      • Empirically supported treatments
        • It is very treatable and most cases do not require medications. It includes a combination of pelvic floor control exercises, training for insertion or dilation, and learning techniques for pain elimination. These treatments can be done from home, however, it is helpful to have the support of a partner in a therapy-like setting.
        • Vaginismus is generally treated with behavioral exercises in which plastic vaginal dilators of increasing size are inserted to help relax the vaginal musculature. A gynecologist usually demonstrates by inserting the narrowest dilator. The woman then increases the size of dilator as she becomes capable of tolerating insertion and containment (for 10 or 15 minutes) without pain or discomfort. Psychological treatment may also be necessary if the woman has a history of sexual trauma.
        • According to the behavioral view, treatment of vaginismus involves a reconditioning of the bodies response to feared objects such as the penis, a speculum, or a tampon, much like the treatment approach for other specific phobias. Using a systhematic desensitization approach, the woman is asked to create a hierarchy of feared objects that she will then progressively work through to insert vaginally over the course of treatment.

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3. Sexual Dysfunction Due to...[Indicate General Medical Condition]


      • DSM-IV-TR criteria
        • A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.
        • B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by the direct physiological effects of a general medical condition.
        • C. The disturbance is not better accounted for by another mental disorder (e.g., Major Depressive Disorder).
        • Select code and term based on the predominant sexual dysfunction:
          • 625.8 Female Hypocative Sexual Desire Disorder Due to...[Indicate general medical condition]: if deficient or absent sexual desire is the predominant feature
          • 608.89 Male Hypoactive Sexual Desire Disorder Due to ...[Indicate general medical condition]: if deficient or absent sexual desire is the predominant feature
          • 607.84 Male Erectile Disorder Due to...[Indicate general medical condition]: if male erectile dysfunction is the predominant feature
          • 625.0 Female Dyspareunia Due to ...[Indicate general medical condition]: if pain associated with intercourse is the predominant feature
          • 608.89 Male Dyspareunia Due to ...[Indicate general medical condition]: if pain associated with intercourse is the predominant feature
          • 625.8 Other Female Sexual Dysfunction Due to ...[Indicate general medical condition]: if some other feature is predominant (e.g., Orgasmic Disorder) or no feature predominates
          • 608.89 Other Male Sexual Dysfunction Due to ...[Indicate general medical condition]: if some other feature is predominant (e.g., Orgasmic Disorder) or no feature predominates
        • Coding Note: Include the name of the general medical condition on Axis I, e.g., 607.84 Male Erectile Disorder Due to Diabetes Mellitus; also code the general medical condition on Axis III
      • Associated Features
        • Dysfunction is due exclusively to physiological effects of a general medical condition. Symptoms can include pain with intercourse, hypoactive sexual desire, male erectile dysfunction, orgasmic disorder or other sexual dysfunctions.
      • Child vs. adult presentation
      • Gender and cultural differences in presentation
      • Epidemiology
      • Etiology
        • Caused by any type of general medical condition that causes physiological sexual dysfunction.
      • Empirically supported treatments

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4. Female Sexual Arousal Disorder (302.72)

  • DSM-IV-TR criteria
        • A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication- swelling response of sexual excitement.
          B. The disturbance causes marked distress or interpersonal difficulty.
          C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
          • Specify type:
            • Lifelong Type
            • Acquired Type
          • Specify Type:
            • Generalized Type
            • Situational Type
          • Specify:
            • Due to Psychological Factors
            • Due to Combined Factors
  • Limited evidence suggests that Female Sexual Arousal Disorder is often accompanied by Sexual Desire Disorders and Female Orgasmic Disorder. The individual with Female Sexual Arousal Disorder may have little or no subjective sense of sexual arousal. The disorder may result in painful intercourse, sexual avoidance, and the disturbance of marital or sexual relationships.
  • Associated Features
    • Personal relationship problems
    • Inability to attain or maintain adequate physical response to sexual excitement. It is considered a disorder when it causes distress or interpersonal conflict
  • Child vs. adult presentation
  • Gender and cultural differences in presentation
  • Epidemiology
    • Inhibited female orgasm ranged from 18% to 76% in clinics, but only 5% to 20% in community samples. Similarly up to 62% of females seeking sex therapy experience arousal disorder, while community estimates are closer to 11%.
  • Etiology
    • May be associated with specific settings, situations and relationships or generally present in all sexual settings. It may be due to psychological factors or a combination of psychological and physical factors.
  • Empirically supported treatments
    • Relaxation techniques and various creams and jellys are suitable lubricants and may help to alleviate the discomfort
    • There is a clitoral device called Eros that was approved y the Food ad Drug Administration in 2000 and is available by prescription. The clitoris swells during sexual arousal because of vasocongestion, and vasocongestion increases clitoral sexual sensations, thus moving somewhat in step with sexual interest and lubrication. This device creates a gentle suction over the clitoris, increasing vasocongestion and sexual sensations (Leland, 2000).
    • The psychological portion of treatment is directed at teaching how to focus on pleasurable thoughts and feelings about sex
    • It is recommended that the sufferer discuss this matter with her gynecologist.

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5. Fetishism (302.81)


  • DSM-IV-TR criteria
    • A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the use of nonliving objects (e.g., female undergarments).
      B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      C. The fetish objects are not limited to articles of female clothing used in cross-dressing (as in Transvestic Fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).
  • Associated Features
    • May be employed or undertake volunteer work to enable behavior to be practiced. For example, taking a job in a shoe shop in the case of a shoe fetish.
    • Early symptoms for a fetish involve excessive touching of the object of desire. The amount of time spent thinking about the fetish object may increase. Over time, the importance of the fetish object expands. In the extreme, it becomes a requirement for achieving sexual pleasure and gratification.
    • The word fetish comes from the French fe'tiche, which is thought to derive from the Portuguese feitico, meaning "magic charm."
    • Fetishism is related to the paraphilia, partialism, which is where people are excessively aroused by a particular body part, such as the feet, breasts, or buttocks.
  • Gender and cultural differences in presentation
  • Child vs. adult presentation
    • Fetishism typically begins by adolescents, although the fetish may have been endowed with special significance earlier in childhood, therefore, children and adults present with this Paraphilia.
  • Epidemiology
  • Etiology
    • The association between an object and sexual arousal may be adolescent curiosity or a random association between the object and feelings of sexual pleasure. A random association may be innocent or unappreciated for its sexual content when it initially occurs. For example, a male may enjoy the texture or tactile sensation of female undergarments or stockings. At first, the pleasurable sensation occurs randomly, and then, in time and with experience, the behavior of using female undergarments or stockings as part of sexual activity is reinforced, and the association between the garments and the sexual arousal is made. A person with a fetish may not be able to pinpoint exactly when his or her fetish began. A fetish may be related to activities associated with sexual abuse.
  • Empirically supported treatments
    • Most persons who have a fetish never seek treatment from professionals. Most are capable of achieving sexual gratification in culturally appropriate situations. As of 2002, American society seems to have developed more tolerance for persons with fetishes than in the past, thus further reducing the already minimal demand for professional treatment.

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6. Sexual Dysfunction Not Otherwise Specified (302.70)


  • DSM-IV-TR criteria
    • This category includes sexual dysfunctions that do not meet criteria for any specific Sexual Dysfunction. Examples include:
      1. No (or substantially diminished) subjective erotic feelings despite otherwise normal arousal and orgasm.
      2. Situations in which the clinician has concluded that a sexual dysfunction is present but us unable to determine whether it is primary, due to a general medical condition, or substance induced.


Proposed Revisions and Additions in the DSM-V for Sexual and Gender Identity Disorders


  • Some disorders included in the DSM-V are Hypersexual Disorder, Paraphilic Coercive Disorder, Sexual Interest/Arousal Disorder in Women, Sexual Interest/Arousal Disorder in Men, and Genito-Pelvic Pain/Penetration Disorder. These are not in the DSM-IV-TR.

1. Hypersexual Disorder (14)

  • In the DSM-V, Symptom Clusters A, B, and C must be met for a diagnosis of Hypersexual Disorder
    • A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:
      • A grest deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.
      • Repetitvely engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states such as anxiety, depression, boredom, and irritability.
      • Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.
      • Reptitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.
      • Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.
    • B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior
    • C. These sexual fantasies, urges, and behaviors are not due to the direct physiological effect of an exogenous substance such as an abused drug or medication.
  • Specify if
      • Masturbation
      • Pornography
      • Sexual behavior with consenting adults
      • Cybersex
      • Telephone Sex
      • Strip Clubs
      • Other


Hypersexual Disorder has been proposed as a new sexual disorder diagnostic category. The evidence in support of this is explained in a review by Martin Kafka (see **Hypersexual Disorder: A Proposed Diagnosis for DSM-V**). There is empirical evidence that supports each A Criterion in the report. There are several other available reports and literature that support this.

  • Rationale
    • Clinical need
      • There is a compelling clinical need for mental health professionals to pinpoint and diagnose men and women of a distict group who are seeking and receiving mental health care. These people are seeing pcychological clinicians because they ahve sexual behaviors that are out of control but that are not intrinsically socially unorthodox. People that have these conditions are, at the moment, diagnosed with Sexual Disorder Not Otherwise Specifiec. This has been called a diagnostic wastebasket and DSM-V editors would like to see it diminished. This affliction is ranked as one of the more serious disorders but it is still a neglected contemporary psychiatric disorder. Men and women who have Hypersexual Disorder have the tendancy to be sexual risk takers. There are at a higher risk to catch and propagate sexually transmitted diseases, including HIV.

    • Research Need
      • There is a need for research to cement an operational definition for this condition. This is needed so that research from diversified theoretical perspectives can unite with a common set of criteria. Specific empirically supported criteria has not been validated.
    • Hypersexual Disorder and its diagnostic neighbors
      • Paraphilic disorders are the closest diagnostic neighbors of this disorder but they have core differences. Pharaphilias are characterized by constant, deviant sexual arousal (e.g., Exhibitionistic Disorder) whereas Hypersexual Disorder is represented by normophilic sexual behaviors that are repetitive, excessive, or disinhibited (e.g., sexual behavior with consenting adults). It is clinically plausible without paraphilias or independently co-associated with paraphilias (e.g., Voyeuristic Disorder and Hypersexual Disorder; telephone sex and masturbation) or conveyed with Hypersexual Disorder (e.g., Pedohebephilic Disorder and Hypersexual Disorder; [child] pornography and masturbation). The Hypersexual Disorder in all these examples has a continuous sexualy behavior that is not paraphilic
    • Hypersexual Disorder and polythetic criteria
      • The operational criteris "A" suggested for Hypersexual Disorder are gathered frome items included in published validated instruments noted that support each criterion. 4 out of 5 "A criteria" are required for a diagnosis. This is based on intems specifically included in published validated instruments although none of these scales contain all of the specific diagnostic A criteria that is proposes for Hypersexual Disorder. The requirement of 4 out of 5 criterion items was chosen as a threshold for the disorder because it is based on clinical grounds and is intended to reduce false-positive diagnoses of Hypersexual Disorder. The threshold need a large amount of field testing.
    • Significant gaps in basic knowledge remain
      • There are gaps in the current knowledge regarding extra former, present, and predictive validators for Hypersexual Disorder. Developmental risk factors, for example, are not presently known. Additional empirically-based knowledge of the disorder in women is also needed.

2. Paraphilic Coercive Disorder

* The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occations

  • Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges are focused on sexual coercion
  • The diagnosis of Paraphilic Coercive Disorder is not made if the patien meets the criteria for a diagnosis of Sexual Sadism Disorder


  • Rationale
    • The Paraphilias Subworkgroup is currently proposing two changes that affect the paraphilia diagnoses. The first change comes from the general agreement that paraphilias are not ipso facto psychiatric disorders. It is proposed that the DSM-V make a discincgion between paraphilias and paraphilic disorder. By itself, a paraphilia would not require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress, impairment, and harm to the individual as well as others. This approach leaves the deictinction between normative and non-normative sexual behavior intact. This could be important for researchers, but without automatically labeling non-normative sexual behavior as psychopathological.
    • The second change applies to paraphilias where nonconsenting persons are involved. Some examples of this are Exhibitionistic Disorder and Voyeuristic Disorder. It is proposed that Criteria B suggest a minimum number of separate victims for the diagnosis of paraphilia in uncooperative patients. This reflects the fact that for a large number of patients referred for assessment of paraphilias is referred after committing a sexual offense. These patients are usually not candid about their urges and sexual fantasies and are also not reliable hisrotians. The criteria have been modified so that the dependence of self-reports is lessened. The word "recurrent" in the DSM-IV TR A criteria only says "more than once." This is too vague to be clinically useful. The minimum number of separate victims varies for diffeent paraphilias. This is an attempt to gather similar rates of false positive and false negative diafnoses for all the paraphilias. The logic is that paraphilias differ in the extent they resemble behavior in the usuall adult's sexual repertoire. Sexual arousal from seeing unsuspecting people naked seems more probably, in the usuall adult, than arousal from harming terrified strangers. It follows that the closer a behavior resembles a potentially normaphilic behavior, the more evidence should be required to decide the behavior is motivated paraphilically. Therefore three victims have been suggested for Voyeuristic Disorder and only two for Sexual Sadism Disorder.
    • Coercive sexual fantasy is not uncommonly reported by rapists participating in treatment. Convicted rapists who have more persistently engage in rape are more likey to show preferential arousal to saliently-coercive rape in laboratory tests than those who have less persistently engaged in rape.
    • There has been a tendency in the past to over-diagnose Paraphilic Coercive Disorder on the bases of repeated coercive sexual behavior. The diagnostic criteris that is proposed here should lead to more appropriate diagnosis. The reliance on "forcing sex on three or more nonconsenting persons on a separate occations" in the indication that the paraphilia is a disorder, will probably have the effect of increasing the accuracy of the ascertainment of this paraphilic interest.

3. Sexual Interest/Arousal Disorder in Women

  • Sexual Interest/Arousal Disorder in Women includes a previous diagnosis of Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder.
A. Lack of sexual interest/arousal for at least six months duration as manifested by at least four of the following indicators. Their durations must last at least six months
    • Absent/reduced interest in sexual activity
    • Absent/reduced sexual/erotic thoughts or fantasies
    • No initiation of sexual activity and is not receptive to a partner's attemps to initiate
    • Absent/reduced secual excitement/pleasure during sexual activity. This would be on at least 75% or more of sexual encounters
    • Desire is not triggered by any sexual/erotic stimulus
    • Absent/reduced genital and/or nongnital physical changes during sexual activity. This has to be on at least 75% or more of sexual encounters
B. The problem causes clinically significant distress or impairment.
C. The sexual dysfunction is not better accounted for by another Axis 1 disorder, except another sexual dysfunction, and is not due exclusively to the direct physiological effects of a substance or a general medical condition.
  • Addition of the following specifiers:
    • Lifelong (since the onset of sexual activity) or acquired
    • Generalized or situational
    • Partner Factors (sexual problems of the partner, the health status of the partner)
    • Relationship factors like poor communication, relationship discord, and discrepancies in desire for sexual activity for example
    • Individual vulnerability factors like depression, anxiety, poor body image, and history of abuse experience for example
    • Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity
    • Medical factors like illness or medication



  • Rationale
    • Women show problems in the differentiation between desire and arousal. For some women, deisre follows arousal and for others it precedes it. The was desire is defined is inconsistent. Some definitions focus on sexual behavior as an indication of desire, and some focus on spontaneous sexual thoughts, and others emphasize the responsive nature of women's desure. The DSM-IV-TR uses a defition of desire that is problematic for some women. Many women report infrequent sexual fantasies. It emphasizes sexual activity as the central focus of the loss of desure. Research indicates that a lot of women do not report frequent sexual fantasies.
    • Woman may possibly not describe "sexual fantasies" in their experiences of desure and there is a low base rate of fatasies that are not deliberatly evoked to boot arousal.
    • There is evidence that desire and arousal overlap and women do not differentiate between them when sexually excited.
    • There is evidence that there is no such thing as spontaneous sexual desire
    • The words "persistent" and "recurrent" were not operationalized clearly in the DSM-IV.
    • There is increasing data showing cross-cultural differences in the expression of sexual desire
    • The causes of sexual disorders are multifactorial.
    • Etiology does not always exist




4. Sexual Interest/Desire Disorder in Men

  • The subworkgrop for Sexual Dysfunction is exploring three options for the diagnostic criteria in men. The first option is to preserve the DSM-IV-TR criteria and title for Hypoactive Sexual Desire Disorder but add "in Men" to the title. The second option is a parallel proposal to what is presented for women with Sexual/Desire Disorder. If this is the option that is selected Sexuak Interest/Arousal Disorder will be a gender-neutral category. The third option would be to require five symptoms instead of six. This would involve the removal of the criterion " Absent/reduced genital and/or nongenital physical changes during sexual activity on at least 75% or more of sexual encounters" from the list.
The workgroup to come to a conclusion based on field trial results. The results of the field trials will also be used to determine
the required number of symptoms necessare to meat criteris for a disorder if Option 2 or Option 3 are Chosen.
  • A. Lack of sexual interest/arousal for a duration of at least six months by at least X (either 5 or 6 indicators will be required depending on which option the workgroup chooses) of the following indicators:
    • Absent/reduced interest in sexual activity
    • Absent/reduced sexual/erotic thoughts or fantasies
    • No initiation of sexual activity and is not receptive to a partner's attempts to initiate
    • Absent/reduced sexual excitement/pleasure during sexual activity on at least 75% or more of the sexual encounters)
    • Desire is not triggered by any sexual/erotic stimulus
    • Absent/reduced genital and/or nongenital physical changes during sexual activity on at lease 75% or more of sexual encounters.
  • B. The problem causes clinically significant distress or impairment
  • C. The sexual dysfunction is not better accounted for by another Axis 1 disorder except another sexual dysfunction and is not due exclusively to the direct physiological effects of a substance or a general medical condition.
  • Specifiers:
    • Lifelong (since the onset of sexual activity) or acquired
    • Generalized or situational
    • Partner factors (partner's sexual problems, partner's health status)
    • Relationship factors like poor communication, relationship discord, and discrepancies in desire for sexual activity
    • Individual vulnerability factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
    • Medical factors like illness or medications


  • Rationale
    • Moat literature has focused primarily on low desire in hypogonadal men or men with Erectile Dysfunction. Three possible options have been proposed for the DSM-V.
      • Option 1 is to retain the DSM-IV-TR criteris for HSDD and to rename it "HSDD in men".
      • Option 2 is to adopt the proposed criteris for Sexual Interest/Arousal Disorder for men and women both.
      • Option 3 is to adopt the proposed Sexual Interest/Arousal Disorder criteria and require that a different number of the symptoms of low desire/sunjective arousal be met.



5. Genito-Pelvis Pain/Penetration Disorder

  • Genito-Pelvic Pain Penetration Disorder includes a previous diagnoses of Vaginismes and Dyspareunia which are not do to a general medical contition
  • A. Persistent or recurrent difficulties for six months or more with at least one of the following:
    • Inability to have vaginal intercourse/penetration on at leadt 50% of attempts
    • Marked vulvovaginal or pelvic pain during at least 50% of vaginal intercourse/penetration attempts
    • Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration on at least 50% of vaginal penetration attempts
    • Marked tensing or tightening of the pelvic floor muscles during attempte vaginal penetration on at least 50% of occasions
B. The problem causes clinically significant distress or impairment
C. The sexual dysfunction is not better accounted for by another Axis 1 disorder, except another sexual dysfunction, and is not to exclusively to the direct physiological effects of a substance.
  • Specify
    • With a General Medical Condition
  • Existing data suggests that there is a lack of reliability for the dignoses of Vaginismus and Dysparenia in the DSM-IV-TR. It also suggests an inability fo differentially diagnose these two disorders. The category that is currently proposed is descriptive and is intended to reflect the situation and also provide a framework to facilitate clinician diagnosis and assessment as well as to allow the inclusion of women suffering from pain and penetration problems into the DSM-V.
  • See here for DSM-V proposed changes -DSM-V - Genito-Pelvis Pain/Penetration Disorder

Sexual and Gender Identity Disorders | Sexual Pain Disorders | Proposed Revisions and Additions in the DSM-V for Sexual and Gender Identity Disorders