You are on page 1of 10


A Comparison of DSM-IV-TR and DSM-5 Definitions for Sexual

Dysfunctions: Critiques and Challenges

Mehmet Z. Sungur, MD and Anil Gndz, MD

Marmara University Faculty of Medicine, Department of Psychiatry, Istanbul, Turkey

DOI: 10.1111/jsm.12379


Introduction. The diagnostic criteria of sexual dysfunctions (SDs) are paramount for the development of sexual
medicine as reliable diagnoses are essential to guide treatment plans. Prior Diagnostic and Statistical Manual of
Mental Disorders (DSM) classications based denitions of SD mostly on expert opinions and included imprecise
terms. The validity of diagnoses of SD has only recently been challanged, and efforts are made to make more
operational denitions.
Aim. This paper aims to compare and contrast the recently released Diagnostic and Statistical Manual of Mental
DisordersFifth Edition (DSM-5) diagnostic criteria of SD with that of Diagnostic and Statistical Manual of Mental
DisordersFourth Edition Text Revision (DSM-IV-TR) and explains the rationale for making changes in the new
DSM-5. It also aims to address some issues to be considered further for the future.
Methods. Online proposed American Psychiatric Association website DSM-5, the new released DSM-5, and DSM-
IV-TR diagnostic criteria for SD were throughly inspected, and an extensive literature search was performed for
comparative reasons.
Main Outcome Measures. Changes in diagnostic criteria of DSM-5 were detected, and DSM-IV-TR and DSM-5
diagnostic criteria for SD were compared and contrasted.
Results. Diagostic criteria were more operationalized, and explicit duration and frequency criteria were set up in
DSM-5 for purposes of good clinical research. Classications based on simple linear sexual response were
abondoned, and diagnostic classications were separetely made for males and females. Desire and arousal disorders
in women were merged.
Conclusions. Drifting apart from linear sexual response cycle may be an advancement in establishing specic
diagnostic criteria for different genders. However, it is still a question of debate whether there is enough evidence to
lump sexual interest and arousal disorders in females. Making more precise denitions is important to differentiate
disorders from other transient conditions. However, there is still room to improve our denitions and nd a way to
include gay and lesbian individuals. Further discussions and debates are expected to be continued in the future.
Sungur MZ and Gndz A. A comparison of DSM-IV-TR and DSM-5 definitions for sexual dysfunctions:
Critiques and challenges. J Sex Med 2014;11:364373.
Key Words. Sexual Dysfunctions; Critiques; Challenges; DSM-5; DSM-IV-TR; Denitions for Sexual

Introduction be variations of ordinary sexual responses that

represent transient alterations in normal sexual

A considerable amount of available information

regarding denition of sexual dysfunctions
(SDs) has been challenged during the last few
functioning. They may also be symptoms of other
medical diseases such as diabetes mellitus. They
may emerge as consequences of relationship
years. problems and/or in response to the sexual prob-
One of the basic challenges is about dening lems of the presenting partner for adaptive pur-
what makes a sexual problem become a dysfunc- poses. Therefore, more precise denitions are
tion or disorder. Conditions such as delayed required to differentiate disorders from other
ejaculation (DE) or erectile dysfunction (ED) may transient conditions.

J Sex Med 2014;11:364373 2013 International Society for Sexual Medicine

A Comparison of DSM-IV-TR and DSM-5 365

Lack of consensus in dening SD leads to prob- Therefore, denitions based on common sexual
lems in determining their prevalence. In a given response cycles are currently challenged, leading
society, prevalence rates and epidemiological data to a major paradigm shift suggesting that male and
are crucial for assessment of overall impact of a female sexualities are different and therefore
clinical condition. Standardized operational crite- subject to be classied and managed differently [9].
ria and reliable measures are therefore needed to
improve our knowledge on prevalence rates of dif-
Why More Precise Duration and Severity Criteria?
ferent SD. This may be important in determining
Changes in A and B Criteria of SD
priorities in health policies and in conducting reli-
able epidemiological and clinical research. Although the A category of DSM focuses on den-
All the Diagnostic and Statistical Manual of ing sexual disorders per se, previous versions of
Mental Disorders (DSM) classications until DSM for SD did not specify precise severity and
present time based denitions of SD on expert duration criteria of diagnostic symptoms. Estab-
opinions that were not supported by sufcient lishing specic criteria related to the duration and
clinical or epidemiological data. Additionally, de- severity of the condition is currently seen as
nitions included vague terms such as satisfactory, another necessity to make better denitions and to
rapid, short, minimal, recurrent, persis- distinguish SD from variations of normal sexual
tent, etc. that were not possible to be quantied functions, from transient sexual problems, and
[1,2]. It is argued that diagnostic criteria of many from sexual difculties related to life events and
SD are so imprecise that they hamper advance- relationship problems [10]. Therefore, DSM-5
ments in the eld of sexual medicine [3]. criteria include specic durations and suggest
Therefore, a search for making better denitions using severity measures. Epidemiological research
emerged as a necessity for scientic evolution. indicates that criteria specifying duration of more
Efforts were made to base denitions on research than 6 months, combined with a criterion of quite
data and to establish more precise operational cri- often (occurring in more than at least 75% of
teria sets in Diagnostic and Statistical Manual of sexual encounters), serve to distinguish SDs from
Mental DisordersFifth Edition (DSM-5). One sexual difculties and transient problems [3].
concrete result of such efforts is acceptance of DSM-5 concludes that criterion A must have
ejaculation occuring within one minute duration been present for at least 6 months as a duration
following vaginal penetration as a necessary con- criteria (criterion B) and for most sexual disorders
struct to diagnose premature ejaculation (PE) [4]. to be experienced in almost all or all (approxi-
mately 75100%) of sexual activities. These dura-
tion and severity measures are expected to
Do Male and Female Sexual Responses Have to
eliminate most of the sexual difculties related to
Follow the Same Pattern?
transient situational variables from SD. No doubt,
Another very important challenge comes from one could still argue the validity of such denitive
increasing recognition that male and female sexu- numbers for making diagnosis, but establishing
ality could be quite different [5]. Until DSM-5, more precise denitions is a necessity for advance-
different genders sexual responses were assumed ment and scientic evolution in the eld of sexual
to be analogous. The Diagnostic and Statistical medicine. The clinicians and researchers are pref-
Manual of Mental DisordersFourth Edition erably expected to agree on operational diagnostic
Text Revision (DSM-IV-TR), published by the criteria based on evidence rather than clinical
American Psychiatric Association [6], classied observations in order to make sure that they are
male and female SD on the same continuum based investigating and treating the same disorder when
on unied sexual response cycles. It assumed a comparing the efcacy of two different interven-
linear cycle for both of the genders that consisted tions [3,11,12].
of successive stages of desire, arousal, and orgasm.
This kind of classication was criticized for not
Individual or Interpersonal Distress?
taking into account the complexity of sexual expe-
riences that are unique for each single person and The B category of the DSM-IV-TR [6] denitions
especially for different genders. There are consid- for SD added marked distress and interpersonal
erable data [5,7,8] today to claim that sexual inter- difculty dimension to all dysfunctions. One
est, motivation, arousal, and pleasure may be challenge is on including terms such as interper-
experienced differently in different genders. sonal difculties or partner distress in the de-

J Sex Med 2014;11:364373

366 Sungur and Gndz

nition as B criteria in order to fulll SD criteria. which was phrased as marked distress or inter-
Although most of the time a sexual activity personal difculty, has been rephrased in
involves two partners (at least), many clinicians DSM-5 as criterion C and is quoted as clinically
today tend to avoid labeling people on the basis of signicant distress in the individual. Although a
their partners distress while they are not them- term such as negative personal consequences
selves uncomfortable. Additionally, some individu- might have captured real-life, personal experi-
als who have SD do not have partners. The ences in a wider spectrum that includes not only
DSM-5 criteria suggested to rephrase marked distress but also avoidance of sexual activities and
distress as clinically signicant distress in the frustration due to negative experiences, the term
individual as the C criterion. It deleted inter- distress is still preferred in general DSM-5 diag-
personal difculty dimension. Further debates nostic criteria including SD [1,4]. One recent
are expected to continue in the future to conclude study concludes that given the lack of data sup-
whether a complaint should be considered as a porting neither the removal nor the retention of
disorder only when it causes personal distress or the distress criterion, distress should always be
both interpersonal difculty and individual distress taken into account in future studies regarding
to validate the partners opinion on top of the SD to improve understanding the association
presenting partners individual distress. between distress and sexual difculties [14]. The
As DSM-5 [4] is relased just recently, this paper wording interpersonal difculty was replaced
aims to compare and contrast DSM-5 denitions with clinically signicant distress in the indi-
of SD with that of DSM-IV-TR. We hope that vidual. It shows the increasing tendency to diag-
it will be thought provoking in facilitating and nose a sexual problem as a disorder only when it
encouraging other authors to think, discuss, causes personal distress rather than interpersonal
debate, and challenge the new and old diagnostic difculties. Another important reason for empha-
criteria of SD. sizing personal distress might be that some indi-
viduals suffering from sexual disorders do not
have partners, and therefore partner distress or
A Comparison of DSM-IV-TR and DSM-5
interpersonal difculties may not be universally
Classifications for SD
applicable to all people [15,16].
All of the DSM-IV-TR diagnostic criteria had A The DSM-5 criteria calls attention to specify-
and B categories. The A category focused on ing all sexual disorders either as lifelong or
dening sexual disorder per se, whereas the B cat- acquired. It also refers to other speciers such as
egory added a marked distress or interpersonal generalized or situational (except genito-pelvic
difculty dimension to the denition of all dys- pain/penetration disorder [GPPD]) but deletes
functions. These categories aimed to differentiate subtyping by etiological factors such as psycho-
a dysfunction from its emotional impact both at logical or combined. This is understandable as
intra- and interpersonal level [13]. The common etiological subtyping is considered to be mislead-
wording selected to emphasize the signicance of ing, reductionist, and is rarely shown to be accu-
frequency in the A criterion for all dysfunctions rate due to paucity of available knowledge
was persistent or recurrent. DSM-IV-TR called concerning etiology. On the other hand, the speci-
attention to three different dimensions for each ers in DSM-5 might be highly important
sexual disorder and suggested clinicians to specify for assessing the nature of the sexual problem
the type of the disorder as (i) lifelong acquired; calling attention to partner, relationship, cultural/
(ii) generalized/situational; and (iii) due to psycho- religious, medical, and individual vulnerability
logical or combined factors. factors that might be crucial in the course of the
The A category that denes the disorder in disorder.
DSM-5 reects current clinical and research The major changes in DSM-5 [4] and the ratio-
ndings. More precise denitions are made based nale to make these changes [3] and some discus-
on data evidence regarding operationalizing vari- sions made by the authors can be summarized as
ables and constructs including severity criteria. follows:
Setting a minimum duration of 6 months as a
necessity was dened as B criterion for all of 1. Diagnostic classication should be separately
the SD. These changes aim to dene more made for males and females as womens sexual
homogeneous group for purposes of scientic responses may not be analogous to men. Addi-
evolution. The B category in DSM-IV-TR, tionally, given the complexity of sexual

J Sex Med 2014;11:364373

A Comparison of DSM-IV-TR and DSM-5 367

responses in women, classications based on arousal are some of the reasons that led
simple linear sexual response cycle may not be authorities to further recommend merging
reecting reality. Therefore, the Masters and desire and arousal diagnosis into one single
Johnson conceptual model of the sexual entity called FSIAD. A certain amount of a
response cycle is now abandoned. total number of criteria (at least three of a total
2. Sexual aversion disorder is deleted from the of six symptoms) are needed to be met in order
classication most probably due to its rare to fulll diagnostic criteria for FSIAD in
diagnosis. It is suggested that people with DSM-5 [4,21,24]. Although the idea of
these aversive symptoms could better be merging the two disorders together is still
coded as other specied SD. mainly based on clinical judgement rather
3. Diagnostic criteria for DSM-5 for hypoactive than sufcient empirical evidence, the sugges-
sexual desire disorder (HSDD) in women is tion has been welcomed by many professionals
now expanded to include absence of respon- and is regarded as one of the most important
sive desire dened by Basson [17] as some changes in DSM-5. Some authors [25] state
women may not have spontaneous sexual that HSDD and FSAD share commonalities at
desire or it may be that there is no such thing the symptom level, but data exist showing that
as spontaneous sexual desire [18,19]. Sexual they are distinguishable from each other [26].
thoughts may act as an internal sexual stimuli, One recent study raised validity and utility
and desire or arousal may be viewed as concerns for the merged diagnosis identifying
responses to these internal stimuli, which a group of women with FSAD who did not
implies that sexual desire is not spontaneous meet the FSIAD diagnostic criteria [27]. In a
but rather a response to covert internal trig- review made by DeRogatis et al. in 2010 [25],
gering processes [20]. Additionally, some Goldstein and Goldstein suggest three catego-
women may engage in sexual activity for non- ries such as HSDD, FSAD, and FSIAD, as
sexual reasons (without any initial direct some women may have both desire and
sexual desire) such as desire of emotional arousal problems while others clearly have
closeness with their partner, which may then only one. They emphasize the disadvantages
be followed by increased desire for sexual of lumping female sexual disorder on the basis
encounter if incentives of sexual activity prove of less precise denitions that may cause
to be arousing. This increased desire follow- more-difcult-to-treat conditions. In the
ing sexual arousal is named as responsive same review [25], a commentary welcomes
sexual desire [17,21]. It is also suggested that this merging due to unpractical and unwork-
decrease in desire in HSDD should not be due able nature of DSM-IV-TR FSAD denition
to adaptive reasons such as discrepancy in based on impaired/absent genital responses
sexual interest between partners and/or due to and the high overlap of the two problems.
relationship problems. Additionally, it is rec- Another study showed that HSDD could be
ommended to consider that the lack of desire identied as a distinct disorder, and it would
should be beyond normal reduction expected be counterproductive to combine the two dis-
with relationship duration and increasing age. orders together [28]. Impaired genital respon-
4. Merging desire and arousal diagnosis into one siveness was not found to be a valid diagnostic
single entity called female sexual interest and criterion in healthy women with or without
arousal disorder (FSIAD): The DSM-IV-TR sexual arousal difculties [18]. Additionally,
denition on female sexual arousal disorder some [18,25] authors suggested that desire
(FSAD) is based mainly on physiological cri- not being triggered by any sexual/erotic
teria, but research literature shows consis- stimulus should be considered as a primary or
tently low correlation between subjective must criterion for diagnosis of FSIAD as the
reports of arousal and objective physiological diagnosis can only be made when sexual
changes that occur [22,23]. The high overlap incentives are present or sufcient. Laan et al.
of different components of desire and arousal suggested that diagnosis of FSIAD should be
in women, the fact that low sexual arousal restricted to obtaining sexual rewards as
often coexist with complaints of low libido, women who engage in sexual activity for non-
and treatment research data supporting that sexual reasons (such as avoiding conicts and
transdermal testosterone used for treatment of increasing emotional closeness) desire sex for
HSDD improved not only the desire but also nonsexual rewards and may not necessarily

J Sex Med 2014;11:364373

368 Sungur and Gndz

become sexually aroused subsequently [25]. distress and fear of women were never con-
On the other hand, those women who become sidered to be necessary criteria for diagnosis
sexually aroused following nonsexual cues and despite the fact that most of the cases attrib-
perceive it asdesire or arousal cannot be uted the cause of the problem to the fear of
diagnosed as suffering from an SD. pain. Additionally, appropriate treatment is
5. DSM-5 criteria set up an explicit duration generally based on the removal of fear of pain,
and frequenecy criteria for female orgasmic not the muscle contractions. There was also
disorder (FOD). However, the DSM-5 de- heterogeneity involved if fear and spasm can
nition deleted following normal sexual occur only during attempts of penetration or if
excitement phase part from the DSM- it can occur both at vaginal examination and
IV-TR denition. This removal of text penetration attempts. Such heterogeneity of
makes it difcult to differentiate FOD from core symptoms made professionals wonder if
FSIAD. The deletion may probably be due vaginismus is a single event or a symptom of
to the fact that orgasm without a previous different clinical conditions. Basing the de-
sexual excitement is difcult to obtain and nition on interference with sex was also not
due to the difculty to dene a normal sexual acceptable as anything including headaches
excitement phase. and watching soap operas could also inter-
6. In DSM-IV-TR, dysparenuia and vaginismus fere with sex without necessarily being dened
were grouped together under the topic of as a sexual disorder. Some researchers even
sexual pain disorders. As they were consid- suggested that vaginismus, which is not differ-
ered to be distinct disorders, diagnosis made ent from dyspareunia, is not a primary SD but
for one of them would be expected to exclude a secondary reaction for the recurrent antici-
the diagnosis of the other. However, no pated experience of genital pain and should
empirical evidence showed that supercial therefore be considered as a pain disorder
dysparenuia can reliably be differentiated [32]. Binik argued that many women with dys-
from vaginismus both for research and pareunia continue to be sexually active, and
clinical purposes [29,30]. The signicant pain emerges not only as a response to sexual
overlap between vaginismus and supercial intercourse attempts but also occurs in other
dysparenuia on symptom dimensions made it situations such as insertion of tampons and
almost impossible to reliably differentiate gynecological exams. However, many clini-
one from the other, leaving the clinicians to cians use the term dyspareunia when they
consider whether they might lie on the same refer to pain of organic etiology [33], and
continuum with supercial dsyparenuia some- labeling it as a psychiatric disorder may not be
times extending to vaginismus [31]. This is appropriate [3]. Overall, merging supercial
probably one of the main reasons that led dsypareunia and vaginismus into GPPD in
some experts to propose new diagnostic crite- DSM-5 is welcomed by many professionals
ria. The new criteria for DSM-5 do not make whereas Laan and Brauer debate that they can
distinction between the two and collapses be different entities on the same continuum,
them into a single diagnostic entity namely with lifelong and generalized vaginismus asso-
GPPD. Another problem with both DSM- ciated with high anxiety and avoidance at one
IV-TR and previous DSM denitions of vagi- end of the spectrum and painful intercourse
nismus was the emphasis given to contraction with high pelvic oor tension on the other end
of vaginal muscles and penetrative aspect [25]. There is some evidence that women with
of sexual activity, a conceptualization based dsypareunia and vaginismus and their partners
on traditional penilevaginal penetration and differ in sexual behaviors and in their response
interference with coitus. This criterion may be to pain as well [34]. Additionally, the interna-
criticized as there is only minimal evidence for tional consensus committee suggested dyspa-
spasms of the vaginal wall. A denition such as reunia denition pain associated with sexual
difculties with vaginal entry despite the intercourse be changed into pain with
womans expressed desire to allow it may be a attempted or complete vaginal entry as some
less specic but a better description as it does women with dsypareunia may resist to
not refer to contractions as an etiological attempts of entry because of pain expectations
factor. Another surprising neglect in previous [3]. The DSM-5 GPPD denition avoids
denitions of vaginismus was that emotional terms such as interference with sex and

J Sex Med 2014;11:364373

A Comparison of DSM-IV-TR and DSM-5 369

emphasizes the signicance marked fear the future but needs further considerations
or anxiety about vulvovaginal pain during and research data. One proposition made was
penetration or anticipation of penetrative sex. to apply FSIAD criteria for men as reviewed
One might suspect why 6-month duration is thoroughly by Brotto [24]. However, the
required (criterion B) for diagnosing GPPD. extensive literature exploring epidemiology
Increasing knowledge about vaginismus and treatment of ED reviewed by Segraves has
through media helps people to recognize the presented considerable data not to subsume
disorder at a very early stage and encourage ED under the category of male sexual interest
them to come forward to demand help soon and arousal disorder due to etiological and/or
after they are confronted with such a problem. treatment reasons [37]. The value and signi-
Additionally, clinical experience shows that the cance of these different propositions are likely
frequency of penetration attempts are more to be understood better by further research
often following initial exposure to the problem. investigating if experiences of desire and
The penetration attempts are reduced over arousal can be differentiated in men, if gender
time due to frustration and hopelessness caused differences in sexual desire may be inuenced
by not being able to penetrate despite numer- by individual psychological factors, and if
ous recurrent attempts. This typical course of motivations for sex are exclusively different in
the disorder and its emergent nature in terms males and females. There is relatively little
of treatment makes it difcult to understand data on mens sexual desire when compared
why the diagnosis should be delayed to a with the paralell research literature in women,
minimum of 6 months despite many inconclu- and therefore further research aimed at under-
sive penetration attempts made in the rst few standing low desire in men are required.
months following initial exposure to the 9. DSM-5 recommends that early ejaculation
problem. Delaying diagnosis to 6 months may (EE) may be used as synonymous to PE as
be interpreted as delaying the treatment unless the ejaculation happens before the person
diagnosis is made and be risky in couples where wishes it. Persistence of at least 6 months
partners may not manage to stay together due duration and frequency of at least in 75%
to loss of hope in solving a problem of an of all sexual encounters criteria are included
emergent nature. in DSM-5 diagnostic criteria for EE. DSM
7. Another issue is whether dyspareunia in men denitions of PE until DSM-5 were all
should be diagnosed with the same criteria as authority-based and included terms such as
that in women. Dsypareunia in men is much persistent, recurrent, minimal and shortly
less common and appears to involve different after, which were vague, multi-interpretable,
factors from that in women. Therefore, it and lacked quantication [38]. Research con-
seems inappropriate to classify male and ducted by a committee appointed by Interna-
female dyspareunia together. Diagnosing tional Society for Sexual Medicine in order
male dyspareunia under unspecied sexual to establish an evidence-based denition for
disorders may be a transient solution until PE showed that the constructs necessary to
more data are gathered for conclusion [35]. dene PE are time from penetration to
8. Regarding male sexual disorders, it is pro- ejaculation, perceived control on ejaculation,
posed to preserve the DSM-IV-TR criteria of and negative personal consequences [1].
HSDD with addition of minimum duration of Intravaginal ejaculation latency time (IELT)
approximetaly 6 months but rename the dis- used to operationalize ejaculation time
order as male hypoactive sexual desire disor- showed that cutoff of 1 minute captured 90%
der to make a separate diagnosis for males. of men who actively sought treatment for EE
Some authors oppose the idea of making [2,39]. Therefore, 1-minute duration is
gender specic denitions and claim that the included in the new denition. Although per-
differences within the same sex are seen as ceived control to delay ejaculation was found
frequently as differences between different to be an important construct, this was not
sexes. Therefore, they suggest that FSIAD adequately emphasized in DSM-5. One limi-
diagnosis in women may also be adopted to tation of the new evidence-based denition is
men merging interest and arousal disorders its limited application to those heterosexual
together in men as well [36]. This suggestion men engaging in vaginal intercourse only and
may result in one gender neutral category in excluding homosexual men.

J Sex Med 2014;11:364373

370 Sungur and Gndz

10. ED may actually be a symptom, even quantify DE further on an intra-vaginal ejacu-

though it is often referred to as a disorder lation time basis may be inappropriate given
[40]. The inuence of the pharmaceutical the wide range of time differences with differ-
industry on ED makes it difcult to establish ent motives in delaying ejaculation. Addition-
improved denitions for DSM-5 without ally, distress may emerge at different time
conicts of interest. A new taxonomy that points for different people and denition of
helps clinicians to delineate cases of pure ED sexual responses should not be based solely on
would be very helpful. While the new DSM-5 its penetrative heterosexual nature. Although
diagnostic criteria bring an explicit duration subjective sensation of orgasm is emphasized
(of at least 6 months) and frequency (occur- for FOD and objective genital response is
ring in approximately 75% of occasions) cri- emphasized in MOD, there is still an ongoing
teria, it is difcult to assume that most men debate on whether the process of ejaculation
will accurately remember the frequency and and orgasm should be separated and whether
duration of their failures when it comes to time of ejaculation necessarily equates with
issues related with erections. Addition of the extent of orgasmic experience [42].
marked decrease in erectile rigidity on top 12. There has been a long-standing debate
of the present DSM-IV-TR criteria of dif- whether hypersexual disorder (HD) should be
culty in obtaining and maintaining an erection considered as a distinct diagnostic category in
should be discussed further. It is naturally the sexual disorders section of DSM-5.
expected to have decreases and increases in Despite the increasing number of cases diag-
erectile rigidity during the natural course of nosed as hypersexual, efforts are made to
sexual activity, and emphasizing decrease in establish operational criteria that it is not
rigidity may increase spectatoring on patients synonymous with sexual addiction, sexual
side, facilitate unnecessary medicalization, compulsivity, or paraphilia-related disorders
and encourage pharmaceutical industry to [43]. The risk-taking dimension of HD makes
promote the use of erection-inducing agents it a serious condition that leads to severe com-
when they are not exclusively indicated. plications such as unwanted pregnancies,
11. The DSM-IV-TR male orgasmic disorder marital discord or divorce, and mortality asso-
(MOD) is replaced in DSM-5 by the term ciated with sexually transmitted diseases.
delayed ejaculation. Preferring the term DE Therefore, HD may be conceptualized as pri-
may be understandable with regard to the marily a nonparaphilic sexual desire disorder
appropriateness of the terminology used. Men with an impulsivity and risk-taking compo-
who seek help for orgasmic problems often nent that is vulnerable to dysphoric mood
complain about their ejaculation time. The states and stressful life events. However, more
DSM-IV-TR emphasizes on subjective expe- research is needed to ll the gaps regarding its
rience of orgasm, whereas most clinical work developmental risk factors, course, prognosis,
is concerned with ejaculation time. However, and biological and psychological concomi-
it must be kept in mind that some orgasms tants. Additionally, there is ongoing debate
occur without ejaculations and not every about medicalizing an aberrant sexual activity
ejaculation is orgasmic. Additionally, many that could be covered under existing diagnosis
clinicians and researchers also prefer to use and whether including it as a distinct entity
the term delayed ejaculation. Literature would lead to an unhelpful redundancy and
search shows more references and citations criticisms in favor of anti-psychiatry move-
made to the term delayed ejaculation when ment. Implications on forensic psychiatry and
compared with the term male orgasmic dis- the criminal justice system should also be con-
order. In this respect, it may be important to sidered (especially with specier cybersex and
establish a congruency between diagnostic pornography) to balance the costs and benets
classication and current preferred daily use of recognizing such a diagnosis [44]. These are
of the term [41]. Another change made in probably some of the reasons why DSM-5
DSM-5 is the addition of frequency (75% of concluded not to include HD as an SD.
sexual occasions) and duration of complaint (6 13. Another change made in DSM-5 is the
months) criteria in order to make a more removal of the etiological subtypes (due to
precise denition and to identify more homo- psychological or combined factors) due to the
geneous groups. On the contrary, efforts to paucity of lack of information concerning

J Sex Med 2014;11:364373

A Comparison of DSM-IV-TR and DSM-5 371

the etiology and additional speciers for as an advancement in terms of establishing more
understanding. Instead some speciers such specic diagnostic criteria for different genders.
as relationship discord and lack of attraction However, despite the present considerable data
to current partner are suggested to be available to propose that sexual interest, motiva-
considered. tion, arousal, and pleasure may be experienced dif-
ferently in different genders, it is still a question of
debate whether there is enough evidence to lump
sexual interest and arousal disorders in females
There are some important issues that need to be into one category namely female sexual interest/
considered in establishing diagnostic criteria and arousal disorder as suggested in DSM-5.
dening SDs or disorders. Whether to lump or split sexual disorders should
One of the main issues is to dene when a sexual be based on the costs and benets of each option
problem becomes an SD. Therefore making more [25].
precise denitions is required in order to differen- Some clinicians and researchers believe that
tiate disorders from other transient conditions. female SDs are a spectrum of disorders with exten-
One way to make more precise denitions is to sive overlap and therefore could not be diagnosed
establish specic duration and frequency criteria specically [45,46]. On the other hand, if there
for SD just like the duration criterion required for are two naturally occurring distinct conditions
many other mental disorders in classication present,with unique characteristics that show phe-
systems. In DSM-5, a duration period of more nomenological overlap at the symptom level, the
than 6 months, combined with a criterion of quite risks of merging them in DSM-5 may be substan-
often (occurring in more than at least 75% of tial in terms of clinical practice and research. In
sexual encounters), is accepted as a dening crite- the DeRogatis paper, Goldstein and Goldstein
rion in general to distinguish SDs from sexual dif- emphasize the signicance of protecting the
culties and other transient problems [3]. This women from having their problems lumped in a
may be considered as a major advancement in way that makes providing treatments more dif-
dening more homogeneous groups for diagnostic cult [25]. Therefore, it is expected that there
purposes. However, adding a standard (6 months) will be further discussions and debates regarding
duration criteria for all SD as in DSM-5 may cause whether this lumping accurately reects the expe-
delay in diagnosing vaginismus cases where a riences of women with disorders of sexual desire
period of 6-month duration may be unnecessary and arousal.
for diagnosis to be made. Inexperienced therapists Apart from gender differences, research results
who stick to diagnostic criteria may delay a treat- reect diversity in members of the same gender as
ment without making a diagnosis.This might cause well. Womens motivations for sex might be dif-
further problems due to the emergent and cultur- ferent from each other, and there is evidence that
ally demanding nature of the problem. responsive desire occurs in women with and
Since impairment of a sexual function does not without arousal difculties. It is recommended
necessarily cause distress for that person, it is that relationship duration and sufciency of
important to emphasize that marked individual partner sexual stimulation must be recognized in
distress rather than interpersonal distress is an future diagnostic framework of dysfunctions [47].
important requirement for classifying a problem Before DSM-5, the terms premature ejacula-
as an SD. In DSM-5, a criterion such as the tion and vaginismus were only used to dene
problem causes clinically signicant distress in the SDs that interfered with vaginal intercourse. Such
individual is accepted in general as a require- a restriction was seen unnecessary as the diagnosis
ment to dene all SDs. This change in wording could not be based on interference with vaginal
probably intends to avoid labeling or stigmatizing entry. As DSM-5 emphasizes more on fear and
people on the basis of their partners distress anxiety of pain instead of muscle contractions, this
while they are not themselves bothered or dis- may be considered as an advancement for diagnos-
tressed. It shows the increasing tendency to diag- tic purposes. The term genito-pelvic pain/
nose a sexual problem as a disorder only when it penetration disorder is also better than the term
causes personal distress rather than interpersonal vaginismus as the latter implies contraction
difculties. of muscles and ignores the womens anxiety and
Drifting apart from unidimensional linear fear. However, there is room for improvement
sexual response cycle for both genders may be seen in diagnostic criteria for both EE and GPPD

J Sex Med 2014;11:364373

372 Sungur and Gndz

due to excluding homosexual orientation and studies: A contribution to the present debate for a new classi-
cation of PE in the DSM-V. J Sex Med 2008;5:107987.
nonpenetrative sexual activities and people 3 Segraves RT, Balon R, Clayton A. Proposal for changes
without partners. This implies lack of research in diagnostic criteria for sexual dysfunctions. J Sex Med
regarding homosexuals and heterosexuals for 2007;4:56780.
whom vaginal intercourse is not part of their 4 American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 5th edition. Washington, DC:
sexual repertoire. Another issue that needed to be Author; 2013.
considered in diagnosis of PE before DSM-5 was 5 Chivers ML, Bailey JM. A sex difference in features that elicit
to operationalize ejaculation time as there were no genital response. Biol Psychol 2005;70:11520.
precise denitions made for IELT. Although an 6 American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th edition, text rev. Washington,
operational criterion such as 1-minute IELT in DC: Author; 2000.
DSM-5 may be considered as a major advance- 7 Chivers ML, Timmers AD. Effects of gender and relationship
ment to evolve scientic progress, there is still context in audio narratives on genital and subjective sexual
room for improvement as no precise duration cri- response in heterosexual women and men. Arch Sex Behav
teria are specied for non-vaginal sexual activities 8 Laan E, Everaerd W, van Bellen G, Hanewald G. Womens
[1,2]. sexual and emotional responses to male- and female-produced
It seems like there is still room for further erotica. Arch Sex Behav 1994;23:15369.
research evidence to conclude about diagnostic 9 Leiblum SR. Sex therapy today current issues and future per-
spectives. In: Leiblum SR, ed. Principles and practice of sex
criteria, and some debates are likely to continue therapy. New York: Guilford Press; 2007:322.
for a long time. 10 Mitchell K, Graham CA. Two challenges for the classication
of sexual dysfunction. J Sex Med 2008;5:15528.
Corresponding Author: Mehmet Z. Sungur, MD, 11 Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall
Marmara University Faculty of Medicine, Department W, McManus S, Nanchahal K, Erens B. Sexual function prob-
of Psychiatry, Istanbul 34738, Turkey. Tel: +90-216- lems and help seeking behaviour in Britain: National probabil-
ity sample survey. BMJ 2003;327:4267.
3637134; Fax: 90-216-4112173; E-mail: mzsungur@ 12 Oberg K, Fugl-Meyer AR, Fugl-Meyer KS. On categorization and quantication of womens sexual dysfunctions: An epide-
miological approach. Int J Impot Res 2004;16:2619.
Conict of Interest: The authors report no conicts of 13 Hatzimouratidis K, Hatzichristou D. Sexual dysfunctions:
interest. Classications and denitions. J Sex Med 2007;4:24150.
14 Hendrickx L, Gijs L, Enzlin P. Distress, sexual dysfunctions,
and DSM: Dialogue at cross purposes? J Sex Med 2013;10:
Statement of Authorship 63041.
15 Byers ES, Grenier G. Premature or rapid ejaculation: Hetero-
Category 1 sexual couples perceptions of mens ejaculatory behavior. Arch
(a) Conception and Design Sex Behav 2003;32:26170.
16 Hartmann U, Schedlowski M, Kruger TH. Cognitive and
Mehmet Z. Sungur; Anil Gndz partner-related factors in rapid ejaculation: Differences
(b) Acquisition of Data between dysfunctional and functional men. World J Urol
Anil Gndz; Mehmet Z. Sungur 2005;23:93101.
(c) Analysis and Interpretation of Data 17 Basson R. The female sexual response: A different model. J Sex
Mehmet Z. Sungur; Anil Gndz Marital Ther 2000;26:5165.
18 Laan E, Both S. What makes women experience desire? Fem
Psychol 2008;18:50514.
Category 2 19 Laan E, van Driel EM, van Lunsen RH. Genital respon-
(a) Drafting the Article siveness in healthy women with and without sexual arousal
disorder. J Sex Med 2008;5:142435.
Mehmet Z. Sungur; Anil Gndz
20 Everaerd W, Laan E, Both S, Van der Velde J. Female sexual-
(b) Revising It for Intellectual Content ity. In: Szuchman LT, Muscarella F, eds. Psychological per-
Mehmet Z. Sungur; Anil Gndz spectives of human sexuality. New York: John Wiley & Sons
Inc; 2000:10146.
21 Graham CA. The DSM diagnostic criteria for female sexual
Category 3 arousal disorder. Arch Sex Behav 2010;39:24055.
(a) Final Approval of the Completed Article 22 Laan E, Everaerd W, van der Velde J, Geer JH. Determinants
Mehmet Z. Sungur; Anil Gndz of subjective experience of sexual arousal in women: Feedback
from genital arousal and erotic stimulus content. Psychophysi-
ology 1995;32:44451.
References 23 Toates F. An integrative theoretical framework for understand-
ing sexual motivation, arousal, and behavior. J Sex Res
1 McMahon CG. The DSM-IV-TR denition of premature 2009;46:16893.
ejaculation and its impact upon the results of epidemiological 24 Brotto LA. The DSM diagnostic criteria for hypoactive sexual
studies. Eur Urol 2008;53:8879. desire disorder in women. Arch Sex Behav 2010;39:22139.
2 Waldinger MD, Schweitzer DH. The use of old and recent 25 Derogatis LR, Laan E, Brauer M, van Lunsen RH, Jannini EA,
DSM denitions of premature ejaculation in observational Davis SR, Fabre L, Smith LC, Basson R, Guay AT,

J Sex Med 2014;11:364373

A Comparison of DSM-IV-TR and DSM-5 373

Rubio-Aurioles E, Goldstein A, Pukall C, Kellogg S, Burrows 37 Segraves RT. Considerations for diagnostic criteria for erectile
L, Morisson P, Krychman M, Goldstein SW, Goldstein I. dysfunction in DSM V. J Sex Med 2010;7:65460.
Responses to the proposed DSM-V changes. J Sex Med 38 Althof SE, Symonds T. Patient reported outcomes used in the
2010;7:19982014. assessment of premature ejaculation. Urol Clin North Am
26 DeRogatis LR, Allgood A, Rosen RC, Leiblum S, Zipfel L, 2007;34:5819.
Guo CY. Development and evaluation of the womens sexual 39 McMahon CG, Althof S, Waldinger MD, Porst H, Dean J,
interest diagnostic interview (WSID): A structured interview Sharlip I, Sharlip ID, Adaikan PG, Becher E, Broderick GA,
to diagnose hypoactive sexual desire disorder (HSDD) in stan- Buvat J, Dabees K, Giraldi A, Giuliano F, Hellstrom WJ,
dardized patients. J Sex Med 2008;5:282741. Incrocci L, Laan E, Meuleman E, Perelman MA, Rosen RC,
27 Clayton AH, DeRogatis LR, Rosen RC, Pyke R. Intended or Rowland DL, Segraves R, International Society for Sexual
unintended consequences? The likely implications of raising Medicine Ad Hoc Committee for Denition of Premature
the bar for sexual dysfunction diagnosis in the proposed Ejaculation. An evidence-based denition of lifelong prema-
DSM-V revisions: 2. For women with loss of subjective sexual ture ejaculation: Report of the International Society for Sexual
arousal. J Sex Med 2012;9:20406. Medicine Ad Hoc Committee for the denition of premature
28 Clayton AH, DeRogatis LR, Rosen RC, Pyke R. Intended or ejaculation. BJU Int 2008;102:33850.
unintended consequences? The likely implications of raising 40 Levine SB. Commentary on consideration of diagnostic crite-
the bar for sexual dysfunction diagnosis in the proposed ria for erectile dysfunction in DSM-V. J Sex Med 2010;7:
DSM-V revisions: 1. For women with incomplete loss of desire 238890.
or sexual receptivity. J Sex Med 2012;9:202739. 41 Segraves RT. Considerations for a better denition of male
29 Binik YM. The DSM diagnostic criteria for dyspareunia. Arch orgasmic disorder in DSM V. J Sex Med 2010;7:6905.
Sex Behav 2010;39:292303. 42 Wylie K, Ralph D, Levin RJ, Corona G, Perelman
30 Binik YM. The DSM diagnostic criteria for vaginismus. Arch MA. Comments on considerations for a better denition
Sex Behav 2010;39:27891. of male orgasmic disorder in DSM V. J Sex Med 2010;7:
31 Steege JF, Zolnoun DA. Evaluation and treatment of 6959.
dyspareunia. Obstet Gynecol 2009;113:112436. 43 Kafka MP. Hypersexual disorder: A proposed diagnosis for
32 Binik YM. Should dyspareunia be retained as a sexual dysfunc- DSM-V. Arch Sex Behav 2010;39:377400.
tion in DSM-V? A painful classication decision. Arch Sex 44 Halpern AL. The proposed diagnosis of hypersexual disorder
Behav 2005;34:1121. for inclusion in DSM-5: Unnecessary and harmful. Arch Sex
33 Basson R. Womens sexual dysfunction: Revised and expanded Behav 2011;40:4878.
denitions. CMAJ 2005;172:132733. 45 Balon R, Segraves RT, Clayton A. Issues for DSM-V: Sexual
34 Laan E, Brauer M, Lakeman MM, van Lunsen RHW Inad- dysfunction, disorder, or variation along normal distribution:
equate pain behavior in women with dyspareunia and primary Toward rethinking DSM criteria of sexual dysfunctions. Am J
vaginismus. Paper presented at ISSWSH 2010 annual meeting Psychiatry 2007;164:198200.
2010, February; St. Petersburg, Florida, USA. 46 Gierhart BS. When does a less than perfect sex life become
35 Davis SN, Binik YM, Carrier S. Sexual dysfunction and pelvic female sexual dysfunction? Obstet Gynecol 2006;107:7501.
pain in men: A male sexual pain disorder? J Sex Marital Ther 47 Carvalheira AA, Brotto LA, Leal I. Womens motivations
2009;35:182205. for sex: Exploring the diagnostic and statistical manual, fourth
36 Hyde JS. The gender similarities hypothesis. Am Psychol edition, text revision criteria for hypoactive sexual desire and
2005;60:58192. female sexual arousal disorders. J Sex Med 2010;7:145463.

J Sex Med 2014;11:364373