The human sexual response and the sexual dysfunctions

Disorder

How sexual desire, arousal, orgasm and resolution work, and the lasting problems with them that cause distress, often from medical causes or drugs.

Updated Nov 13, 2026

Key points

DSM-5-TR female dysfunctions are female sexual interest/arousal disorder, female orgasmic disorder and genito-pelvic pain/penetration disorder; in men the main problems are low desire, erectile dysfunction and premature or delayed ejaculation.
Criteria need symptoms on at least 75 percent of occasions, for at least 6 months, with distress.
SSRIs cause sexual dysfunction in more than half of patients, mainly trouble reaching orgasm, plus lower libido and erectile dysfunction; bupropion and mirtazapine lack these sexual effects.
Other drug causes include antipsychotics, tricyclic antidepressants, some antihypertensives, 5-alpha-reductase inhibitors and antiandrogens.
Medical causes include diabetes, neurological disease, low testosterone, high prolactin and low estrogen with vaginal dryness.
In the circular model, desire can be responsive to stimulation and can build after arousal begins.

What it is

The classic linear model describes the sexual response as spontaneous desire, then excitement and plateau, orgasm and resolution; the circular model of Rosemary Basson and colleagues adds that sexual activity often starts from emotional intimacy or other motives, and desire can be responsive, building once arousal begins. DSM-5-TR requires symptoms on at least 75 percent of occasions for at least 6 months, causing distress. Sexual problems are common: an estimated 30 to 50 in 100 women report them, but only about 12 in 100 are distressed, and distress is what makes a problem a disorder.

Key facts

Erection is mediated by a sacral parasympathetic reflex; emission begins with stimulation of alpha-adrenergic receptors.
Premature ejaculation is usually caused by inexperience, anxiety and other psychological factors; SSRIs can contribute to delayed ejaculation.
Female sexual interest/arousal disorder merged the former separate desire and arousal disorders.
Genito-pelvic pain/penetration disorder combines pain with intercourse, fear of pain and pelvic floor muscle tightening; low estrogen with vaginal dryness can contribute.
Depression, anxiety, past sexual trauma and conflict in the relationship all inhibit desire and arousal.

Step by step

Take a detailed sexual history, in private, including the relationship, mental health and any past trauma.
Review every drug: SSRIs, antipsychotics, some antihypertensives, 5-alpha-reductase inhibitors and antiandrogens.
Examine the patient and order tests such as testosterone, prolactin and thyroid function when the history suggests them.
Treat the causes and offer psychological treatment such as cognitive behavioral therapy or mindfulness-based practices, with or without medicines.
Refer for pelvic floor therapy when pain or musculoskeletal problems predominate.

The DSM-5-TR sexual dysfunctions at a glance

Dysfunction	Core feature	Common contributors	First approach
Male hypoactive sexual desire disorder	Persistently low or absent sexual thoughts and desire	Depression, drugs, relationship problems	Treat causes; couple or sex therapy
Low desire from low testosterone	Low desire with a low morning testosterone level	Hypogonadism	Measure morning testosterone
Erectile disorder	Cannot get or keep an erection firm enough	Diabetes, neurological disease, drugs, anxiety	See the erectile dysfunction page
Premature (early) ejaculation	Ejaculation earlier than wished	Inexperience, anxiety	Stop-start and squeeze techniques
Delayed ejaculation	Marked delay or absence of ejaculation	SSRIs, psychological factors	Review drugs; psychological treatment
Female sexual interest/arousal disorder	Little interest or desire and/or low arousal	Depression, drugs, relationship conflict	Cognitive behavioral therapy or mindfulness; flibanserin or bremelanotide in premenopausal women
Female orgasmic disorder	Orgasm delayed, rare, absent or much less intense	Anxiety, SSRIs	Psychological treatment; review drugs
Genito-pelvic pain/penetration disorder	Pain, fear of pain, pelvic floor tightening with penetration	Low estrogen with vaginal dryness, past trauma	Pelvic floor therapy, treat dryness
Substance/medication-induced dysfunction	Onset with starting or raising a drug	SSRIs, antipsychotics, some antihypertensives	Lower the dose or switch to a drug with fewer effects
Paraphilic disorders (not a dysfunction)	Atypical sexual interests causing distress or harm	Different category	See the paraphilic disorders page

Clinical notes

Take a sexual history routinely, in private and without assumptions about orientation or relationships; review every drug.
Look for and treat medical causes, and check testosterone, prolactin and thyroid function when the history suggests them.
Cognitive behavioral therapy and mindfulness-based practices are effective, with or without medicines.
For SSRI-related problems, options include lowering the dose or switching to an antidepressant that impairs sexual response less, such as bupropion or mirtazapine; data on adding bupropion conflict.
Flibanserin and bremelanotide are approved for low desire in premenopausal women; testosterone is not recommended in premenopausal women.

Test yourself

Think of the answer, then tap the question to see it.

What is the key idea of Basson's circular model of sexual response?

Desire can be responsive: sexual activity may start from intimacy or other motives, and desire can build after arousal begins.

Which antidepressant class commonly causes sexual dysfunction, and what does it cause?

SSRIs: in more than half of patients, mainly trouble reaching orgasm, plus lower libido and erectile dysfunction.

Which antidepressants have the fewest sexual side effects?

Bupropion and mirtazapine, which lack the sexual adverse effects of SSRIs.

What makes a sexual problem a DSM-5-TR sexual dysfunction?

Symptoms on at least 75 percent of occasions for at least 6 months that cause distress.

What mediates erection, and what starts emission?

Erection: a sacral parasympathetic reflex; emission: stimulation of alpha-adrenergic receptors.

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Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline.

Sources: Overview of Female Sexual Function and Dysfunction (MSD Manual Professional Edition, 2026); Overview of Male Sexual Function and Dysfunction (MSD Manual Professional Edition, 2026); Sexual Interest/Arousal Disorder (MSD Manual Professional Edition, 2026); Drug Treatment of Depression (MSD Manual Professional Edition, 2026).

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Representative model, for educational purposes only.