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THE JOURNAL OF UROLOGY® Vol. 163, 888 – 893, March 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.



Purpose: Female sexual dysfunction is highly prevalent but not well defined or understood. We
evaluated and revised existing definitions and classifications of female sexual dysfunction.
Materials and Methods: An interdisciplinary consensus conference panel consisting of 19
experts in female sexual dysfunction selected from 5 countries was convened by the Sexual
Function Health Council of the American Foundation for Urologic Disease. A modified Delphi
method was used to develop consensus definitions and classifications, and build on the existing
framework of the International Classification of Diseases-10 and DSM-IV: Diagnostic and Sta-
tistical Manual of Mental Disorders of the American Psychiatric Association, which were limited
to consideration of psychiatric disorders.
Results: Classifications were expanded to include psychogenic and organic causes of desire,
arousal, orgasm and sexual pain disorders. An essential element of the new diagnostic system is the
“personal distress” criterion. In particular, new definitions of sexual arousal and hypoactive sexual
desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In
addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points
and outcomes were proposed, and important research goals and priorities were identified.
Conclusions: We recommend use of the new female sexual dysfunction diagnostic and classi-
fication system based on physiological as well as psychological pathophysiologies, and a personal
distress criterion for most diagnostic categories.
KEY WORDS: sexual dysfunctions, psychological; female; guidelines; classification; Delphi technique

Female sexual dysfunction is a multicausal and multidi- development of clinical research and practice has been the
mensional problem combining biological, psychological and absence of a well defined, broadly accepted diagnostic frame-
interpersonal determinants. It is age related, progressive work and classification for female sexual dysfunction.
and highly prevalent, affecting 20% to 50% of women. Based Nosological and diagnostic classifications have varied
on epidemiological data from the National Health and Social among different diagnostic systems.2, 3 According to the
Life Survey a third of women lack sexual interest and nearly World Health Organization International Classifications of
a fourth do not experience orgasm.1 Approximately 20% of Diseases-10 (ICD-10) the definition of sexual dysfunction
women report lubrication difficulties and 20% find sex not includes “the various ways in which an individual is unable
pleasurable. Female sexual dysfunction has a major impact to participate in a sexual relationship as he or she would
on quality of life and interpersonal relationships. For many wish.”4 Specific categories in the nomenclature include a lack
women it has been physically disconcerting, emotionally dis- or loss of sexual desire (F52.0), sexual aversion disorder
tressing and socially disruptive. (F52.1), failure of genital response (F52.2), orgasmic dysfunc-
In contrast to the widespread interest in research and tion (F52.3), nonorganic vaginismus (F52.5), nonorganic dys-
treatment of male sexual dysfunction, less attention has been pareunia (F52.6) and excessive sexual drive (F52.7).
paid to the sexual problems of women. Few studies have In contrast, the DSM-IV: Diagnostic and Statistical Man-
investigated the psychological and physiological underpin-
ual of Mental Disorders (DSM-IV) of the American Psychiat-
nings of female sexual dysfunction and fewer treatments are
ric Association, which is specifically limited to psychiatric
available for women than for men. A major barrier to the
disorders, concerns nomenclature for mental disorders and
was not intended to be used for classification of organic
Accepted for publication October 1, 1999. causes of female sexual dysfunction.5 In the DSM-IV sexual
Supported by the Sexual Function Health Council of the American
Foundation for Urologic Disease through educational grants provided dysfunctions are defined as “disturbances in sexual desire
by Affiliated Research Centers, Eli Lilly/ICOS Pharmaceuticals, Pen- and in the psychophysiological changes that characterize the
tech Pharmaceuticals, Pfizer Inc., Procter & Gamble, Schering-Plough, sexual response cycle and cause marked distress and inter-
Solway Pharmaceuticals, TAP Pharmaceuticals and Zonagen. personal difficulty.” Disorders in women include hypoactive
* Financial interest and/or other relationship with Affiliated Re-
search Centers, Astra, Bayer AG, Bristol-Myers Squibb, Eli Lilly, sexual desire (302.71), sexual aversion (302.79), female
Fournier Group, Glaxo Wellcome, Lilly/ICOS, Matrix Pharma, arousal disorder (302.72), female orgasmic disorder (302.73),
NexMed, NitroMed, Pentech, Pfizer Inc., Pfizer Canada Ltd., Pfizer dyspareunia (302.76) and vaginismus (306.51). The DSM-IV
UK, Pharmacia & Upjohn, Proctor & Gamble, Schering-Plough,
Senetek, Shwarz-Pharma, Solvay Pharmaceuticals, Syntec, Syntex, provides outcome criteria of “causes marked distress” and
TAP Pharmaceuticals, Vivus and/or Zonagen. “interpersonal difficulty” compared to the broader ICD-10

including endocrinology. pathophysiology. Median rating was used as a of female sexuality. them. Equivocal biannual meeting of the International Society of Impotence definitions were those with ratings in the 4 to 6-point range Research in Amsterdam in August 1998. and function. A definition was Council of the American Foundation for Urologic Disease. pharmacology. psychology. epidemiology. and not the position of the society that may have nominated opment Conference on Female Sexual Dysfunction. Nominations were provided by specialty societies. Before the confer- some cases. a high degree of overlap or co. The 19 panelists from Canada. of disciplinary backgrounds. rehabilitation medicine and urology. men with a preponderant discussion of organic causes and Subsequently the panel began consensus deliberations in- physical determinants for erectile dysfunction. are typically diagnosed indepen. development of appropriateness scales dysfunction that would include psychogenic and organically and panel preparation. Panel co-chairs were selected. Recently an international appropriateness of use of clinical procedures or diagnostic multidisciplinary consensus development conference on fe. 9 This model emphasizes tors with representation from academic and private practice that sexual response involves a temporal sequencing and coor. orgasm and satisfaction. medicine. settings. The advantages classifications of female sexual dysfunction. The consensus statement Criteria for diagnostic decision making were evaluated had immediate and far reaching effects in shaping the direc. and opment Conference on Impotence set the research agenda for strengths and weaknesses of existing diagnostic systems. ton consisted of closed session deliberations and involved dently of etiology. and Research on the causes and treatment of female sexual is designed to develop consensus guidelines regarding the dysfunction has lagged far behind. and a modified Delphi technique for based disorders. Italy.13 thesizes the opinions of clinicians and research experts. definitions and a classification system for female sexual dys- comprehensive review of etiology and pathophysiology. The resulting guidelines ment. 11 A cerning physiology. A clinical definition or diagnosis was considered ap- propriate when there was sufficient consensus.6. and somatic components (ICD-10).14 The care model for patient assessment and treatment. decision making. agenda and list of objectives were also provided in advance. 15 It syn- treatment algorithm. fication system for female dysfunction that would parallel the The meeting began with a review of current epidemiological clinical and basic science developments for men. including approach is widely referred to as the Rand method for med- an emphasis on educational interventions and a step care ical decision making and technology assessment.8. particularly con- larly in recent prevalence studies of female dysfunction. group discus- for clinical evaluation and end points. Panel consensus voting was used to decide The first Consensus Development Panel on Female Sexual whether a particular definition or diagnosis was appropriate Dysfunction was convened by the Sexual Function Health for a homogeneous category of patients. disorders. as the method draws on evaluated scientific information as well as current research a broad base of clinical and research data available at assess- and clinical practice in the field. It may be useful to develop a classi. knowledge gaps and priorities for future research.12. with a modified Delphi method. Each panelist fulfilled the aforementioned criteria and is arate diagnostic category of “sexual dysfunction due to a gen. and identify critical sion and reevaluation of the resulting consensus guidelines. Furthermore. and readings on female sexual dysfunction. On ing was required. The final panel response cycle model first described by Masters and Johnson. The overall aim was or when panelists disagreed on the proper rating. FEMALE SEXUAL DYSFUNCTION 889 outcome criterion of “being unable to participate in a sexual All panelists were selected on the basis of research or relationship as he or she would wish. ence all panelists were provided with a complete bibliography morbidity has been noted among the sexual disorders. To composition of the consensus panel were established. The meeting duration was more than 15 hours. the other hand.12 The major volving use of the Rand methodology for development of new findings included a new definition of erectile dysfunction. guidelines for clinical diagnosis. currently involved in research or treatment of female sexual eral medical condition” for sexual problems diagnosed as exclu. tages of the human sexual response cycle model. and au- The ICD-10 and DSM-IV rely heavily on the human sexual thorship of key publications was considered. The principal disadvantages are the limitations of were intended to be used by health care professionals and the currently available data and the subjective nature of the general public. diagnosis and treatment. The dination of several phases. and the format and sures of agreement and disagreement were also tabulated. which was based on group ratings on a 9-point scale of clinical appro- METHODS priateness. definition. family both systems are based on the conceptualization of sexual re. sexual disorders. Fundamental elements in- based definition and classification system for female sexual clude panel selection. 10.1. Panelists were invited to base judgments on personal views scribe the results of the first International Consensus Devel. 7 comprised leading European and North American investiga- and later elaborated on by Kaplan. Denmark. A specific goal was to develop a consensus group decision making process. and develop a conference format measure of the central tendency of panelist ratings. including sexual desire (libido). Netherlands and the United States represented a wide range arousal (excitement). to identify a multidisciplinary group of experts in the field All ratings were confidential. gynecology.15 By drawing on the clinical knowledge and male sexual dysfunction was convened to begin to address experience of experts the process provides detailed clinical the shortcomings and problems associated with previous guidelines for a broad range of situations. Mea- and agenda. We de.14. advantages and disadvan- The 1992 National Institutes of Health Consensus Devel. This consensus development tion of research in basic and industry related studies of male method involves intensive review of a specific topic area by sexual dysfunction. We reviewed and are cost-effectiveness and timeliness. classifica- diagnostic system that is applicable in medical and mental tion. in defining sexual dysfunction. physiology. Other objectives were to develop guidelines decision making and consensus development. The DSM-IV provides a sep. Since the approval of sildenafil a more an expert panel. nursing. obtain definitions that panelists accepted as reasonable the . sponse as a “psychosomatic process” involving psychological psychiatry. which may be largely or entirely organic in several key decision making components. The consensus panel meeting on October 22. particu. 13 data on female sexual dysfunction. such as erectile dysfunction. Furthermore.” In different ways both clinical expertise in female sexual dysfunction as well as systems recognize the need for a subjective distress criterion their position as “thought leaders” in this emerging field. 1998 in Bos- dyspareunia and vaginismus. structured group discussion and consensus recent consensus panel has recommended use of a process of voting according to a strict mathematical formula. A meeting health settings is needed. An deemed clearly appropriate if the median rating was 7 to 9 initial planning meeting was held in conjunction with the and clearly inappropriate if it was 1 to 3 points. Full attendance at the consensus conference meet- sively due to the physiological effects of a medical condition.

the published questionnaires general structure as the DSM-IV and ICD-10. demonstrating adequate partner. Validation of these absence) of sexual fantasies/thoughts. B— generalized versus situational type and tant for future development. 19 The method is best suited for within other somatic responses. careful control of stimulus conditions and response variables delay in or absence of attaining orgasm following sufficient is maintained. subject. which causes personal dis.16. Major drawbacks ability to attain or maintain sufficient sexual excitement. is shown in the were developed before the current classification and do not Appendix. For example. there appears to be signifi. or genital (lubrication/swelling) or movement artifacts. Female sexual dysfunction Subtyping is based ideally on the best available evidence is an under researched and poorly understood area.1 sexual problems in women. End points and outcomes. disorders. causing personal distress. To date there are no standardized measures of distress Each of these diagnoses is subtyped as A—lifelong versus related to sexual dysfunction in women. might be a useful overall outcome index. sexual dysfunction. 17 However. laboratory tests and physical ex. New questionnaire and Definitions. which causes personal distress. ing measures of clitoral and labial temperature and oxygen- Sexual Pain Disorders: Dyspareunia is the recurrent or ation. Several questionnaire measures of female sexual function RESULTS are available in the literature and some meet basic psycho- The final classification system. It is noteworthy that some women with Epidemiological research on the prevalence. Further standardization and validation of these been added. A maximum of 2 votes was per. the . proaches have been proposed and are in development. given that common years and did not include a detailed clinical evaluation. This task is not simple.18. Recognizing the broad be based in part on history of sexual difficulties as well as need for basic and applied research in the area. Anatomical studies are needed to delineate more precisely cant co-morbidity among diagnostic categories (for example the pathway of vital nerves. arousal. A composite measure of sexual response. the diagnosis of vaginismus would tent theme of the panel deliberations. none has been adequately of the musculature of the outer third of the vagina that validated or standardized in patients or healthy controls. For clinical trials it is necessary A recent study indicated that sexual dysfunction is highly to specify clear end points and outcomes for female sexual prevalent in women but was limited to those younger than 60 dysfunction. predictors and vaginismus are able to tolerate speculum insertion. a measurable decrease in personal distress as well as im- provement in overall sexual satisfaction. that is desire. vaginal and clitoral Doppler and blood flow measures. healthy and sexually dysfunctional women. which follows the same metric criteria. and a new category of secondary end points. persistent genital pain associated with sexual intercourse. of adequate experimental or clinical trial data was a consis- amination. depending on the study design and sexual pain disorder. particularly measures of personal dis- sistent genital pain induced by noncoital sexual stimulation. Accordingly. innovative nerve sparing operative approaches during pelvic Clinical trial research in female sexual dysfunction is in surgery. which may be expressed as a lack wide individual differences and potential susceptibility to of subjective excitement. including noncoital sexual pain. For sexual If no agreement was reached. (subjective arousal) responses to sexual stimulation. event logs and patient diary ity in research and clinical practice. mixed. thoughts or fantasies about sexual activity. Research needs and priorities. measures are strongly recommended. The lack from the medical history.890 FEMALE SEXUAL DYSFUNCTION extreme low and high scores were excluded from the median be based on the consensus conference definitions. Another concept for agreement was that ratings active sexual desire disorder clinical end points should in- needed to be clustered in any 3-point range. arterial inflow and venous drain- desire. arousal. orgasm. and/or desire for or instruments should be conducted before or in conjunction receptivity to sexual activity. such as low desire and anorgas. tress. psychogenic. which was considered necessary to maintain continu. interferes with vaginal penetration. repeat measures designs (phase II trials) in which Orgasmic Disorder is the persistent or recurrent difficulty. described in the DSM-IV and ICD-10 were pre. ical components. which causes personal Quality of life measures are important in clinical trials of distress. the earliest stages. C— etiologic origin (organic. outcomes of sexual dysfunction in women is urgently needed. For future trials end points should women are poorly understood at present. function. which causes personal distress. This area is impor- acquired type. Other self-report measures described in the literature in- served. Expert panel review and sub. Further epidemiological studies are needed and should be mia. there are no widely used or Biological mechanisms of sexual arousal and orgasm in standardized end points. Global assessments of efficacy are also used in definitions of several disorders have been altered to reflect many clinical trials. if statistically understanding of the sexual response. Sexual Desire Disorders: Hypoactive sexual diary measures are in development and hopefully will be desire disorder is the persistent or recurrent deficiency (or available shortly for use in clinical trials. the panel patient inability to tolerate insertion of a speculum during a identified major themes or topics for further research. the methods. even if the range clude measures of receptivity to as well as spontaneous straddled the appropriateness categories defined previously. further discussion occurred arousal disorder in women clinical end points should include and the vote was retaken.20 Despite the obvious interest and appeal Vaginismus is the recurrent or persistent involuntary spasm of these alternative measures.10 Additionally. pelvic examination. and are potentially useful as primary or current clinical and research practice. On the other hand. swelling) and central mitted on any specific issue. includ- tress. Several other physiological measurement ap- sexual stimulation and arousal. and vaginometry. with ongoing clinical trials. Specific meas- dysfunction. This knowledge may not only improve physiological nosis. validity and reliability in psychophysiological studies of Sexual Arousal Disorder is the persistent or recurrent in. Noncoital sexual pain disorder is recurrent or per. include the absence of an absolute standard of measurement. but also may lead to sound. Sexual aversion disorder is the persistent or recurrent phobic To date vaginal photoplethysmography has been the most aversion to and avoidance of sexual contact with a sexual widely used physiological measure. orgasmic and sexual pain ures of personal distress are not included in these measures. It is noteworthy that the 4 major categories of address some aspects of current definitions. unknown). based on the consensus definitions of sexual dysfunction. For hypo- calculation. committee deliberations were held before preparation of the Changes in sexual responsiveness should be associated with final report. has trial setting. frequently involve overlapping subjective and physiolog. measures of peripheral (lubrication. sexual pain disorders) which is not age of the multiple organs involved in normal female sexual always classifiable according to a primary or secondary diag. clude structured interviews. For example.

controlled outcome studies of in recognizing that sexual activity for women need not nec- psychosexual counseling for various indications are strongly essarily involve penile vaginal intercourse and the category indicated. Likewise. Parameters should include but nition of “failure of genital response. vaginal lubrication and vag. Hypoactive given. The definition of sexual arousal disorder was expanded to tive concomitants of arousal in women. This new category is also important functions in women. Most physi. genital A new category of noncoital sexual pain disorder was added engorgement. made via clinical interview or standardized questionnaire. Clinician assessment of personal distress involves query- ing the patient about the level of dissatisfaction or bother DISCUSSION concerning the sexual difficulty. 11 A particularly and that she is still able to enjoy sexual relations strong need has been identified for new definitions and clas. a woman who Female sexual dysfunction is a highly prevalent condition. It was The relationship among sexual dysfunction in women. genital (lubrication/swelling) or other somatic responses. thus. Although inclusion of a personal distress criterion for most of the there is evidence that psychological sex therapy interven. or during menstruation). has not been adequately studied. 10 However. The safety and effectiveness of specific treatments of sexual pain disorder may apply to nonheterosexual women in defined patient populations (for example postmenopausal. seldom reaches orgasm may report that it does not bother her affecting up to 40% of women in the United States. the proposed ing adequate sexual functioning. In these instances a diagnostic criteria. reaction of the sexual partner may be a cause of concern or served. some women do not view low sification of female sexual dysfunction as well as a new set of sexual desire as a personal problem. Further research on this of satisfaction with their sexual relationship. While the major categories absence of personal distress on the part of the patient. nomenclature for mental conditions and. post-cancer therapy) remain to be evaluated. only minimally understood at present. which is to be applied to recur- inal elasticity. FEMALE SEXUAL DYSFUNCTION 891 neurophysiology of the female sexual response. comparable age and socioeconomic status. post-hysterectomy or other pelvic surgery. orgasmic disorder and vagin- of psychosexual therapy alone or in combination with phar. Similarly. consideration of psychiatric disorders. to the classification system. the definition The effects of aging and menopause on female sexual func. Physician and patient needs are assessment instruments could be developed. rent or persistent genital pain induced by noncoital sexual Clinical trials of vasoactive agents and steroidal therapies stimulation. Thus. although factors. An essential element of the new diagnostic system is the jury. tions that characterize female sexual arousal. are no validated sexual distress specific instruments for im- tions.” are not limited to measurements of genital blood flow. It was noted that a significant number of women are strongly encouraged. the role of steroid hormones in the modulation of sexual persistently lower than that of the partner or women of desire and arousal in women is not well understood. dysfunction regardless of etiology. 22 The determinants Recognizing the wide range of physical and subjective reac- of sexual desire in women also remain to be evaluated.21. engaging in alternative sexual behaviors. the new defi- Urgent investigation is needed concerning development of nition refers to “lack of subjective excitement or a lack of reproducible measurement devices and instruments for eval. for hypoactive sexual desire dis- tions are efficacious for some disorders. The assessment of personal distress can be female sexual dysfunction are urgently needed. For instance. noted that some patients with this diagnosis have apparent physical or emotional distress and overall quality of life is desire for sexual contact but are unable to initiate or respond highly variable. This new definition is more inclusive than the ICD-10 defi- sponse in the clinical setting. the problem. diagnostic categories. the definition would not apply to the woman who lacks role of neurotransmitters and local vasoactive substances in desire only in some circumstances (for example during peri- determining vascular smooth muscle tone. It is uncertain whether vasoactive experience pain during noncoital forms of sexual stimulation drugs widely used for treatment of male erectile dysfunction who would not be included in the current categories of vag- will have clinical usefulness in the treatment of specific dys. This phenomenon is incorporate nongenital and subjective dimensions of arousal. Many studies have strongly recommended. mediate use in clinical trials of female sexual dysfunction. in the absence of evidence based justification for bother to the patient but is insufficient as a basis for diag- departure from these systems. such as sexual thoughts or fan. Thus. nor are the public health or cost implica. medication use and concomitant illnesses have not currently there is not enough evidence to warrant removal of been adequately delineated. despite the topic and the etiology of sexual desire disorders in general is ability to achieve arousal or orgasm. For example. if a woman reports that her partner is made in several areas. limited to tasies and desire for or receptivity to initiation by a partner. Conversely. Currently there not well defined. The of sexual dysfunction in the ICD-10 and DSM-IV were pre. Similarly. genital sensation. sexual arousal disorder.” uating physiological parameters of the female sexual re. dissatisfied with her lack of orgasm but that it does not The definition of hypoactive sexual desire was broadened bother her personally. The consensus conference was convened diagnosis of sexual dysfunction would not be given due to the specifically to meet these needs. ismus an essential element of the diagnosis is the require- macological treatment are needed. vasodilation and ods of marital conflict) or at certain times (for example before vaginal lubrication. Like. a specific diagnosis would not be to include a lack of receptivity to sexual activity. with her partner. tors mediating the effects of aging on sexual function in Some panelists questioned the inclusion of sexual aversion women the role of hormones. organic and psycho- . further clinical trials order. inismus or dyspareunia.1. Of the fac. spinal cord in.1. the new consensus The 2 important elements in the new definition are the classification system applies to all forms of female sexual persistent lack of desire and resulting personal distress. even if sexual desire was wise. which was developed to provide accepted markers of desire. psychosocial and interpersonal in the broader category of sexual desire disorders. studies of physician awareness and competency in for the individual. definition emphasizes the persistent lack or deficiency of well In contrast to the DSM-IV. cians and other health care providers receive little or no Existing measures of distress can be used or disease specific formal training in this area. many women experience a lack to contact due to phobic aversion. significant changes were nosis. would not apply in the absence of personal distress related to tioning are important areas for further research. ment that the condition causes significant personal distress Finally. the category or placement in a different dimension. including the Thus. Counseling may still be recommended in such cases sexual desire is difficult to define in absolute terms given the due to the conflict or incompatibility in expectations regard- lack of reliable population norms. noted a lack of association between physiological and subjec.

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