ICD-11HA02.0	ANORGASMIA Anorgasmia
ICD-10F52.3	Orgasmic dysfunction
DSM-5-TRF52.31 / F52.32	Female 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

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

3. Epidemiology

• Women experience clinically significant anorgasmia in 5–10% of cases; men experience delayed ejaculation in 1–4%.
• 30–70% sexual side effects with antidepressant (SSRI) use.

4. Aetiology 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

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

6.4 Differential diagnosis

7. Examination and assessment

• FSFI, IIEF.
• Hormonal panel.
• Neurological and urologic (acquired suspicion).

8. Treatment

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

8.1 Treatment methods

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

8.2 Differences between sources

• Nurnberg H.G. et al. JAMA 2008 — sildenafil in SSRI-induced female sexual dysfunction.
• 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 weak; FDA warnings hidden component.

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 intimate relationship with partner.

11. Sources

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