Diagnostic Features
The essential feature of Substance-Induced Sexual Dysfunction is a clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty (Criterion A). Depending on the substance involved, the dysfunction may involve impaired desire, impaired arousal, impaired orgasm, or sexual pain. The dysfunction is judged to be fully explained by the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) (Criterion B). The disturbance must not be better accounted for by a Sexual Dysfunction that is not substance induced (Criterion C). This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the sexual symptoms are in excess of those usually associated with the intoxication syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
A Substance-Induced Sexual Dysfunction is distinguished from a primary Sexual Dysfunction by considering onset and course. For drugs of abuse, there must be evidence of intoxication from the history, physical examination, or laboratory findings. Substance-Induced Sexual Dysfunctions arise only in association with intoxication, whereas primary Sexual Dysfunctions may precede the onset of substance use or occur during times of sustained abstinence from the substance. Factors suggesting that the dysfunction is better accounted for by a primary Sexual Dysfunction include persistence of the dysfunction for a substantial period of time (i.e., a month or more) after the end of Substance Intoxication; the development of a dysfunction that is substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or a history of prior recurrent primary Sexual Dysfunctions.
Specifiers
The following specifiers for Substance-Induced Sexual Dysfunction are selected based on the predominant sexual dysfunction. Although the clinical presentation of the sexual dysfunction may resemble one of the specific primary Sexual Dysfunctions, the full criteria for one of these disorders need not be met.
With Impaired Desire. This specifier is used if deficient or absent sexual desire is the predominant feature.
With Impaired Arousal. This specifier is used if impaired sexual arousal (e.g., erectile dysfunction, impaired lubrication) is the predominant feature.
With Impaired Orgasm. This specifier is used if impaired orgasm is the predominant feature.
With Sexual Pain. This specifier is used if pain associated with intercourse is the predominant feature.
Substance-Induced Sexual Dysfunctions usually have their onset during Substance Intoxication, and this may be indicated by noting With Onset During Intoxication.
Recording Procedures
The name of the Substance-Induced Sexual Dysfunction begins with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the sexual dysfunction. The diagnostic code is selected from the listing of classes of substances provided in the criteria set. For substances that do not fit into any of the classes (e.g., fluoxetine), the code for “Other Substance” should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code on Axis I (see Appendix G). The name of the disorder is followed by the specification of predominant symptom presentation (e.g., 292.89 Cocaine-Induced Sexual Dysfunction, With Impaired Arousal). When more than one substance is judged to play a significant role in the development of the sexual dysfunction, each should be listed separately (e.g., 291.89 Alcohol-Induced Sexual Dysfunction, With Impaired Arousal; 292.89 Fluoxetine-Induced Sexual Dysfunction, With Impaired Orgasm). If a substance is judged to be the etiological factor, but the specific substance or class of substances is unknown, the category 292.89 Unknown Substance-Induced Sexual Dysfunction may be used.
Specific Substances
Sexual Dysfunctions can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cocaine; opioids; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Acute intoxication with or chronic Abuse of or Dependence on substances of abuse has been reported to decrease sexual interest and cause arousal problems in both sexes. A decrease in sexual interest, arousal disorders, and orgasmic disorders may also be caused by prescribed medications including antihypertensives, histamine H2 receptor antagonists, antidepressants (especially selective serotonin reuptake inhibitors), neuroleptics, anxiolytics, anabolic steroids, and antiepileptics. Painful orgasm has been reported with fluphenazine, thioridazine, and amoxapine. Priapism has been reported with use of chlorpromazine, trazodone, and clozapine and following penile injections of papaverine or prostaglandin. Medications such as antihypertensive agents or anabolic steroids may also promote depressed or irritable mood in addition to the sexual dysfunction, and an additional diagnosis of Substance-Induced Mood Disorder may be warranted. Current clinical experience strongly suggests that Substance-Induced Sexual Dysfunction is usually generalized (i.e., not limited to certain types of stimulation, situations, or partners).
Differential Diagnosis
Substance-induced sexual dysfunctions are most likely to occur during Substance Intoxication. The diagnosis of the substance-specific Intoxication will usually suffice to categorize the symptom presentation. A diagnosis of Substance-Induced Sexual Dysfunction should be made instead of a diagnosis of Substance Intoxication only when the dysfunction is judged to be in excess of that usually associated with the intoxication syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. If psychological factors also play a role in the onset, severity, exacerbation, or maintenance of a sexual dysfunction, the diagnosis is the primary Sexual Dysfunction (with the subtype Due to Combined Factors).
A Substance-Induced Sexual Dysfunction is distinguished from a primary Sexual Dysfunction by the fact that the symptoms are judged to be fully explained by the direct effects of a substance.
A Substance-Induced Sexual Dysfunction due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the person is receiving the medication (e.g., antihypertensive medication). Once the treatment is discontinued, the sexual dysfunction will remit within days to several weeks (depending on the half-life of the substance). If the sexual dysfunction persists, other causes for the dysfunction should be considered. Side effects of prescribed medications that affect sexual function may lead individuals to be noncompliant with the medication regimen if they value sexual performance over the benefits of the medication.
Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the sexual dysfunction is caused by the physiological consequences of the general medical condition rather than the medication, in which case Sexual Dysfunction Due to a General Medical Condition is diagnosed. The history often provides the primary basis for such a judgment. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether the medication is the causative agent. If the clinician has ascertained that the dysfunction is due to both a general medical condition and substance use, both diagnoses (i.e., Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction) are given. When there is insufficient evidence to determine whether the Sexual Dysfunction is due to a substance (including a medication) or to a general medical condition or is primary (i.e., not due to either a substance or a general medical condition), Sexual Dysfunction Not Otherwise Specified would be indicated.
Diagnostic criteria for Substance-Induced Sexual Dysfunction
A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2):
(1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication
(2) medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by a Sexual Dysfunction that is not substance induced. Evidence that the symptoms are better accounted for by a Sexual Dysfunction that is not substance induced might include the following: the symptoms precede the onset of the substance use or dependence (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Sexual Dysfunction (e.g., a history of recurrent non-substance-related episodes).
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.
Code [Specific Substance]-Induced Sexual Dysfunction:
(291.89 Alcohol; 292.89 Amphetamine [or Amphetamine-Like Substance]; 292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other [or Unknown] Substance)
Specify if:
With Impaired Desire
With Impaired Arousal
With Impaired Orgasm
With Sexual Pain
Specify if:
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
