The Changes in ICD-11 Related to Sexual Health and Dysfunction and Their Implication for Clinical Practice

ABSTRACT

The classification of sexual health-related conditions was reformulated in 11th revision of International Classification of Diseases (ICD-11) following current evidence, best practice, and taking human rights into consideration, which is expected to reflect and provide guidance for more integrative clinical approaches. Overcoming the artificial, yet historical, distinction between “organic” and “non-organic” conditions, sexual dysfunctions classified in the “Mental and Behavioral Disorders” and “Disorders of Genitourinary System” in ICD-10 were listed in a new chapter called “Conditions Related to Sexual Health.” In practice, this approach has been consistently recommended. However, diagnostical clasification was not congruent with the recommendation. Dysfunctions, defined with a non-normative but individual-based threshold, are categorized according to different stages of the sexual response cycle, similar to ICD-10 and Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5). However, similarities and distinctions in the clinical presentation of the dysfunction in men and women were also considered, resulting in differences from the DSM-5 approach. Gender Incongruence is classified in this newly formed “Conditions Related to Sexual Health” chapter, not with mental disorders as in the earlier version, reflecting the current non-pathologizing understanding of gender diversity. Furthermore, the criteria for these conditions were revised to embrace the variability in the experience of gender identity. In addition, the residuals of sexual orientation-related diagnostic categories were removed. Paraphilic disorders categories replaced “Disorders of sexual preference” in ICD-10, with significant modifications in conceptualization and classification.

INTRODUCTION

In the field of sexual health and dysfunctions, there has been a considerable accumulation of research evidence and significant changes in the best practices related to the assessment and management of the relevant conditions in the two and a half decades following the approval of ICD-10, International Classification of Diseases by World Health Organization (World Health Organization 1992). ICD-11 was approved in May 2019 (World Health Organization 2022). In the history of the ICD, the interval of the last two revisions has been the longest. During this period, there has been a shift in the understanding of human sexuality, the rights of individuals both in social life and during healthcare, and the prioritization of the individual in healthcare provision. Although there are differences in the priority given to individuals’ responsibility and the organization of care among countries (Giami 2002), the conceptualization of sexual health has extended to include sexual rights and especially the right of sexual pleasure for all, leaving no one behind and excluding the risk of violence and discrimination (Coleman et al. 2021, Mitchell et al. 2021). World Health Organisation’s Department of Mental Health and Substance Abuse and the Department of Reproductive Health and Research worked together on proposals for revisions related to sexuality and sexual health. Two departments assigned a joint Working Group on Sexual Disorders and Sexual Health to develop recommendations. Finally, ICD-11 was submitted to the 144th Executive Board Meeting in January 2019 and approved during the 72nd World Health Assembly in May 2019 (World Health Organization 2022).

The reformulation of the classification of sexual health-related conditions in ICD-11 was expected to reflect these developments and provide guidance for more integrative clinical approaches and public health implementations. This brief narrative review aims to present and discuss changes brought by ICD-11 in the field of sexual health. It is not intended to be a comprehensive review of all changes in ICD. However, the clinical significance of the changes is emphasized.

Sexual Dysfunctions and Sexual Pain

Overcoming the artificial yet historical distinction between “organic” and “non-organic” conditions, sexual dysfunctions classified in the “Mental and Behavioral Disorders” and “Disorders of Genitourinary System” in ICD-10 were listed in a new chapter called “Conditions Related to Sexual Health” in ICD-11 (World Health Organization 2022). This relocation appears as an attempt to overcome the constraints of the mind-body split, which is still prevailing in health in general but persists as a significant problem in sexuality as well. This change reflects the accumulating evidence on the complex interaction of physiological, psychological, interpersonal, social, and cultural factors involved with the emergence and maintenance of sexual dysfunctions. In each case, clinicians are encouraged to assess and describe diverse etiological qualifiers, such as conditions associated with a disorder or disease, with a medication or substance, with a lack of knowledge, with relationship factors, or with cultural factors, which are not mutually exclusive. In sexual health practices, refraining from considering sexual health issue as organic and psychogenic has been consistently recommended for decades. However, diagnostic classification was not congruent with this approach.

Although in the text of ICD-11, the commitment to the biopsychosocial model of sexuality was emphasized, this relocation also led to concerns over greater medicalization of sexual dysfunctions (Meana et al. 2020). Although ICD-11 does not attempt to delineate limits of medical specialties through diagnostic categorization, the relocation of the sexual dysfunction away from the mental disorders group carries the potential of prioritization of the pharmacological and surgical management of the conditions rather than sexual therapy. Sexuality related health issues often require counselling, and not infrequently sexual therapy is indicated. With this change, healthcare professionals without adequate expertise on mental health and psychotherapy may proceed with these interventions. Especially in countries without specific regulations on the practice of psychotherapy, such inappropriate interventions may lead to delays in the achievement of the assistance needed, and even may have disruptive consequences.

In ICD-11, sexual dysfunctions are categorized according to different stages of the sexual response cycle, similar to ICD-10 and DSM-5 (Parish et al. 2021). The dysfunctions are defined with a non-normative but individual-based threshold; the failure in satisfaction of the individual is considered as the threshold of a diagnosis rather than the expectation of the partner or the anticipation of society for any sexual response. The similarities and distinctions in the clinical presentation of the dysfunction in men and women were also considered, resulting in differences from the DSM-5 approach. Thus, some diagnoses that are described in a gender-specific manner, such as arousal disorders, are separately defined for each gender. Whereas “Hypoactive Sexual Desire Disorder” and “Anorgasmia” are categories that can be diagnosed in both men and women. In DSM-5, female sexual arousal and desire disorders were combined in a single category due to frequent comorbity and the difficulties in dissociating these sexual responses in clinical population. This distinction brought by DSM-5 is still controversial (Sungur and Gündüz 2014, Sarin et al. 2013). Despite the change in DSM, these two conditions are considered two distinct categories in ICD-11. There is evidence supporting two different conditions with regards to genetic features and treatment response (Reed et al. 2016). Further research on these separate diagnostic categories may lead to a better understanding.

In male sexual dysfunctions, ICD-11 permits a distinction between ejaculation and the subjective experience of orgasm (Reed et al. 2016). This feature, which is not present in DSM-5, may prove beneficial in research and clinical management of the conditions in individuals presenting with these symptoms. The terminologies of “Premature Ejaculation” and “Impotence” were changed to “Early Ejaculation” and “Erectile Dysfunction” with ICD-11, respectively. A clinically significant difference in the definition of “Early Ejaculation” in ICD-11, compared to that of ICD-10 and DSM-5, is the lack of a cut-off point for ejaculation time. However, clinical and epidemiological evidence suggests cut-off points for ejaculation times (Waldinger and Schweitzer 2019), and this change may be considered a potential source of mistakes in clinical applications and research. Yet, a threshold mainly based on the time of ejaculation may interfere with the access to care in some cases.

With regards to sexual pain, which is grouped separately, “Vaginismus” is namely replaced with “Sexual Pain-Penetration Disorder,” which resembles the name of the diagnostic category in DSM-5, “Genito-pelvic Pain/Penetration Disorder.” However, ICD-11 did not incorporate “Dyspareunia” and “Vulvodynia” into “Sexual Pain-Penetration Disorder”; instead, they are retained in the chapter on genitourinary disorders. This was based on the differences in etiologies, affected populations, and, most importantly, differences in the clinical management and sexual therapeutic approach (Reed et al. 2016). The clinical description of “Sexual Pain-Penetration Disorder” is broadened compared to “Genito-pelvic Pain/Penetration Disorder” so that it includes the emotional components, fear and anxiety, and the pain associated with the penetration. Vaginal spasm, increase in muscular tonus and contraction are only components of a general emotional response (van der Velde et al. 2001), they are often prioritized in the clinical assessment and interventions. In addition to the fact that the emotional and cognitive features are the primary features of the condition, there is a high rate of mental disorder comorbity in this population (Yildirim et al 2019). Such a change in the description of the condition in ICD-11 may enhance a more comprehensive approach not disregarding the psychological component of the sexual problems.

Diagnostic Categories Related to Sexual Orientation

Diversity in sexual orientation has not been considered to be associated with any mental disorder, and nonheterosexual orientation has not been considered a pathology for decades (Drescher 2015). However, in ICD-10, some diagnostic categories related to sexual orientation were kept for then assumed clinical and research benefits (World Health Organization 1992). Nevertheless, in the following decades, these diagnoses were almost never used for research, and their clinical application has not been proven to be practical (Cochran et al. 2014, Reed et al. 2016). The category “Ego-dystonic Sexual Orientation” was already criticized for only being applicable to nonheterosexual orientations (Drescher 2015).

The distress described in the “Sexual Maturation Disorder” regarding the uncertainty of sexual or gender identity has its origin in the prevalent discriminatory attitudes in society. An identity exploration with the possibility of identity features which may be unacceptable for others or beyond the widely expected boundaries may lead to anxiety and fear. Prevalent discrimination against sexual orientations has been shown to delay self-identification and disclosure, and increase the stress associated with the identity features (Campbell et al. 2023, Layland et al. 2023). Furthermore, rather than meriting a distinct category, the discomfort associated with the sexual identity features was shown to be a feature of earlier stages of identity development in individuals with characteristics considered unfavorable by society (Cass 1979, Troiden 1989, Bishop et al. 2023). In other words, the individual’s concern during identity exploration has been dominantly proposed to arise from the experienced or anticipated stigma, exclusion, discrimination, and violence associated with the orientation (Hatzenbuehler and Pachankis 2016). The association of identity features in an essentialist, therefore pathologizing manner to the diagnostic categories was heldresponsible for the stigma and discrimination associated with minority identities, at least partially (Winter et al. 2009, Drescher 2015). Psychological and behavioral problems associated with both conditions have been consistently shown to be related to the discrimination and stigma experienced (Meyer 2003, Hendricks ve Testa 2012). Finally, the disturbance in intimate relationships arising due to identity features was not considered a distinct diagnostic category, leading to the removal of the “Sexual Relationship Disorders.” Therefore, removing these categories was justified due to poor support for their diagnostic validity and clinical utility (Campbell et al. 2015), in addition to the current principles of human rights.

Although the categories removed in the last version were not by themselves responsible for the pathologizing medical approach to nonheterosexual orientations, this change emphasizes the World Medical Association’s stance recognizing the diversity in human sexuality and condemning discrimination, stigmatization, and criminalization (World Medical Association, 2023). Despite increasing evidence on the harmful effects and strong arguments on their unethical nature (Fish and Russell 2020; Davison and Walden 2024), sexual orientation change efforts still persist, and often, medical professionals are involved (Fenaughty et al 2023). Although an increasingly positive attitude in the general population towards diversity in sexual orientation is reported (Jarasiunaite-Fedosejeva and Kravcenko 2022), the stigma and discrimination persist globally, and they are still considered responsible for the health disparities in sexual minorities (Pachankis et al 2021). In addition to diminishing medical false justifications for the stigma, discrimination, and criminalization, this revision can be considered a call for ethical and evidence-based care for all.

Gender Identity and Expression Incongruent with Sex Assigned at Birth

Persistent incongruence between the sex assigned at birth and gender identity is classified as “Gender Incongruence” in the newly formed chapter on “Conditions Related to Sexual Health” instead of “Mental, Behavioral and Neurodevelopmental Disorders”. This decision reflects the current non-pathologizing understanding of gender diversity (Drescher 2015). Gender identity-related diagnostic categories have long been criticized for underlying the stigmatization experienced by trans and gender-diverse individuals (Drescher et al. 2012, Winter et al. 2016). The demand by the supporters of this view was the total removal of the diagnostic category from the DSM, which was not the case in the final revision, DSM-5 (American Psychiatric Association 2013). Instead, during the revision of the DSM, the name of the category, which was Gender Identity Disorder, was changed in a way not to include the words “identity” or “disorder.” However, the diagnostic category of “Gender Dysphoria” is still listed among mental disorders in DSM-5. Similarly, ICD-11 also excluded an identity-related term (“Transsexualism”) from the list of disorders. In ICD-11, taking one more step forward, the newly formed category of “Gender Incongruence” is no longer listed among mental disorders. Gender Incongruence does not necessarily require the existence of distress, which is not an essential feature of the condition. “Gender Incongruence” as described in ICD-11 emphasizes the often present demand for gender-affirmation. This demand for medical assistance is the main reason for retaining the condition as a diagnostic category.

Furthermore, the criteria for this condition were revised to embrace the scientifically documented diversity in the experience of gender identity, which aligns with the change in DSM-5 from the earlier ICD-10 definition which included the term “the opposite sex” and thus followed a strict binary understanding of gender. This change in ICD-11 is expected to influence gender-affirming medical practices, rendering them accessible to people with a broader range of gender experiences than the earlier definition in ICD-10.

A different line of debate concerning the maintenance or removal of a gender identity-related diagnostic category for children resulted in the replacement of the “Gender identity disorder of childhood” in ICD-10 with “Gender incongruence of childhood” in ICD-11. Retaining such a diagnostic category was argued to describe the diversity in gender identity, children’s own experince of exploration and development as a pathology; therefore contributed to the discrimination, and constituted the basis for gender identity change efforts, without evidence (Drescher et al. 2016). However, mainly due to proposed benefits, such as the provision of clinical care and appropriate services to a vulnerable group and the opportunity to develop practice standards and guidelines, the category is retained. Nevertheless, the diagnostic threshold is kept high in order to prevent false labeling, which was one of the counterarguments for retaining the category. The incongruence is required to persist for at least two years, and the diagnosis should not be based solely on gender-variant behavior or preferences. However, the category is still strongly criticized for adding to the gender-minority stress and social rejection of those children who are in the process of exploring their gender identity and expression and learning to cope with the stigma associated with both (Suess Schwend et al. 2018). The opponents of this diagnosis suggest that non-pathologizing codes (such as “Factors influencing health status or contact with health services”) could be used for access to healthcare (Winter et al, 2019). The removal of this category by the ICD-11 Working Group is suggested to be more consistent with the removal of the categories related to the distress experienced during identity formation concerning sexual orientation in nonheterosexual individuals (Cabral et al. 2016).

Finally, the “dual-role transvestism” category in ICD-10 has been discarded. This condition described crossgender dressing (by itself challenging to delineate) as a temporary gender experience limited with clothing, without sexual excitement and demand for gender-affirmation. This diagnosis was almost never employed, and its clinical and research utility was unclear (Reed et al. 2016).

Overall, even though there is still room for improvement in the classification of gender identity-related health issues, the changes introduced by the ICD-11 appear to be in alignment with the most recent recommendations for evidence-based care for trans and gender-diverse individuals (Coleman et al 2022). This change may potentially influence the struggle against persisting gender diversity-related stigma, its consequences and the barriers to access to care (Falck and Bränström 2023). The provision of access to care without the need to define a mental disorder category, the abolition of the requirement for binary identities for gender-affirming care seem to be major advantages that could be widely disseminated via a globally recognized classification system as ICD.

Paraphilic Disorders

In ICD-11, the “Paraphilic Disorders” categories replaced “Disorders of Sexual Preference” in ICD-10 (World Health Organization 2022). “Paraphilic Disorders” are retained in the “Mental, Behavioral, and Neurodevelopmental Disorders Chapter” in ICD-11. They were not moved to the newly formed chapter on sexual health since the assessment and treatment of these conditions were considere to require specialized expertise in mental health (Reed et al. 2016). However, both the conceptualization and the classification of the conditions were significantly modified.

In essence, instead of labeling some sexual preferences and patterns of sexual behavior solely based on their atypicality or the distress associated with the social disapproval, mainly those paraphilias which involve others who can not or do not provide consent or the nature of the paraphilic behavior is associated with a significant risk of injury or death were retained (Krueger et al. 2017). In ICD-11, Pedophilic, Exhibitionistic, Voyeuristic, Frotteuristic, and Coercive Sexual Sadism Disorders are described in this domain. Fetischism, Fetishistic transvestism, and Sadomasochism are not listed as distinct categories. These conditions were considered to include solitary and consensual activities, which are not necessarily associated with functional impairment. Coercive Sexual Sadism Disorder differs from consensual sadomasochism, which is not found to be associated with psychological or social dysfunction (Wismaijer et al. 2013; Brown et al. 2020). This recently formed category is defined by the core feature of sexual arousal being the infliction of physical or psychological suffering on a non-consenting person.

However, diverse paraphilic interests that are sufficient to cause distress in the individual beyond the social consequences can still be diagnosed, even the paraphilias that have been removed as a category. Holding the possibility of diagnosis in the presence of other paraphilias is based on the risk of injury or death to the individual or others. This has been criticized since many other behaviors are not considered mental disorders solely due to the risks associated (Moser 2018). Such a choice to maintain a broader view of paraphilic disorders suggests the persistence of the pathologization of atypical sexual interest, which lies on social rather than scientific background (Giami 2015, Moser and Kleinplatz 2020). Finally, the persistent pattern of sexual arousal clause in the definition of these disorders in ICD-11 maintains the distinction between paraphilic disorders and criminal behaviors, which do not necessarily occur in the context of a mental disorder, and conditions associated with other mental disorders (Reed et al. 2016).

Overall, the changes in this group of disorders were reported to be an improvement in clinical utility and not associated with anticipated medicolegal difficulties in two countries (Abdalla-Filho et al. 2019, Briken et al. 2019). Therefore, the conceptual specification introduced by the ICD-11 may be considered an opportunity to restrict the discriminatory approach to the individuals’ sexual preferences in the assessment of atypical sexual interest and behavior, yet, not limiting the access to medical assistance when required.

Compulsive Sexual Behavior Disorder

ICD-10 included “Excessive Sexual Drive” as a category listed among sexual dysfunctions (World Health Organization 1992). In the last decades, increasing research interest resulted in an accumulation of knowledge in out-of-control sexual behavior, several models of psychopathology, and few attempts to classify among other disorders (Briken 2020). Based on current evidence, ICD-11 included “Compulsive Sexual Behavior Disorder,” and rather than a category of sexual dysfunction, located the condition among impulse control disorders, such as pathological gambling, kleptomania, and pyromania (World Health Organization 2022). The preference of this location is a move away from the behavioral addiction model of the disorder (Sassover and Weinstein 2022). Without an attempt to describe the etiology or motivation underlying the disorder, which is practical in such a heterogenous group, ICD-11 emphasizes the “lack of self-control,” which reflects on the sexual behavior of the individual. The emphasis on self-control in the definition is also helpful in the clinical management of the condition. However, debate, research, and interest in the nature and treatment of the disorder still continue. Including this category in ICD-11 appears to increase research interest (Stein et al. 2020). In addition, it is expected to facilitate individuals’ application and access to care.

CONCLUSION

Diagnostic classifications are expected to evolve with accumulating evidence on the nature of health-related conditions. The innovations introduced in ICD as a result of years of work by experts in the field reflect the progress in the knowledge on sexual health and dysfunction, in addition to the change in the human rights perspective related to diagnostic categories discussed. However, many issues concerning the categories, their description, and their location in diagnostic groups are matters of discussion. ICD-11 is anticipated to facilitate research in these areas, making it possible to answer essential questions in the future and improve clinical care and public health services.