REVIEW

CURRENT
OPINION Sexual disorders beyond DSM-5:
the unfinished affaire
Felipe Navarro-Cremades a, Chiara Simonelli b, and Angel L. Montejo c

Purpose of review
To provide an overview of post-The Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
classifications related to human sexuality. After reviewing the literature on classification and clinical
practice of sexual disorders, some of the most important contributions on main sexological classifications
and frameworks were selected, especially from January 2016 till June 2017.
Recent findings
New relevant contributions on psychiatric and sexological classifications and frameworks have been
proposed, such as the international classification of diseases 11th revision (ICD-11), research domain criteria,
the third edition of the Diagnostic Manual in Sexology and the person-centered psychiatry perspective.
Summary
ICD-11 proposals regarding conditions related to sexual health including sexual dysfunctions and gender
incongruence as well as vaginismus, such as sexual pain disorder, paraphilic disorders as mental
Disorders. The disorders associated with sexual development and orientation, are proposed for deletion.
The other perspectives aforementioned are also presented.
Keywords
classification, DSM-5, ICD-11, sexual disorders, sexual dysfunctions

INTRODUCTION Relevant questions are still open — for example

&&

Sexual health is defined from positive and contextual dimensional vs. categorical perspectives [6 ,7] and
&& &

perspectives [1], and sexual health is important along
&
the cycle of life of every person [2 ]. Sexuality is a key
domain in the lives of individuals and their partners
& ICD-11 PROPOSALS
[2 ]. Sexual disorders and dysfunctions are different
from other clinical or life situations, and precise
definitions are therefore required to differentiate dis-
&
orders from them [2 ,3]. Sexual problems are highly
prevalent among psychiatric patients, and they may
be caused by the psychopathology and its pharmaco-
& ICD CHARACTERISTICS
therapy [4,5 ]. After conducting a systematic litera-
ture review using the usual scientific databases, some
relevant publications have been selected for com-
ment that were published mainly from January
2015 to the end of June 2017. Some contributions
are partially and faithfully reproduced in an attempt
to preserve the original speech of the authors. Many
relevant contributions have been rejected because
they contain information that is at least partially
redundant with the selected one.
This article is focused mainly on the current
revision of The International Classification of Dis-
eases 11th revision (ICD-11) from the WHO, which
is expected to be approved by the World Health
&&
Assembly in May 2018 [6 ].
validity vs. utility perspectives [6 ,7,8 ].
The ICD-11 working group on sexual disorders and
sexual health (WGSDSH) proposed relevant contri-
&&
butions [6 ] that are adapted and summarized here.
ICD-11 has been developed and published by the
WHO to address the needs of countries, and it covers
all health conditions, whereas The Diagnostic and
Statistical Manual of Mental Disorders, 5th ed.
a
Miguel Hernández University, Elche, Spain, IAMS, International Acad-
emy of Medical Sexology, bLa Sapienza University, Roma, Italy and
c
University of Salamanca, Institute of Biomedicine of Salamanca
(IBSAL), Salamanca, Spain, IAMS
Correspondence to Angel L. Montejo, MD, PhD, University of Salamanca,
IASM, Institute of Biomedicine of Salamanca, Salamanca, 37004, Spain.
E-mail: amontejo@usal.es
Curr Opin Psychiatry 2017, 30:417–422
DOI:10.1097/YCO.0000000000000367

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Sexual disorders
KEY POINTS
 Sexual problems are highly prevalent among
psychiatric patients, and they may be caused by the
psychopathology and its pharmacotherapy.
 New ICD-11 proposals include several new conditions
that should be taken into account such as CRSH, desire
and arousal, orgasmic, ejaculatory, and sexual pain
disorders.
 Some important changes versus DSM-5 include a new
terminology for sex dysphoria such as sex
incongruence referred to child and adult. A new
chapter for paraphilic disorders is included.
 Disorders associated with sexual development and
orientation are deleted similarly to DSM-5 avoiding
either ethical, transcultural or value judgment
interpretations.
 Other diagnostic systems or frameworks are presented
such as RDoC, DMS-III and PcP to extend perspectives
in sexuality.
(DSM-5) covers only mental disorders. The ICD and
the DSM have distinct constituencies and purposes
and have been developed within different institu-
&& & &
tional contexts [6 ,9 ]. The WGSDSH proposes a
new chapter on conditions related to sexual health
(CRSH). Future selected directions will include inter-
actions on categories ICD-11/DSM-5 and relations
with the research domain criteria (RDoC) National
Institute of Mental Health (NIMH) initiative [10].
ICD-11 has been developed and published by
the WHO to address the needs of countries, and it
covers all health conditions, whereas the DSM-5
covers only mental disorders
THE ICD AND SEXUAL HEALTH
The following concepts are related to sexual health
and can be measured and reported: sexual dysfunc-
tion, female genital mutilation, sex incongruence,
&
sexually transmitted infections (STIs) [11 ,12],
violence against women (VAW) [13], unwanted
pregnancy, induced abortion, posttraumatic stress
disorder (PTSD) from sexual violence cause [13] and
others.
The ICD-11 incorporates a more integrated
approach to sexual health by integrating the mind
and body aspects in a less-stigmatizing way [14,15].
ICD 11 BETA DRAFT
Chapter 06, which is entitled ‘Mental, behavioral or
neurodevelopmental disorders’, includes paraphilic
disorders. Chapter 17 contains CRSH. Field studies
418 www.co-psychiatry.com
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are currently being implemented via the Internet
through the Global Clinical Practice Network
[16,17]. The ICD-11 beta platform presents a brief
glossary of definitions for all categories that are
available for public review [18]. The guidelines con-
tain a section that discusses boundaries between
disorders and normality, and the ‘Additional Infor-
mation’ section also discusses different presenta-
tions of the disorders. The final version of the
guidelines will include additional information
[16–18].
FROM ICD-10 TO ICD-11: SELECTED
PROPOSED CHANGES
The WGSDSH has proposed an integrated classifica-
&&
tion of sexual dysfunctions for ICD-11 [6 ]:
Sexual dysfunctions: ICD-11 proposed
classification and diagnostic guidelines
(1) Sexual response is a complex interaction of
psychological, interpersonal, social, cultural,
physiological and sex-influenced processes,
and one or more of these factors may impact
&
any stage of the sexual response cycle [2 ,11 ].
Any of these factors may contribute to the
&& &
development of sexual dysfunction [6 ,11 ].
(2) Sexual dysfunctions are organized into four main
groups: sexual desire and arousal dysfunctions,
orgasmic dysfunctions, ejaculatory dysfunctions
and other specified sexual dysfunctions. A group-
ing of sexual pain disorders has also been pro-
posed. Categories, where possible, apply to both
men and women, emphasizing commonalities in
sexual response.
(3) Sexual dysfunctions are ‘syndromes that com-
prise the various ways in which adult people
may have difficulty experiencing personally sat-
isfying, noncoercive sexual activities’. A sexual
dysfunction must ‘1) occur frequently, although
it may be absent on some occasions; 2) have
been present for at least several months (that
can be excepted for acute cause); and 3) be
associated with clinically significant distress’.
Exclusion criteria include sexual dysfunction
associated with pelvic organ prolapse.
(4) There is no normative standard for sexual activ-
ity. Satisfactory sexual functioning is subjec-
tively defined as being satisfying to the
individual.
(5) ICD-11proposal does not make any difference
between ‘organic’ and ‘nonorganic’ sexual dys-
functions in order to simplify the classification
&&
making it more useful and clinical [6 ,14,15].
Volume 30  Number 6  November 2017

(6) Qualifiers may be applied to identify the impor-
tant clinical characteristics of a sexual dysfunc-
tion. A temporal qualifier indicates whether
the sexual dysfunction is lifelong or acquired.
A situational qualifier indicates whether the
sexual dysfunction is generalized or situational.
(7) Etiological qualifiers include the following: dis-
order or disease classified elsewhere or an injury
or surgical treatment, a medication or sub-
stance, a lack of knowledge regarding sexuality,
psychological or behavioral factors, relationship
factors and cultural factors.
(8) Other proposed changes for ICD-11 from ICD-
10 categories of sexual dysfunctions affect to the
following categories: excessive sexual drive
&& &
[6 ,19 ,20,21], which is deleted, loss or lack
of sexual desire, sexual aversion, lack of sexual
enjoyment and failure of genital response.
(9) Comparison with DSM-5 on sexual dysfunctions.
(a) CIE-11 proposals are different from the
DSM-5 in its attempt to integrate sexual
dysfunction, which may have a range of
etiological or contributory dimensions that
may be recorded using the etiological quali-
fiers.
(b) The ICD-11 proposed classification allows
for a sexual dysfunction diagnosis in situa-
tions in which this is an independent focus
of treatment, regardless of presumed cause.
A DSM-5 diagnostic of sexual dysfunction
would not be assigned if the cause of a
sexual dysfunction is a nonsexual medical
disorder, a medical condition or the effects
of a substance or medication.
(c) The ICD-11 is a classification of all health
conditions, thus providing the possibility
for greater integration.
(d) The ICD-11 proposed category ‘hypoactive
sexual desire dysfunction’ can be applied to
both men and women, but ‘female sexual
arousal dysfunction’ is classified separately.
There is significant comorbidity between
desire and arousal dysfunction. The DSM-
5 category ‘female sexual interest/arousal
disorder’ combines dysfunctions of sexual
desire and sexual arousal in women.
&&
(e) Sexual pain disorder(s) [6 ]. The ‘sexual
pain penetration disorder’ category in the
ICD-11 proposal includes vaginismus,
excluding dyspareunia and vulvodynia,
which are classified in the ‘Genitourinary’
chapter. The DSM-5 category ‘Genito-pelvic
pain/penetration disorder’ includes vaginis-
mus, dispareunia and vulvodynia that
are not completely attributable to other
medical conditions.
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Sexual disorders beyond DSM-5 Navarro-Cremades et al.
(f) ICD-11 proposes a conceptual change on
the delayed ejaculation category, emphasiz-
ing the subjective experience of orgasms
and separating it from the ejaculatory
phenomenon. In DSM-5, this is treated as
delayed ejaculation.
Gender incongruence: ICD-11 proposed
changes from the formerly sex identity
disorders (ICD-10) and comparison with
DSM-5
&& &
1) Comparison with DSM-5 [6 ,9 ]. The ICD-11
proposal includes a ‘Gender Incongruence’
[22–24] grouping within the CRSH, including
child [23] and adult sex incongruence categories.
DSM-5 retains the categories on childhood and
adult forms of sex dysphoria (formerly sex iden-
tity) based on the concept of self-perceived
&&
incongruence [6 ,24].
2) The ICD-11 removes the categories related to
transgender identity from mental disorders
&
[11 ] and reconceptualizes the category of trans-
sexualism as sex incongruence of adolescence
and adulthood and the category of sex identity
disorder of childhood as sex incongruence
of childhood.
Both categories may be associated with clinically
significant distress or impairment in important
areas of functioning.
Paraphilic disorders: ICD-11 proposals and
comparison with DSM-5
(1) Disorders of sexual preference are proposed to
be renamed as paraphilic disorders in the ICD-11
&&
[6 ,25,26]. The regulation of private behavior
without health consequences to the individual
or to others is not a legitimate focus of public
health or health classification that is particularly
pertinent to the classification of atypical sexual
preferences referred to as paraphilias. The ICD-11
paraphilic disorders consist primarily of patterns
of atypical sexual arousal that focus on noncon-
senting others, as these conditions could be con-
sidered to have public health implications.
ICD-11 paraphilic disorders include the follow-
ing: exhibitionistic disorder, voyeuristic disor-
der and pedophilic disorder. In addition, other
categories have been proposed: coercive sexual
sadism disorder, frotteuristic disorder and other
paraphilic disorders involving nonconsenting
individuals; and paraphilic disorder involving
solitary behavior or consenting individuals.
www.co-psychiatry.com 419
Sexual disorders
Three ICD-10 categories (i.e. fetishism, fetishis-
tic transvestism and sadomasochism) will be
removed from the classification. Paraphilic dis-
orders will be retained in the ICD-11 chapter on
&&
mental and behavioral disorders [6 ].
&&
(2) Comparison with DSM-5 [6 ].
Paraphilic disorders in the proposed changes for
the ICD-11 align more closely with DSM-5. Sexual
masochism disorder, fetishistic disorder and trans-
vestic disorder are included in DSM-5. All three are
recommended for the deletion on ICD-11 and can
be diagnosed as other paraphilic disorders involving
solitary behavior or consenting individuals only
if they are associated with significant distress or
significant risk of injury or death.
The duration requirement proposed for para-
philic disorders in ICD-11 is more flexible than
the 6-month requirement of DSM-5.
Functional impairment is included relatively
automatically in diagnostic criteria for DSM-5,
but has not been included as a part of the proposed
ICD-11.
Psychological and behavioral disorders
associated with sexual development and
orientation (ICD-10)
All categories in this grouping including the sexual
relationship disorder category have been recom-
&&
mended for deletion in ICD-11 [6 ] and are not
included in DSM-5 [3]. Proposed diagnostic guide-
lines for the formerly described disorders will be
made available for review and comment by mem-
bers of WHO’s Global Clinical Practice Network [27]
and subsequently for public review prior to finaliza-
tion of the ICD-11. The ICD-11 potential impact of
changes is major and far-reaching, as the ICD is used
by states to define access to health services and to
formulate public policies and laws; it is also used by
&
health professionals [11 ].
Conditions ‘cross-listed’ to the sexual health
chapter
&
ICD-10 vs. ICD-11 (Code Title/Chapter) [11 ]
(1) STIs (ICD-10) vs. infectious diseases (ICD-11).
(2) VAW (ICD-10) vs. external causes of morbidity
and mortality (ICD-11).
(3) Unwanted pregnancy (ICD-10) vs. factors influ-
encing health status and contact with health
services (ICD-11).
(4) Induced abortion (ICD-10) vs. pregnancy, child-
birth and the puerperium (ICD-11).
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(5) VAW [28] impacts on women’s health including
PTSD of sexual cause. VAW is related to post-
traumatic sexual stress disorder (PTSSD) based
on the third edition of the Diagnostic Manual in
Sexology (MDS-III) from a spectrum perspec-
tive/dimensional proposal [29,30].
(6) Diagnosis of ‘Post Traumatic Sexual Stress Spec-
trum’ (PTSSS) has been recently proposed [13].
PTSSS would include three diagnoses that
extend to three levels of the posttraumatic sex-
ual stress (MDS III) disorder [29,30] with a
dimensional perspective: subthreshold or par-
tial PTSSD, PTSSD and complex PTSSD. A robust
literature provides support for these three diag-
nostics from PTSD [13,31].
OTHER CLASSIFICATONS AND
FRAMEWORKS
Research domain criteria
The main objectives of the RDoC Project by the
& &
(NIMH [10,32 ,33,34 ] include improving the clini-
cal utility of psychiatric diagnoses for the ICD/DSM
and exploring, in an innovative way, the etiopatho-
genetic bases of psychopathology. ICD/DSM and
RDoC can be regarded as complementary [15].
The DSM-ICD model embraces an Aristotelian
view of categorization of mental disorders as discrete
entities, whereas RDoC adopts a Galilean model of
psychopathology as the product of dysfunctions in
neural circuitry [35].
RDoC rests on several assumptions (e.g. trans-
diagnostic, translational and dimensional) and differ-
ent levels of analysis (e.g. biological and behavioral).
RDoC appears to be a valuable alternative or
complement to the DSM-ICD classifications [35].
RDoC proposes a two-dimensional matrix for
research. This matrix has seven units of analysis
on the horizontal axis, which are organized from
more to less basics to growing complexity: genes,
molecules, cells, circuits, physiology, behavior and
(self-) reports. On the vertical axis, five domains/
constructs are the next systems: negative valence,
positive valence, cognitive, for social processes and
&
arousal/regulatory [32 ,35,36]. The main selected
publications are available from the NIMH RDoC
&
literature [34 ].
MDS III
The third edition of the diagnostic manual in sexol-
ogy (DMS III) is a diagnostic system that refers
exclusively to human sexuality [29,30]. DMS III
contains four chapters: sexology, disorders in
Volume 30  Number 6  November 2017

sexology, etiology and classification [37,38]. The
English version of the DMS III Spanish edition is
expected to be available in 2017.
Person-centered psychiatry and sexology
perspectives
Person-centered sexology (PCS) represents a holistic
approach that includes sexual health and sexual
well being. PCS is derived from models of person-
centered medicine and psychiatry. The comprehen-
sive diagnostic formulation in sexual health has two
components: a standardized multiaxial formulation
using ICD categories and an idiographic formula-
tion. A global assessment of sexual problems and
dysfunctions should be comprehensive and person-
& &
centered and partner-centered [2 ,31,39 ].
Others relevant diagnostic assessment and clas-
sification contributions based on a person-centered
psychiatry (PcP) paradigm include the following:
The person-centered integrative diagnosis (PID)
& F.N. and C. S. have no conflicts of interest.
[39 ], which interactively includes positive and
negative aspects of health within the person’s life
context. PID uses the ICD system and focuses on the
totality of the person. PID would employ categori-
cal, dimensional and narrative approaches. PID
articulates science and humanism and goes beyond
the nosological and differential diagnoses.
The Latin American Guide for Psychiatric Diag-
&
nosis (GLADP) [39 ,40] is based on PID and includes
the dyadic relationship.
The RCS model [41] for evaluation and inter-
vention on sexual dysfunctions, highlighting the
relationship, communication and sexuality (RCS)
factors in the dyadic relationship.
DSM-5
The DSM-5 perspective has been taken into account
in previous reviews on human sexuality. Some
examples include sexual dysfunction and traumatic
&
brain injury (TBI) [42 ]; sexual dysfunction and
& 6. Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and
medical disorders [43 ]; mental consequences of
&
VAW and girls [44 ]; a conceptual framework of
&&
sexual dysfunction in DSM-5 and ICD-11 [45 ];
and sexual pain disorders [46].
CONCLUSION
DSM-5 seems to include only an unfinished view of
sexual disorders. ICD-11 proposals include a new
chapter on CRSH with sexual dysfunctions (desire
and arousal, orgasmic, ejaculatory, sexual pain dis-
orders and other) and gender incongruence of chil-
dren and adults. The paraphilic disorders are located
in the chapter on mental disorders and disorders
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Sexual disorders beyond DSM-5 Navarro-Cremades et al.
associated with sexual development and orientation
(ICD-10) are deleted.
Other relevant contributions on psychiatric and
sexological classifications and frameworks include
the RDoC project; the MDS III; and the PcP perspec-
tive and its developments such as the PID, the
GLADP and the RCS dyadic model. There is a need
of integration of all these models to develop a new
way to sexuality classification from a clinical and
research point of view.
Acknowledgements
None.
Financial support and sponsorship
A.L.M. has been a consultant for, received grant/research
support and honoraria from, Lundbeck, Otsuka, Pfizer,
Janssen and Roche.
Conflicts of interest
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READING
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& of special interest
&& of outstanding interest
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Volume 30  Number 6  November 2017