| Sexual dysfunctions DSM-5 | |
| To fulfill the DSM-5 criteria of sexual dysfunction - the dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. | |
| Delayed ejaculation | Patient will present as → a 42-year-old male reports difficulty achieving ejaculation during intercourse for the past six months, despite normal desire and arousal. He often requires over 30 minutes of stimulation to climax. He has a history of hypertension and diabetes mellitus, both well-controlled, and is taking an SSRI for anxiety. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months
TX: There isn't an approved drug treatment for delayed ejaculation. "Off-label" treatments may include:
References: UpToDate |
| Erectile disorder | Patient will present as → a 34-year-old heterosexual male who presents to your clinic for concerns regarding erectile dysfunction. He works for Facebook and admits to working long hours in a very stressful environment. He reports having morning and night-time erections. The problem started approximately one year ago and has had a significant impact on his relationships. Often times he is unable to obtain an erection and when he does his penis is often flaccid and it is difficult to achieve penetration. This has resulted in significant distress and he has almost completely stopped dating. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.
TX: Treatment options include oral phosphodiesterase inhibitors - These drugs include sildenafil (Viagra), vardenafil, avanafil, and tadalafil
References: Merck Manual · UpToDate |
| Female orgasmic disorder | Patient will present as → a 34-year-old female reports an inability to achieve orgasm during sexual activity despite normal desire and arousal. She has a supportive partner and denies pain during intercourse. She has a history of depression and is taking an SSRI. Presence of either of the following symptoms and experienced on almost all or all (approximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.
TX: First-line treatment of female orgasmic disorders is directed masturbation, which involves a series of prescribed exercises
References: Merck Manual · UpToDate |
| Female sexual interest/arousal disorder | Patient will present as → a 33-year-old woman with a chief complaint of trouble having intercourse. She is completely disinterested in sex, and she is not receptive to her partner’s attempts to initiate foreplay. She reports that when they do have sex, she never achieves orgasm. This is affecting her current relationship with her boyfriend. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following for a minimum duration of approximately 6 months
TX: Education about sexual anatomy and function
References: Merck Manual · UpToDate |
| Genito-pelvic pain/penetration disorder | Patient will present as → a 29-year-old female who reports pain during intercourse and difficulty with vaginal penetration. She experiences pain both during initial penetration and throughout intercourse, leading to avoidance of sexual activity. She also has discomfort with tampon use and gynecological exams. Examination reveals tender pelvic floor muscles and involuntary muscle contractions, indicating vaginismus. Persistent or recurrent difficulties with one (or more) of the following for a minimum duration of approximately 6 months
TX: Treatment of cause when possible (e.g., topical estrogen for atrophic vaginitis)
References: Merck Manual · UpToDate |
| Male hypoactive sexual desire disorder | Patient will present as → a 53-year-old male complaining of a lack of desire for sex with his wife causing him marked distress for the past year. His wife has been very hurt by his lack of response to her advances, and he reports that this is having a significant strain on their relationship. Prior to this, he was interested in sex, and he and his wife would have intercourse 1-2x per month. He is very active and continues to compete in triathlons. He has no significant past medical history. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity for a minimum duration of approximately 6 months
TX: Common treatments for HSDD include testosterone therapy and other medications, as well as sex therapy References: Merck Manual · UpToDate |
| Premature (early) ejaculation | Patient will present as → a 32-year-old male presents to the clinic with concerns about consistently experiencing ejaculation within one minute of vaginal penetration, which has been occurring for the past year. He reports feeling distress and frustration about this issue, which has also caused tension in his relationship. He describes normal sexual desire and arousal but notes that he often ejaculates before he or his partner wishes. He denies any issues with erectile dysfunction and reports that this problem occurs in nearly all sexual encounters, including masturbation. He has no significant medical history and is not taking any medications. On examination, there are no physical abnormalities. The patient is otherwise healthy and reports a stable relationship with his partner. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it
TX: SSRIs are first-line treatment
References: Merck Manual · UpToDate |
| Substance/medication-induced sexual dysfunction | Patient will present as → a 45-year-old male reports a decrease in sexual desire and erectile dysfunction starting three months ago, coinciding with the initiation of a beta-blocker for hypertension. He had normal sexual function prior and can achieve but not maintain an erection, causing distress. Substance-induced sexual dysfunction refers to a condition in both men and women in which patients have difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications (legal or illicit) |
| Paraphilic disorders DSM-5 | |
| Voyeuristic disorder | Patient will present as → a 20-year-old male college student was reported by others for spying through the windows of his fellow female dormmates. Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first
References: Merck Manual |
| Exhibitionistic disorder | Patient will present as → a 23-year-old male who goes to city park during the summer months in an overcoat. He enjoys walking around the park exposing his genitals to strangers. He then runs away so as to avoid getting caught. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.
TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first
References: Merck Manual |
| Frotteuristic disorder | Patient will present as → a 29-year-old male who was brought in by his wife and older brother. According to them, the patient has a desire to rub his privet area against other people, when the opposing person is not looking. He has done this action in their home, and to his wife when she is doing the dishes, or even cooking dinner and began to rub against his brother when he would be helping his with things around the house. Sexual gratification attained by touching or rubbing against a nonconsenting individual TX: Treating frotteurism usually includes psychotherapy and behavior therapy
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| Sexual masochism disorder | Patient will present as → a 23-year-old male who concerned that his behavior has resulted in his inability to maintain a relationship. He reveals that he requires his partners to strangle him and humiliate him in order for him to achieve and maintain an erection. Sexual gratification in response to undergoing humiliation, bondage, or suffering
TX: Treatment for sexual masochistic disorder typically involves psychotherapy and medication that can reduce sex drive
References: Merck Manual |
| Sexual sadism disorder | Patient will present as → a 42-year-old white man seeking help for depression and suicidal ideations. In a detailed interview, the patient reveals his involvement in sexual acts that make him guilty. He reports that he and his girlfriend of the last two years had been involved in cutting and drawing blood from each other’s bodies while engaging in sexual activity. The two also drink each other’s blood while involved in these sexual activities, and he reports that cutting and drinking his partner’s blood is the only way that he can reach orgasm. On physical exam, you note numerous scars on his arms and chest that are very deep and in different stages of healing. Sexual gratification in response to inflicting humiliation, bondage, or suffering TX: Sexually sadistic interests do not require treatment unless causing significant impairment or distress, or harm to self or another has occurred
References: Merck Manual |
| Fetishistic disorder | Patient will present as → a female brings her 29-year-old boyfriend to a couples therapist because she is uncomfortable with his behavior. She found him clutching her feet during intercourse, and noticed that he insists on being able to see her feet while they engage in sexual acts. Sexual arousal is obtained by specific objects
TX: Treatment of fetishistic disorder may include psychotherapy, drugs, or both
References: Merck Manual |
| Pedophilic disorder | Patient will present as → a 33-year-old male gymnastics teacher insists that all his students take a shower after class. He supervises the children showering and becomes sexually aroused. Repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children (generally 13 years or younger), and either act on these urges or experiences clinically significant distress or impairment
TX: In the US, the treatment of choice for pedophilia is IM medroxyprogesterone acetate
References: Merck Manual |
| Transvestic disorder | Patient will present as → a 39-year-old male presents to the clinic expressing feelings of distress and guilt related to recurrent and intense sexual arousal from dressing in women’s clothing. He reports that these urges have been present since adolescence and that he engages in cross-dressing privately, primarily during times of stress. The patient states that these activities provide him with significant sexual gratification, but he experiences considerable shame and fear of being discovered. He notes that this has affected his self-esteem and relationships, leading him to avoid intimate relationships and social situations where his behavior might be exposed. He denies any desire to transition or persistent discomfort with his assigned male gender. There is no history of trauma or abuse, and he has no significant medical or psychiatric history. Defined as a condition in which there is persistent (at least 6 months), recurrent, and intense sexual arousal from wearing clothes associated with the opposite gender as evidenced by fantasies, urges, or behaviors
TX: For those individuals diagnosed with Transvestic disorder, who experience significant distress or impairment related to their cross-dressing behaviors, the treatment typically involves psychotherapy. Here are some potential therapeutic approaches:
Note: A therapist should be sensitive and knowledgeable about issues related to gender identity and sexual orientation. It’s essential for individuals seeking treatment to feel understood, respected, and accepted in their identity.
The aim of treatment should not be to eliminate cross-dressing behaviors per se, but to reduce any distress or dysfunction associated with these behaviors, and support the individual in their self-expression and identity. It’s important to stress that the goal is not to “cure” the individual of cross-dressing or change their gender identity. Instead, therapy should help them manage any associated distress and live a fulfilling life in line with their identity. Finally, it’s important to remember that the concepts of gender identity and sexual orientation are complex and evolving, and the classification of certain behaviors as disorders can be controversial. Society’s understanding and acceptance of diverse identities are changing, and this can impact both how disorders are defined and how they are treated. References: Merck Manual |