Female Orgasmic Disorder15,16
A. At least one of the two following symptoms:
1. Delay in, or absence of, orgasm
2. Markedly reduced intensity of orgasmic sensation
B. Symptom(s) must have been present for at least 6 months and be experienced on 75% or more of occasions of sexual activity
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
D. The problem causes clinically significant distress or impairment17,18
Addition of the following specifiers19,20,21,31:
Lifelong (since the onset of sexual activity) or acquired
Generalized or situational
Partner factors (partner’s sexual problems, partner’s health status)
Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experience)
Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
Medical factors (e.g., illness, medication)
15 Change to polythetic criteria and addition of “markedly reduced intensity of orgasmic sensation” to reflect the fact that orgasm is not an “all or nothing” phenomenon and that diminished intensity of orgasm may be a problem for some women (Graham, C. A. Female Orgasmic Disorder (FOD) Literature review). Removal of the text “following a normal excitement phase”. This requirement suggests that a DSM-IV diagnosis of Female Arousal Disorder would preclude a diagnosis of Female Orgasmic Disorder, whereas the DSM-IV text included a clear statement that both diagnoses can be made. This requirement also implies that women’s experiences of sexual excitement are uniform, whereas there is good evidence of substantial variability (Graham, C. A. Female Orgasmic Disorder Literature review). Lastly, none of the prevalence studies to date have assessed whether women have experienced a “normal excitement phase.”
16 The proposal would be to include similar statements in the text, rather than the diagnostic criteria, and also expand on the importance of partner variables and relationship functioning in clinical assessment of women presenting with orgasmic difficulties.
17 The rationale for adding severity and duration criteria is to avoid pathologizing normal variations and short-term changes in orgasmic functioning women may experience. “Persistent and recurrent” are not clearly operationalized in DSM-IV. This criterion has been added because of research evidence that the duration of orgasm problems specified significantly affects prevalence rates (see studies reviewed in Graham, C. A. FOD Literature review). Six months was chosen, as a large-scale national survey classified women experiencing orgasm difficulties for at least six months as having persistent problems (Mercer et al., 2003). The addition of frequency criteria is based on published recommendations (Balon, 2008; Balon et al., 2007; Segraves et al., 2007). This frequency also corresponds to the “usually/always” criteria adopted in a study by Oberg et al. (2004).
18 Many studies associate sexual distress with partner-related factors. The extent of “interpersonal difficulty” is now assessed as a specifier, and not part of the distress criterion.
19 The recommendation to remove the subtypes “Due to Psychological Factors” and “Due to Combined Factors” is made because of increasing evidence that both psychological and physical factors are implicated in the etiology of orgasm problems (Basson & Weijmar Schultz, 2007). The addition of the subtype “with concomitant problems in sexual interest/arousal” is based on the observations that women with lifelong (since the onset of sexual activity) FOD may also have arousal/interest difficulties (Anderson & Cyranowski, 2002; Basson, 2002)
20 Recognition of the fact that in many cases, the causes of sexual disorders are multifactorial and that medical factors may partially contribute to the etiology of a disorder. Adding medical factors as a specifier does reflect the possible importance of these variables in clinical assessment and treatment.
21 The addition of these specifiers reflects the considerable research evidence documenting the importance of partner and relationship factors in woman’s experiences of orgasm (Graham, C. A. FOD Literature Review). There is also evidence that different cultures and religions have markedly different perspectives on female orgasm (Heiman, 2007) and that the prevalence of orgasmic problems varies across cultures (Laumann et al., 2005).
31 The current specifier presumes knowledge of etiology, which often does not exist.
References
Andersen, B. L., & Cyranowski, J. M., (1995). Women’s sexuality: Behaviors, responses, and individual differences. Journal of Consulting and Clinical Psychology, 63, 891-906.
Balon, R. (2008). The DSM criteria of sexual dysfunction: Need for a change. Journal of Sex and Marital Therapy, 34, 186-197.
Balon, R., Segraves, R. T., & Clayton, A. (2007). Issues for DSM-V: Sexual dysfunction, disorder, or variation along normal distribution: Toward rethinking DSM criteria of sexual dysfunctions. American Journal of Psychiatry, 164, 198-200.
Basson, R. (2002). Are our definitions of women’s desire, arousal, and sexual pain disorders too broad and our definition of orgasmic disorder too narrow? Journal of Sex and Marital Therapy, 28, 289-300.
Basson, R., & Weijmar Schultz, W. (2007). Sexual sequelae of general medical disorders. Lancet, 369, 350-352.
Graham, C. A. (2009). Review of the DSM diagnostic criteria for Female Orgasmic Disorder Archives of Sexual Behavior, doi 10.1007/s10508-009-9542-2.
Heiman, J. R. (2007). Orgasmic disorders in women. In S. R. Leiblum (Ed.), Principles and practices of sex therapy (pp. 84-123). New York: Guilford.
Laumann, E. O., Nicolosi, A., Glasser, D. B., Paik, A., Gingell, C, Moreira, E., & Wang, T. (2005). Sexual problems among women and men aged 40-80 years: Prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. International Journal of Impotence Research, 17, 39-57.
Mercer, C. H., Fenton, K. A., Johnson, A. M., Wellings, K., Macdowall, W., McManus, S., et al. (2003). Sexual function problems and help seeking behaviour in Britain: National probability sample survey. British Medical Journal, 327, 426-427.
Oberg, K., Fugl-Meyer, A. R., & Fugl-Meyer, K. S. (2004). On categorization and quantification of women’s sexual dysfunctions: An epidemiological approach. International Journal of Impotence Research, 16, 261-269.
Segraves, R. T., Balon, R., & Clayton, A. (2007). Proposal for changes in diagnostic criteria for sexual dysfunctions. Journal of Sexual Medicine, 4, 567-580.
Dimensional Assessment Instrument for Female Orgasmic Disorder
1. Over the past six months, have you experienced an absence of orgasm (on at least 75% or more of sexual encounters)?
0 = No
1 = Yes, on about 25% of sexual encounters
2 = Yes, on about 50% of sexual encounters
3 = Yes, on about 75% of sexual encounters
4 = Yes, on all sexual encounters
2. Over the past six months, have you experienced a delay in orgasm (on at least 75% or more of sexual encounters)?
0 = Never
1 = Yes, mild delay
2 = Yes, moderate delay
3 = Yes, severe delay
4 = Yes, extreme delay
3. Over the past six months, have you experienced markedly reduced intensity of orgasm (on at least 75% or more of sexual encounters)?
0 = Never
1 = Mildly reduced intensity
2 = Moderately reduced intensity
3 = Severely reduced intensity
4 = Extremely reduced intensity
Female Orgasmic Disorder (formerly Inhibited Female Orgasm)
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.