Sexual classification systems are based on precise and understandable definitions of sexual dysfunctions and are needed for investigative research, determination of diagnostic standards, and delineation of treatment strategies. The four major categories of sexual dysfunctions include disorders of sexual desire/interest, arousal, orgasm, and sexual pain. The purpose of this article is to review the major features, differences, and similarities of the six classification systems widely used in sexual medicine, including the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders, the National Institute of Health Consensus Conference on Impotence, the American Foundation for Urologic Diseases, International Consensus Conference on Women’s Sexual Dysfunction, and the First and Second International Consultations on Sexual Dysfunctions. Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. J Sex Med 2007;4:241–250.
Why Do We Need Definitions?
Classification systems are extremely crucial for research, diagnostic, and management purposes. Such systems include identification and definition of conditions, which help determine diagnostic criteria and appropriate treatment options used in everyday clinical practice. Most research efforts are methodologically based on strict and clear definitions and widely accepted classification systems.
Classification Systems in Sexual Medicine
Historically, several classification systems have been proposed for sexual dysfunction. For several decades, the two most widely used classification systems for sexual dysfunctions have been the International Classification of Diseases (ICD)-10 provided by the World Health Organization (WHO)  and the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV provided by the American Psychiatric Association . The four major categories of dysfunction in both systems are desire, arousal, orgasmic, and sexual pain disorders. Both sets regard sexual dysfunctions as involving physical and psychological constituents but believe it possible to separate these.
Several initiatives have been undertaken since 1992 in order to both define and classify sexual dysfunction in a more accurate way, which reflects the revolutionary new developments in sexual medicine during the past decades. These include the National Institute of Health (NIH) Consensus Conference on Impotence (1992) , the American Foundation for Urologic Diseases (AFUD)-sponsored International Consensus Panel on women’s sexual dysfunction (2000) , as well as the 1st and 2nd International Consultation on Sexual Dysfunctions (2001 and 2004) [5–7].
The ICD-10 Classification
The classification is the latest in a series, which has its origins in the 1850s. The International Statistical Institute adopted the first edition, known as the International List of Causes of Death, in 1893. The WHO took over the responsibility for the ICD at its creation in 1948 when the sixth revision, which included causes of morbidity for the first time, was published. The ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into use in the WHO Member States as of 1994.
The ICD-10 is the international standard diagnostic classification for all general epidemiological and many health management purposes. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables, such as the characteristics and circumstances of the individuals affected. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and hospital records. In addition to enabling the storage and retrieval of diagnostic information for clinical and epidemiological purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by the WHO Member States.
The ICD-10 classification of sexual dysfunctions is reported in Appendix 1. A basic feature of the ICD-10 definitions is that sexual function per se is defined as the various ways in which an individual is able to participate in a sexual relationship as he or she wishes. The ICD-10 uses defined categories, which are subcategorized into organic (N-series) and nonorganic (F-series) dysfunctions. Several inconsistencies are built into the system; for example, the ICD-10 does not include delayed ejaculation as a category by itself, presumably regarding retarded ejaculation as equivalent to lack of orgasm. Furthermore, female arousal disorder is mainly described in terms of vaginal physiological response, while for the men, satisfactory intercourse is included in the definition of erectile dysfunction (ED).
The American Psychiatric Association publishes the DSM , which is considered the reference book for any professional who makes psychiatric diagnoses in the United States and most other countries. The DSM-IV also built upon the same model as the ICD-10. The current version is the revised IV edition (DSM-IVR). It covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, optimal treatment approaches, and prognosis. Mental health professionals use this manual when working with patients in order to better understand their illness and potential treatment, and to help third-party payers (e.g., insurance) understand the needs of the patient.
The DSM uses a multiaxial or multidimensional approach for diagnosis because it is rare that other factors in a person’s life do not affect their mental health. It assesses five dimensions/axes:
Axis I: Clinical Syndromes (e.g., depression, schizophrenia, social phobia).
Axis II: Developmental Disorders and Personality Disorders (e.g., paranoid, antisocial, and borderline personality disorders).
Axis III: Physical Conditions which play a role in the development, continuance, or exacerbation of Axes I and II Disorders.
Axis IV: Severity of Psychosocial Stressors, including events in a person’s life (e.g., death of a loved one, starting a new job, college, unemployment, and even marriage) that can impact the disorders listed in Axes I and II.
Axis V: Highest Level of Functioning, rating the person’s level of functioning at both the present time and the highest level within the previous year.
This approach helps the clinician understand how the above four axes are affecting the person and what type of changes could be expected.
The DSM-IVR includes a separate chapter dedicated to “Sexual Disorders and Dysfunctions,” including all conditions with primarily characterized impairment in normal sexual functioning, including an inability to perform or reach an orgasm, painful sexual intercourse, a strong repulsion of sexual activity, or an exaggerated sexual response cycle or sexual interest (Appendix 2). According to the classification, “a medical cause must be ruled out prior to making any sexual dysfunction diagnosis and the symptoms must be hindering the person’s everyday functioning.” When combinations of psychological and organic conditions are judged to be cause for a certain dysfunction, the DSM-IV advocates the subtype: “due to combined factors.”
Important features of the DSM-IV are the two definition (A and B) categories. The A category focuses on defining sexual disorders per se. The B category of the DSM-IV definitions adds a distress dimension to all dysfunctions: “The disturbance causes marked distress or interpersonal difficulty.” These A and B sets of definitions enable distinction of a dysfunction per se from its emotional impact (but only if marked)—intra- as well as interpersonally. The B category does not leave a possibility for inclusion of mild or sporadically occurring distress. There is currently a discussion on the adequacy of the ICD-10 and the DSM-IV definition systems. To many experts, particularly pertaining to women’s sexuality, these definitions appear too “medicalized” (see the proposed classification of the AFUD Consensus on female sexual dysfunction and the 2nd International Consultation on Sexual Medicine).
The common denominator of all is: “persistent or recurrent.” A and B categories also make the classification between lifelong vs. acquired (after a period of “normal” functioning). Moreover, the DSM-IV calls attention to another dimension, namely, whether the dysfunction is generalized/global (occurring in several different situations) vs. situational (certain situations). It is underlined that the clinical evaluation should include etiological factors. The category also includes gender identity disorder and sexual aversion disorder.
The NIH Consensus on Impotence and the AFUD International Consensus on Female Sexual Dysfunction
Several consensus panels have been organized on different issues of sexual dysfunction; two of them played important roles in the development of the field. The first was organized in 1991 by NIH in order to develop, for the first time, a definition of ED, summarize the existing level of knowledge, and identify emerging research needs. The NIH Consensus defined erectile dysfunction—the term was introduced as a substitution for the word “impotence”—as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance . This definition has been criticized because “satisfactory sexual performance” seems confusing from the clinical perspective, since it depends on multiple psychological, relationship, and intrapersonal factors.
The second consensus panel was organized by the AFUD in order to recommend a new diagnostic and classification system for women’s sexual dysfunctions, built upon a new model of women’s sexual response . Going beyond the previous differentiation between psychologic and somatic classifications, this model offered for the first time a holistic approach to care which takes into consideration interactions in women’s sexual dysfunctions. According to this perspective, impairment in sexual response or interest may not be dysfunctions per se, but adaptive reactions to problems in sexual relationships or because of intrapersonal factors. Sexual dysfunctions may be generally significantly interrelated, as it appears unsound to assume that one sexual disorder per se can be expected to be a solitary phenomenon for any given individual. However, the consensus recognized that definitions from a classification and differential diagnostic point of view remain necessary and recommended a set of definitions that includes a personal distress dimension for most of the dysfunctions (Table 1). The final classification system follows the same general structure as the DSM-IVR and the ICD-10; the four major categories of dysfunction—desire, arousal, orgasmic, and sexual pain disorders—were preserved and considered necessary to maintain continuity in research and clinical practice. On the other hand, the definitions of several disorders have been altered to reflect current clinical and research practice and a new category of sexual pain disorder, including noncoital sexual pain, has been added.
|I. Sexual desire disorders|
|A. Hypoactive sexual desire disorder|
|B. Sexual aversion disorder|
|II. Sexual arousal disorder|
|III. Orgasmic disorder|
|IV. Sexual pain disorders|
|C. Other sexual pain disorders|
The International Consultation on Sexual Medicine
The International Consultation was organized for the first time in Paris in 1999 (International Consultation on Erectile and Sexual dysfunctions) as a collaboration between the International Consultation for Urological Diseases and the major sexual medicine and urological associations, sponsored by the WHO. The 2nd Consultation took place in the same location in 2003, expanding the scope to cover both men and women’s sexual dysfunction (International Consultation on Sexual Medicine). More than 200 multidisciplinary experts from 60 different countries were involved in 17 different committees, working for 2 years to produce the current “bible” of sexual medicine, relying on evidence-based medicine principles, and officially adapting the principles of patient-centered care at the same time. The work is published in a book and in the inaugural issues of The Journal of Sexual Medicine as a series of articles condensed from the book, including two leading articles on the recommendations of the International Consultation on Sexual Dysfunction in men and women, respectively [6,7]. Several deliberations took place regarding the published definitions, which do not generally separate dysfunctions of organic and psychologic causes; because they are not mutually exclusive, they should be clarified through the etiology/diagnostic workup. The Consultation also emphasized that men’s sexual interest/desire dysfunction has, to some extent, been neglected in epidemiologic research but is quite commonly seen in clinical practice, and suggested a definition identical to the one for women. The definitions of sexual dysfunctions for women came primarily from deliberations by the work of the AFUD International Consensus Development panel.
The Consultation also discussed a classification of severity of sexual dysfunction other than the widely used scales and questionnaires (e.g., International Index of Erectile Function (IIEF), Brief Male Sexual Functioning Inventory (BSMFI), Female Sexual Function Index (FSFI)). The two-grade scale (yes/no) may be too rigorously undifferentiated and may lead to exaggeration of the severity of any given dysfunction. The four-grade (no/mild/moderate/complete) scale introduced by the Massachusetts Male Aging Study (MMAS) in describing the prevalence of ED has been widely used. Using single-question self-assessment seems appropriate, as close correlations have been found with the prevalence of ED, tapped simultaneously by the IIEF erection domain, three erectile domain items of the BSMFI, and the one four-grade item used by in the classical treatise of the prevalence of ED in the MMAS.
2nd International Consultation on Sexual Medicine: Definitions
Sexual interest/desire dysfunctions (men and women)
Diminished or absent 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 become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.
Sexual arousal dysfunctions (men)
Erectile dysfunction is defined as the consistent or recurrent inability of a man to attain and/or maintain penile erection sufficient for sexual activity. Consistency is an important component of the definition of ED. A 3-month minimum duration is accepted for establishment of the diagnosis. In some instances of trauma or surgically induced ED (e.g., post-radical prostatectomy), the diagnosis may be given prior to 3 months.
Sexual arousal disorders (women)
The area of sexual arousal disorders in women is divided into three subtypes.
Subjective sexual arousal dysfunction is the 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.
Genital sexual arousal dysfunctions: characterized by complaints of impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensation from caressing genitalia. Subjective sexual excitement still occurs from nongenital sexual stimuli.
Combined genital and subjective arousal dysfunction: characterized by absent 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).
Furthermore, persistent genital arousal dysfunction is also included in this category.
Persistent genital arousal dysfunction is defined as spontaneous, intrusive, and unwanted genital arousal, e.g., tingling, throbbing, and 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 feeling of arousal persists for hours or days.
Premature/Rapid or Early Ejaculation
It is the persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it, over which the sufferer has minimal or no voluntary control, which causes the sufferer and/or his partner bother or distress. Early ejaculation is defined according to three essential criteria: (i) brief ejaculatory latency; (ii) loss of control; and (iii) psychological distress in the patient and/or the partner. Ejaculatory latency of 2 minutes or less may qualify the diagnosis, which should include consistent inability to delay or control ejaculation, and marked distress about the condition. Subtypes of the disorder include lifelong vs. acquired, global vs. situational, and the co-occurrence of other sexual problems, primarily ED. Attention should be paid that many men are unaware that loss of erection after ejaculation is normal; thus, they may erroneously complain of ED when the actual problem is early ejaculation.
Men’s orgasmic dysfunction
Men’s orgasmic dysfunction includes a spectrum of disorders in men ranging from delayed ejaculation to a complete inability to ejaculate, anejaculation, and retrograde ejaculation.
Delayed ejaculation is undue delay in reaching a climax during sexual activity.
Orgasmic dysfunction is inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations or marked delay of orgasm from any kind of sexual stimulation.
Anejaculation is the absence of ejaculation during orgasm.
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.
Women’s sexual pain disorders
Dyspareunia is persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.
Vaginismus is 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, involuntary pelvic muscle contraction, and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed.
Sexual aversion disorder (men and women)
Sexual aversion disorder is defined as extreme anxiety and/or disgust at the anticipation of or attempt to have any sexual activity.
Priapism is defined as an unwanted erection not associated with sexual desire or sexual stimulation that lasts longer than 4 hours. Three different types of priapism can be distinguished, although there may be some overlap between categories: (i) low-flow or ischemic priapism; (ii) high-flow, well-oxygenated priapism; and (iii) recurrent or stuttering priapism, which is usually high-flow but may become low-flow and anoxic.
Peyronie’s disease, named after the French physician Francois de la Peyronie, is an acquired disorder of the tunica albuginea, characterized by the formation of a plaque of fibrous tissue and often accompanied by penile pain, deformity on erection, and ED. It should be differentiated from localized cavernous fibrosis associated with direct trauma to the corpus, injury from fractured penis, or damage to the cavernous tissue (e.g., after intracavernosal injection).
ICD-10 Classification of Sexual Dysfunction
|N48.4||Impotence of organic origin|
|Excludes: psychogenic impotence (F52.2)|
|F52||Sexual dysfunction, not caused by organic disorder or disease|
|Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. Sexual response is a psychosomatic process and both psychological and somatic processes are usually involved in the causation of sexual dysfunction.|
|Excludes: Dhat syndrome (F48.8) (neurotic disorder)|
|F52.0||Lack or loss of sexual desire|
|Loss of sexual desire is the principal problem and is not secondary to other sexual difficulties, such as erectile failure or dyspareunia.|
|Hypoactive sexual desire disorder|
|F52.1||Sexual aversion and lack of sexual enjoyment|
|Either the prospect of sexual interaction produces sufficient fear or anxiety that sexual activity is avoided (sexual aversion) or sexual responses occur normally and orgasm is experienced but there is a lack of appropriate pleasure (lack of sexual enjoyment).|
|F52.2||Failure of genital response|
|The principal problem in men is erectile dysfunction (difficulty in developing or maintaining an erection suitable for satisfactory intercourse). In women, the principal problem is vaginal dryness or failure of lubrication.|
|Female sexual arousal disorder|
|Male erectile disorder|
|Excludes: impotence of organic origin (N48.4)|
|Orgasm either does not occur or is markedly delayed.|
|Inhibited orgasm (male) (female)|
|The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction.|
|Spasm of the pelvic floor muscles that surround the vagina, causing occlusion of the vaginal opening. Penile entry is either impossible or painful.|
|Excludes: vaginismus (organic) (N94.2)|
|Dyspareunia (or pain during sexual intercourse) occurs in both women and men. It can often be attributed to local pathology and should then properly be categorized under the pathological condition. This category is to be used only if there is no primary nonorganic sexual dysfunction (e.g., vaginismus or vaginal dryness).|
|Excludes: dyspareunia (organic) (N94.1)|
|F52.7||Excessive sexual drive|
|F52.8||Other sexual dysfunction, not caused by organic disorder or disease|
|F52.9||Unspecified sexual dysfunction, not caused by organic disorder or disease|
DSM-IV Classification: Sexual Disorders and Dysfunctions
Gender Identity Disorder
A strong and persistent identification with the opposite gender. There is a sense of discomfort in their own gender and may feel they were “born the wrong sex.” This has been confused with cross-dressing or transvestic fetishism, but all are distinct diagnoses. Other mental disorders may be present, e.g., depression, anxiety, relationship difficulties, and personality disorders, while homosexuality is commonly present.
Sexual Aversion Disorder
Persistent or recurring aversion to or avoidance of sexual activity, which results in significant distress for the individual and is not better accounted for by another disorder or physical diagnosis.
Hypoactive Sexual Desire Disorder
“Deficient or absent sexual fantasies and desire for sexual activity,” that “result in significant distress for the individual and is not better accounted for by another disorder or physical diagnosis.” The course of this disorder can be consistent or periodic, and can therefore resurface after a period of remission if relationship or life stressors re-emerge.
Male Erectile Disorder (Impotence)
“Recurring inability to achieve or maintain an erection until completion of the sexual activity, which results in significant distress for the individual and is not better accounted for by another disorder (e.g., drug abuse) or physical diagnosis.” Previously referred to as impotence, medical causes of this disorder must be ruled out first. Short of any physiological cause, male erectile disorder is typically a result of “performance anxiety” or fears of not being able to achieve or maintain an erection.
Female Sexual Arousal Disorder
Inability to attain or maintain adequate lubrication in response to sexual excitement until completion of sexual activity, which results in significant distress and is not better accounted for by another disorder or the use of a substance.
Recurrent or persistent genital pain associated with sexual intercourse. Can be diagnosed in males or females, is not better accounted for by another diagnosis (psychiatric or physical), and is not the direct effect of substance use.
There is a relationship of this disorder with victims of rape and sexual abuse. May also be related to vaginismus.
Recurrent or persistent involuntary spasm of the vaginal muscles that interferes with sexual intercourse. It must cause significant distress and must not be due to a medical condition or another disorder. There is a relationship of this disorder with victims of rape and sexual abuse, strict religious upbringings, and issues of control.
Female Orgasmic Disorder
Delay of orgasm following normal excitement and sexual activity. Due to the widely varied sexual response in women, it must be judged by a clinician to be significant, and the person’s age and situation must be taken into account. The condition is persistent or occurs frequently and causes significant distress. Is not a direct effect of substance use. Some research suggests that womens’ failure to achieve an orgasm is related to intimacy issues, feelings of fear and anxiety, and a sense of not being safe within the intimate relationship or relationships in general.
Male Orgasmic Disorder
Delay or absence of orgasm following normal excitement and sexual activity. Due to the widely varied sexual response in men, it must be judged by a clinician to be significant, taking into account the person’s age and situation. The condition is persistent or occurs frequently and causes significant distress. Is not a direct effect of substance use.
Although a medical cause needs to be ruled out first, male orgasmic disorder is often thought of as beginning in adolescence or early adulthood because sexual intimacy becomes related with a negative life event or aspect.
Ejaculation with minimal sexual stimulation before or shortly after penetration and before the person wishes it. The condition is persistent or occurs frequently and causes significant distress. Is not a direct effect of substance use.
Medical causes must be ruled out first. Relationship stress, novelty of a relationship, anxiety, and issues related to control and intimacy can all play a role in the development of this disorder.
AFUD Consensus Definitions of Women’s Sexual Disorders and Dysfunctions
Hypoactive Sexual Desire Disorder is the persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress. Sexual aversion disorder is the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.
Sexual Arousal Disorder is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses.
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 the recurrent or persistent genital pain associated with sexual intercourse.
Vaginismus is the 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 Disorder is recurrent or persistent genital pain induced by noncoital sexual stimulation.
CME Multiple Choice Questions
For each of the following questions, please circle the correct answer.
Why do we need classification system and definitions of sexual dysfunction?
- 1For research purposes
- 2For diagnostic purposes
- 3For considering appropriate treatment options
- 4For statistical purposes
- 5All the above
Which is the most widely accepted classification system in the world of sexual medicine?
- 1The ICD-10
- 2The DSM-IVR
- 3The AFUD International Consultation classification system
- 4The one proposed by the International Consultation on Sexual Medicine
- 5All the above
Which one of the following categories is not considered solely as a sexual dysfunction category?
- 1Sexual desire disorders
- 2Sexual arousal disorders
- 3Gender identity disorders
- 4Orgasmic disorders
- 5Sexual pain disorders
Which of the following categories was introduced by the AFUD International Consensus development on Female Sexual Dysfunction?
- 1Hypoactive sexual desire disorder
- 2Erectile dysfunction
- 3Noncoital sexual pain
What is considered important in defining the presence of a sexual complaint?
- 1The objective diagnostic criteria of the dysfunction
- 2The opinion of the physician according to his clinical experience
- 3The complaint of the partner (self-reported)
- 4The personal distress dimension of the reported dysfunction
- 5None of the above
Erectile dysfunction is defined as the consistent or recurrent inability of a man to attain and/or maintain penile erection sufficient for
- 1Satisfactory sexual performance
- 2Satisfactory sexual intercourse
- 3Sexual activity
- 4Sexual satisfaction of the partner
- 5All the above
Which of the following is NOT a common denominator of most sexual dysfunctions?
- 1Persistent/recurrent vs. sporadic
- 2Lifelong vs. acquired
- 3Generalized/global vs. situational (certain situations)
- 4Pure psychogenic vs. pure organic
- 5All of the above
The most widely used classification of the severity of a sexual dysfunction is
- 1A two-grade scale (yes/no)
- 2A three-grade scale (mild/moderate/severe)
- 3A four-grade scale (no/mild/moderate/complete)
- 4A five-grade scale (no/recurrent/lifelong/situational/persistent)
- 5None of the above
Women’s sexual arousal dysfunction includes
- 1Subjective sexual arousal
- 2Genital sexual arousal dysfunctions
- 3Combined genital and subjective arousal dysfunction
- 4Persistent genital arousal dysfunction
- 5All the above
Dyspareunia is defined as
- 1Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse
- 2Persistent 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
- 3Delay of orgasm following normal excitement and sexual activity
- 4Recurrent or persistent genital pain induced by noncoital sexual stimulation
- 5Persistent or recurring aversion to or avoidance of sexual activity
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