Clinical Psychiatry

Anorgasmia

ICD-10F52.3Orgasmic dysfunction
DSM-5-TRF52.31 / F52.32Female Orgasmic Disorder / Delayed Ejaculation

1. Definition and nosology

Anorgasmia (ICD-11: HA02.0; DSM-5-TR Female Orgasmic Disorder F52.31 in women; Delayed Ejaculation F52.32 in men) — persistent difficulty, delay, or absence of reaching orgasm after sufficient sexual arousal; or reduced intensity of orgasm.

Duration ≥ 6 months; situational or generalized; lifelong or acquired.

2. History

  1. Masters & Johnson (1970) — classic description of orgasmic phase disorder.
  2. ISSWSH and ISSM guidelines.

3. Epidemiology

  • Women experience clinically significant anorgasmia in 5–10% of cases; men experience delayed ejaculation in 1–4%.
  • Sexual side effects occur in 30–70% of patients taking antidepressants (SSRIs).

4. Etiology and pathogenesis

  • Medication-related (SSRI, antipsychotic, opioid).
  • Neurological (pelvic surgery, MS, diabetic neuropathy).
  • Endocrine (hypothyroidism, hyperprolactinemia).
  • Psychological — anxiety, trauma, knowledge deficiency.
  • Age and hormonal changes.

5. Clinical features

  • Difficulty or absence of achieving orgasm.
  • Decreased intensity of orgasm.
  • Distress, avoidance.

6. Diagnosis

6.1 Unified diagnostic criteria (DSM-5-TR)

A. Delay, absence, or reduced intensity of orgasm following sufficient sexual arousal — in all or almost all instances (75–100%).

B. Duration ≥ 6 months.

C. Distress.

6.2 Differences between sources

  • ISSM Delayed Ejaculation Guideline.
  • ISSWSH — orgasm dysfunction in women.

6.3 Diagnostic algorithm

  • Clinical interview (sexual history, orgasm with masturbation, orgasm with partner).
  • FSFI (in women) / IIEF (in men).
  • Medication and comorbidity analysis.
  • Endocrine (testosterone, prolactin, thyroid).

6.4 Differential diagnosis

Condition Distinguishing feature
HSDD (HA00) Decreased desire dominant.
Retrograde ejaculation Orgasm present, ejaculate into bladder.
SSRI-induced Medication-related timing.
ED (HA01.1) Erectile disorder.

7. Examination and assessment

  1. FSFI, IIEF.
  2. Hormonal panel.
  3. Neurological and urologic (acquired suspicion).

8. Treatment

  • Etiological approach — management of medication, endocrine, neurological causes.
  • SSRI-induced anorgasmia:
    1. Medication switch — bupropion, mirtazapine, vortioxetine alternatives;
    2. Dose reduction; drug holiday (with caution in SSRIs);
    3. Bupropion adjunct;
    4. Sildenafil adjunct in women for SSRI-induced dysfunction — Nurnberg JAMA 2008 RCT.
  • Psychotherapy and behavior — orgasm-oriented therapy (Heiman & LoPiccolo); CBT, mindfulness (Brotto L.A.).
  • Directed masturbation training in women — directed masturbation; vibrator.
  • Delayed Ejaculation in males — psychotherapy, modification of masturbation pattern; no specific FDA-approved pharmacotherapy.
  • Hormonal therapy only in confirmed deficiency.

8.1 Treatment methods

  • Bupropion — As adjunct or switch in SSRI-induced anorgasmia.
  • Directed Masturbation — Heiman & LoPiccolo program; effective for primary anorgasmia in women.
  • Mindfulness-CBT — Brotto research; in female sexual dysfunction.

8.2 Differences between sources

  1. Nurnberg H.G. et al. JAMA 2008 — sildenafil in SSRI-induced female sexual dysfunction.
  2. Brotto L.A. mindfulness studies.

9. Prognosis

For women, directed masturbation yields 60–90% efficacy for primary anorgasmia; in SSRI-induced cases, pharmacological strategies provide improvement.

10. Myths and misconceptions

Myth 1: “Women must achieve orgasm through penetration”

Evidence: Most women (~70%) require clitoral stimulation; orgasm with only penetration is normal variation, not anatomical norm.

Myth 2: “Anorgasmia is a sign of ‘frigidity’ in women”

Evidence: Anorgasmia often related to knowledge, technique, anxiety, or medication; not a character trait.

Myth 3: “SSRI-induced anorgasmia is transient, requires no treatment”

Evidence: Chronic; pharmacological interventions or adjunctive strategies are effective; ongoing distress is clinically significant.

Myth 4: “Over-the-counter ‘orgasm enhancers’ are effective”

Evidence: Evidence is weak; FDA has warned about hidden components.

Myth 5: “Vibrator use deprives the patient of orgasm with a partner”

Evidence: On the contrary, it is effective in training for primary anorgasmia; can be integrated into an intimate relationship with a partner.

11. Sources

  • WHO. ICD-11. HA02.0 Anorgasmia. 2024.
  • APA. DSM-5-TR. 2022.
  • Nurnberg H.G. et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. JAMA 2008;300(4):395–404.
  • Brotto L.A. et al. Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction. J Sex Med 2016;13(4):538–571.
  • Heiman J.R., LoPiccolo J. Becoming Orgasmic. Prentice Hall, 1988.