Nosology of the Sexual Dysfunctions: Are They Appropriate to Older Adults?

The International Classification of Diseases, Tenth Revision ( ICD-10), describes sexual dysfunction on the basis of the inability of the individual to participate in a sexual relationship. On the other hand, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5) describes it as the inability to respond sexually or experience sexual pleasure. Neither diagnostic manual addresses age as a contextual factor in sexual response, though DSM-5 notes that aging may be associated with a normative decrease in sexual response. In this review, we argue that the diagnosis of sexual dysfunction in the elderly should be based on age-related expectations. As examples, in older women, diagnostic criteria should factor in the considerations that vaginal dryness is associated with genital pain on penetration and with anorgasmia, as components of the genitourinary syndrome of menopause. In older men, the criteria for rigidity of erection and time to ejaculation may be unduly stringent and are not calibrated to changes in autonomic function with age. The lack of consideration of aging physiology in diagnostic systems and the predominance of ageist stereotypes restrict the validity of diagnoses of sexual dysfunction in older adults; there is the possibility of both under and over diagnosis, based upon the attribution models of the patient and the clinician. Age sensitivity during medical training would help reduce ageist stereotyping in clinical practice. Sexual health education in older adults would help familiarize them with and relieve distress related to body changes that may be distressing and that may impact their quality of sexual life.