Beverly Whipple, PhD, RN, FAAN and Annette Fuglsang Owens, MD, PhD
Definitions of men’s and women’s sexual disorders are reconsidered as new research findings emerge. This article serves to summarize the most recent efforts to develop a terminology and concepts for identifying various sexual problems concerning women.
The term sexual disorders is preferred for women rather than sexual dysfunctions. This terminology was recommended at the World Association for Sexual Health World Congress held in Montreal in 2005. In this article, sexual dysfunctions will be used in its historical context.
The current classification of sexual disorders (Table 1) in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), or DSM-IV-TR, is based on an older, linear model of human sexual response, which describes a sequence of mainly genitally focused events (desire, arousal, orgasm) (Kaplan, 1979; Masters & Johnson, 1966). The concept of the linear model was based on research conducted on males and does not fit well with female sexual responses (Basson, 2001a, 2001b, 2006; Sugrue & Whipple, 2001; Tiefer, 1988). Hence, the current DSM – IV-TR guidelines for classification and diagnosis of sexual disorders are not as appropriate when it comes to addressing and/or diagnosing female sexual disorders as they are with male sexual “dysfunctions.”
Two international consensus development conferences were held in 1998 and in 2003 in order to revise the definitions for women’s sexual dysfunction. The first consensus panel was convened prior to the 1998 meeting of the Female Sexual Function Forum (FSFF), now named the International Society for the Study of Women’s Sexual Health (ISSWSH). This consensus panel consisted of 19 interdisciplinary experts in female sexual dysfunction from five countries. The goal of the consensus development conference was to evaluate and revise the existing DSM definitions and classifications of female sexual dysfunction as well as those from the World Health Organization’s International Statistical Classification of Disease and Related Health Problems-10 (ICD-10) from a psychogenic and organic perspective and to provide clinical end points and outcomes for research and therapy. The 1998 consensus classification is summarized in Table 2 (Basson et al., 2000).
Although, as compared to the DSM and ICD-10 guidelines, “personal distress” was added as a criterion, and a new category of noncoital sexual pain disorder was added, these guidelines were not readily accepted (Sugrue & Whipple, 2001). One of the main problems with this classification of female sexual dysfunction was that it is based on the triphasic functional pattern of desire, arousal, and orgasm. This is the sexual response that was described by Masters and Johnson and later modified by Kaplan (Kaplan, 1979; Masters & Johnson, 1966).
Although the triphasic model has widespread acceptance, it is based on the male linear model of sexual function, which may not describe the sexual experience of women. Women can experience sexual arousal, orgasm, and satisfaction without sexual desire, and they can experience desire, arousal, and satisfaction without orgasm. If a woman has sexual satisfaction and does not go through all of the linear phases of the sexual response cycle, should she be considered as having a sexual dysfunction? In addition, this model does not take into account the documented variety of ways that women respond sexually (Whipple, 2002).
Nonlinear models of sexual response have been proposed by Whipple and Brash-McGreer (1997) based on Reed’s model and Basson (2001a, 2001b). These various models are further discussed in the Association of Reproductive Health Professionals’ (ARHP) Clinical Proceedings (2005).
Following the first consensus development meeting, Sugrue and Whipple (2001) pointed out the need to begin with identifying and defining what is normal before any pathology can be discussed:
“One could argue that based on what women report to researchers, clinicians, and peers, normal sexual function for a woman, free of physical or psychological impediments, would include:
- capacity to experience pleasure and satisfaction independent of the occurrence of orgasm;
- desire or receptivity to experience sexual pleasure and satisfaction;
- physical capability of responding to stimulation (vasocongestion) without pain or discomfort;
- capability of experiencing orgasm under suitable circumstances (the desire to orgasm, lack of distraction, effective stimulation, erotic focus, and so forth).If the above descriptors, or ones similar to them, were viewed as characteristic of normal sexual function, then the persistent absence or modification of any of the above descriptors would constitute a sexual dysfunction.” (p. 224)
The Second International Consultation on Sexual Medicine was held in Paris in July of 2003. An International Definitions Committee of 13 experts from seven countries proposed a number of fundamental changes to the existing definitions of women’s sexual disorders and presented their new definitions, which are summarized in Table 3 (Basson et al., 2004). A more thorough discussion of the evolution of these models can be found in the ARHP’s Clinical Proceedings (2005).
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
- Association of Reproductive Health Professionals. (2005). Women’s sexual health in midlife and beyond. Association of Reproductive Health Professionals Clinical Proceedings. Washington, DC: Association of Reproductive Health Professionals.
- Basson, R., Berman, J., Burnett, A., Degrogatis, L., Ferguson, D., Foucroy, J., Goldstein, I., Graziottin, A., Heiman, J., Laan, E., Leiblum, S., Padma-Nathan, H., Rosen, R., Segraves, K., Segraves, R. T., Shabsigh, R., Sipski, M., Wagner, G., & Whipple, B. (2000). Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications. Journal of Urology, 163, 888–893.
- Basson, R. (2001a) Human sex-response cycles. Journal of Sex & Marital Therapy, 27, 33–43.
- Basson R. (2001b). Female sexual response: The role of drugs in the management of sexual dysfunction. Obstetrics and Gynecology, 98, 350–353.
- Basson, R., Leiblum, S., Brotto, L., Derogatis, L., Fourcroy, J., Fugl-Meyer, K., et al. (2004). Revised definitions of women’s sexual dysfunction . Journal of Sexual Medicine, 1 (1), 40–48.
- Basson, R. (2006). Sexual desire and arousal disorders in women. New England Journal of Medicine, 354, 1497–1505.
- Kaplan, H. S. (1979). Disorders of sexual desire. New York: Brunner/Mazel.
- Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown & Co.
- Sugrue, D. P., & Whipple, B. (2001). The consensus-based classification of female sexual dysfunction: Barriers to universal acceptance. Journal of Sex & Marital Therapy, 27, 221–226.
- Tiefer, L. (1988). A feminist critique of the sexual dysfunction nomenclature. Women and Therapy, 7, 5–21.
- Whipple, B. (2002). Women’s sexual pleasure and satisfaction: A new view of female sexual function. The Female Patient (Primary Care Edition), 27 (8), 39–44; and (OB/GYN Edition) 2, (8), 44–47.
- Whipple, B., & Brash-McGreer, K. (1997). Management of female sexual dysfunction. In M. L. Sipski & C. Alexander (Eds.), Sexual function in people with disability and chronic illness: A health professional’s guide (pp. 511–536). Gaithersburg, MD: Aspen Publishers.
- World Health Organization. (1992). ICD 10: International statistical classification of disease and related health problems. Geneva: World Health Organization.
Table 1 : DSM-IV-TR Sexual Dysfunctions
Sexual Desire Disorders
Hypoactive Sexual Desire Disorder
Sexual Aversion Disorder
Sexual Arousal Disorders
Female Sexual Arousal Disorder
Male Erectile Disorder
Female Orgasmic Disorder
Male Orgasmic Disorder
Sexual Pain Disorders
Sexual Dysfunction Due to a General Medical Condition
Female Hypoactive Sexual Desire Disorder Due to**
Male Hypoactive Sexual Desire Disorder Due to**
Male Erectile Disorder Due to**
Female Dyspareunia Due to**
Male Dyspareunia Due to**
Other Female Sexual Dysfunction Due to**
Other Male Sexual Dysfunction Due to**
Substance-Induced Sexual Dysfunction
Sexual Dysfunction NOS (Not otherwise specified)
The following specifiers apply to all primary sexual dysfunctions:
Lifelong Type/Acquired Type
Generalized Type/Situational Type
Due to Psychological Factors/Due to Combined Factors
* (Not Due to a General Medical Condition)
** (Indicate the General Medical Condition)
Source: American Psychiatric Association, (2000), Diagnostic and statistical manual of mental disorders (4th ed., text revision) (Washington, DC: American Psychiatric Association), pp. 22–23.
Table 2 : First International Consensus Development Conference Definitions of Women’s Sexual Dysfunction (1998)
Sexual desire disorders include:
A. Hypoactive sexual desire disorder (HHSD), defined as the persistent or recurrent defi-ciency (or absence) of sexual fantasies and/or desire for, or receptivity to, sexual activity, which causes personal distress.
B. Sexual aversion disorder (SAD), defined as the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.
Female sexual arousal disorder (FSAD) is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as a lack of subjective excitement or a lack of genital lubrication/swelling or other somatic response.
Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.
Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse, which causes personal distress.
Vaginismus is recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.
Noncoital Sexual Pain
Noncoital sexual pain disorder is recurrent or persistent genital pain induced by noncoital sexual stimulation, which causes personal distress.
Source: Basson et al., (2000), Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications, Journal of Urology , 163, 888–893.
Table 3 : Second International Consensus Development Conference Definitions of Women’s Sexual Dysfunction (2003)
Women’s Sexual Interest/Desire Disorder. There are absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations (here defined as reasons/incentives) for attempting to have sexual arousal are scarce or absent. The lack of interest is considered to be beyond the normative lessening with life cycle and relationship duration.
Subjective Sexual Arousal Disorder. Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.
Combined Genital and Subjective Arousal Disorder. Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).
Genital Sexual Arousal Disorder. Complaints of absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital stimuli.
Persistent Sexual Arousal Disorder. Previously considered extremely rare, the complaint of intrusive spontaneous genital throbbing unrelieved with orgasm is being increasingly encountered in clinical practice. Therefore, the committee proposed the following definition.
Spontaneous intrusive and unwanted genital arousal (e.g., tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically, but not invariably, unpleasant. The arousal is unrelieved by one or more orgasms and the feelings of arousal persist for hours or days.
Women’s Orgasmic Disorder. Despite the self-report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation.
Vaginismus. The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is often (phobic) avoidance and anticipation/fear/experience of pain, along with variable involuntary pelvic muscle contraction. Structural or other physical abnormalities must be ruled out/addressed.
Dyspareunia. Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.
Source: Basson et al. (2004), Revised definitions of women’s sexual dysfunction, Journal of Sexual Medicine, 1 (1), 45.