Other Specified Sexual Dysfunction, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), is a category that encompasses sexual dysfunctions not covered by the specific categories outlined in the manual. This classification is used when an individual's symptoms cause significant distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class (American Psychiatric Association [APA], 2023).

Individuals presenting with Other Specified Sexual Dysfunction may exhibit a wide range of symptoms. These symptoms are typically specific and significant enough to warrant clinical attention. Yet, they do not align precisely with the criteria for other established sexual dysfunctions such as erectile disorder, female orgasmic disorder, or premature (early) ejaculation. For instance, an individual might experience sexual arousal difficulties that are situational and not pervasive enough to be classified under a more specific dysfunction.

Clinical presentations can vary greatly, depending on the individual's unique experiences and symptoms. The distress experienced by the individual is a crucial component in identifying and understanding this disorder. It's important to note that the symptoms must not be attributable to the physiological effects of a substance (such as a drug of abuse or medication) or another medical condition.

Treatment approaches for Other Specified Sexual Dysfunction are tailored to the individual's specific symptoms and might involve a combination of psychotherapy, behavioral therapy, education, and, in some cases, medication.

Diagnostic Criteria

Other Specified Sexual Dysfunction in the DSM-5-TR is a category that allows clinicians to specify the reason that the criteria for a specific sexual dysfunction are not met. This diagnosis is used when symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning but do not fully align with the criteria of other sexual dysfunctions. The DSM-5-TR outlines several examples under this category, including persistent genital arousal disorder and sexual dysfunction due to a general medical condition (APA, 2023).

Persistent genital arousal disorder (PGAD), for instance, involves spontaneous, persistent, and uncontrollable genital arousal in the absence of sexual desire. This condition, often distressing for patients, has been studied for its impact on quality of life and mental health. A study by Leiblum and Nathan (2001) was one of the first to identify and describe this disorder, noting the significant distress and impairment in functioning it caused in women.

Sexual dysfunction due to a general medical condition is another example where sexual dysfunction is judged to be a direct physiological consequence of a different medical condition. This diagnosis is supported by research indicating that various medical conditions, such as diabetes and cardiovascular diseases, can lead to sexual dysfunctions. A study by Lindau et al. (2007) provided insight into the prevalence of sexual problems among older adults, highlighting the impact of health status on sexual activity and function.

It's crucial to understand that the diagnosis of Other Specified Sexual Dysfunction requires a thorough assessment to rule out other mental disorders, the effects of substances, or medical conditions. This diagnosis is not just a "catch-all" category but is used when the symptoms are significant and clearly related to sexual dysfunction. However, they do not meet the full criteria for a more specific disorder.

In the DSM-5-TR, "Other Specified Sexual Dysfunction" is a category that is used when an individual's sexual dysfunction symptoms are significant and distressing but do not meet the full criteria for any of the specific sexual dysfunctions outlined in the manual. This category allows for the specification of the particular reason why the presentation does not meet the criteria for any specific sexual dysfunction disorder. The DSM-5-TR provides several specifiers, or examples, to guide clinicians in identifying and categorizing these presentations:

• Persistent Genital Arousal Disorder: This specifier is used for cases where individuals experience spontaneous, intrusive, and unwanted genital arousal (e.g., erections, clitoral engorgement) that is unrelated to sexual desire or sexual activity and continues for an extended period.
• Sexual Dysfunction Due to a General Medical Condition: This specifier is appropriate when the sexual dysfunction is believed to be a direct physiological consequence of another medical condition.
• Other Specifiers: Clinicians are also given the flexibility to specify other reasons why sexual dysfunction does not meet the criteria for a more specific disorder. These could include situations where the symptoms do not have a clear pattern or where only certain aspects of a disorder are present.

It's important to note that the "Other Specified" category is distinct from "Unspecified Sexual Dysfunction," which is used when the clinician chooses not to specify the reason that the criteria for a specific sexual dysfunction are not met, often due to insufficient information.

These specifiers help provide a more precise diagnosis and guide treatment planning. The choice of specifier is based on the clinician's judgment and the specific characteristics of the individual's symptoms.

The Impacts

The impacts of Other Specified Sexual Dysfunction, as categorized in the DSM-5-TR, are multifaceted and can significantly affect an individual's psychological, relational, and overall quality of life. This category includes a range of sexual dysfunctions that do not meet the full criteria for specific disorders but still cause considerable distress or interpersonal difficulty.

One significant impact of these sexual dysfunctions is on mental health. Individuals with sexual dysfunctions often experience heightened levels of anxiety, depression, and feelings of inadequacy. A study by Atlantis and Sullivan (2012) revealed a strong association between sexual dysfunction and poor mental health outcomes, including depression and anxiety disorders. This study highlighted the need for holistic approaches in treating sexual dysfunctions, considering both physiological and psychological aspects.

The relational impact is another critical aspect. Sexual dysfunctions can lead to strained relationships, diminished intimacy, and, in some cases, relationship breakdowns. Research by McCabe and Althof (2014) focused on the impact of sexual dysfunction on the partner and the relationship, emphasizing that sexual dysfunctions are not just individual issues but relational ones. Their study found that partners of individuals with sexual dysfunctions also experienced emotional distress, feelings of rejection, and dissatisfaction with their sexual relationship.

Quality of life is also significantly affected by sexual dysfunctions. A comprehensive study by Shifren et al. (2008) looked into the overall quality of life in women with sexual dysfunctions. The study found that sexual dysfunction was associated with a lower quality of life, including reduced well-being and happiness. This relationship was observed irrespective of age, menopausal status, and other demographic factors.

These studies collectively indicate that the impacts of Other Specified Sexual Dysfunction are profound and extend beyond just the sexual aspect of an individual's life. They underscore the importance of a comprehensive approach to assessment and treatment, which considers the psychological, relational, and quality of life aspects.

The Etiology (Origins and Causes)

The etiology of Other Specified Sexual Dysfunction, a category in the DSM-5-TR, is complex and multifactorial. This category encompasses various sexual dysfunctions that do not meet the criteria for more specific disorders but still cause significant distress or impairment. The causes of these dysfunctions can be psychological, physiological, or a combination of both.

Psychological factors are often a significant contributor to sexual dysfunctions. Stress, anxiety, and depression are commonly associated with sexual dysfunctions. Bancroft and Janssen (2000) conducted a study exploring the impact of mood states on sexual arousal. They found that negative mood states, particularly anxiety, can significantly impair sexual arousal and response. This study highlighted the importance of psychological factors in understanding sexual dysfunction.

Physiological factors also play a crucial role in the development of sexual dysfunctions. Medical conditions such as diabetes, cardiovascular diseases, and neurological disorders can lead to sexual dysfunction. Research by Shamloul and Ghanem (2013) reviewed the impact of chronic illnesses on erectile function. They found that chronic diseases, especially those involving vascular or neurological impairment, are strongly linked to the development of erectile dysfunction. This study underscores the need to consider underlying medical conditions in the assessment and treatment of sexual dysfunctions.

Additionally, the side effects of certain medications can contribute to sexual dysfunction. Antidepressants, antihypertensives, and antipsychotics are among the medications frequently implicated in sexual dysfunction. A review by Serretti and Chiesa (2009) examined the sexual side effects of antidepressants, revealing that these medications can have varying impacts on sexual function, depending on the class of drug and the individual's response.

Interpersonal factors, such as relationship issues and partner dynamics, can also influence the development of sexual dysfunction. A study by Metz and McCarthy (2004) highlighted the role of interpersonal dynamics in sexual dysfunction, showing that relationship satisfaction and communication are critical factors in the development and maintenance of sexual disorders.

These studies collectively indicate that the etiology of Other Specified Sexual Dysfunction is diverse and often involves an interplay of psychological, physiological, and interpersonal factors. Understanding these various contributors is essential for effective diagnosis and treatment.

Comorbidities

The comorbidities of Other Specified Sexual Dysfunction, as categorized in the DSM-5-TR, can be diverse, encompassing both psychological and physiological conditions. This category of sexual dysfunction, while not meeting the criteria for more specific disorders, still presents significant challenges, often co-occurring with other health issues.

One of the most common comorbidities is mental health disorders, such as depression and anxiety. Research has consistently shown a bidirectional relationship between sexual dysfunction and depression. For example, a study by Atlantis and Sullivan (2012) found that sexual dysfunction was significantly associated with an increased risk of depression and anxiety. This relationship suggests that the presence of sexual dysfunction can exacerbate symptoms of depression and anxiety and vice versa.

Another significant comorbidity is cardiovascular disease. Erectile dysfunction, for instance, is often an early indicator of cardiovascular issues. A landmark study by Montorsi et al. (2003) demonstrated that erectile dysfunction could precede coronary artery disease in almost 70% of cases. This finding underscores the importance of assessing cardiovascular health in patients presenting with sexual dysfunction.

Endocrine disorders, particularly diabetes mellitus, are also commonly associated with sexual dysfunctions. A study by Maiorino et al. (2014) highlighted the prevalence of sexual dysfunction among diabetic patients, showing that both erectile dysfunction in men and sexual arousal disorders in women were significantly higher in the diabetic population compared to non-diabetics.

Neurological disorders are another vital comorbidity to consider. Multiple sclerosis, Parkinson's disease, and spinal cord injuries are known to impact sexual function. A study by Lew-Starowicz and Rola (2013) explored sexual dysfunction in patients with neurological disorders, finding a high prevalence of sexual difficulties among this population.

These studies highlight that Other Specified Sexual Dysfunction often does not occur in isolation but is frequently accompanied by a range of other health issues. Understanding these comorbidities is crucial for providing comprehensive care to individuals with sexual dysfunction.

Risk Factors

Other Specified Sexual Dysfunction, as classified in the DSM-5-TR, encompasses a range of sexual dysfunctions that do not meet the full criteria for specific disorders. Understanding the risk factors for these conditions is crucial for prevention and treatment. The risk factors are multifaceted, encompassing psychological, physiological, and lifestyle-related aspects.

Psychological factors are significant risk factors for sexual dysfunctions. Stress, anxiety, and depression are frequently associated with the onset and exacerbation of sexual dysfunction. A study by Laumann et al. (1999) on sexual dysfunction in the United States found that psychological factors, including stress and anxiety, were strongly linked to sexual problems. Their research highlighted the importance of mental health in sexual functioning.

Physiological factors, particularly chronic illnesses, are also significant risk factors. Conditions such as diabetes, cardiovascular diseases, and neurological disorders have been linked to sexual dysfunction. For instance, a study by Bacon et al. (2003) on the health of men in the Massachusetts Male Aging Study revealed that diabetes and hypertension were significantly associated with erectile dysfunction. This research underscores the role of chronic medical conditions in sexual health.

Lifestyle factors, including smoking and alcohol use, are also known risk factors. A study by Feldman et al. (2000) on the association between smoking, drinking, and sexual dysfunction found that cigarette smoking was significantly associated with a higher risk of erectile dysfunction. Similarly, excessive alcohol consumption has been linked to sexual dysfunction, as evidenced by a study by Peate (2005), which examined the impact of lifestyle factors on sexual health.

Medications are another important risk factor. Certain drugs, such as antidepressants, antihypertensives, and antipsychotics, are known to affect sexual function. A review by Montejo et al. (2001) on the sexual side effects of psychiatric drugs provided comprehensive evidence on how these medications can impact sexual health.

These studies collectively indicate that the risk factors for Other Specified Sexual Dysfunction are diverse, involving an interplay of psychological, physiological, lifestyle, and medication-related factors. Identifying these risk factors is vital for clinicians to provide targeted interventions for individuals experiencing sexual dysfunctions.

Case Study

Background: Sexual dysfunctions are common, yet often underreported, concerns in clinical practice. The DSM-5-TR category of Other Specified Sexual Dysfunction encompasses those sexual dysfunctions that do not meet the full criteria for a specific disorder but still cause significant distress. This case study explores the management of a patient diagnosed with this condition.

Case Presentation: Mr. A, a 38-year-old male, presented to the clinic with complaints of distressing sexual symptoms that did not align with any specific sexual dysfunction as outlined in the DSM-5-TR. He reported experiencing episodes of premature ejaculation, but these episodes were infrequent and irregular, making it difficult to categorize them under the established criteria for premature ejaculation.

Clinical Findings: Mr. A was physically healthy, with no significant medical history that could contribute to his symptoms. However, he disclosed experiencing considerable stress at work and in his personal life. He also reported occasional episodes of anxiety, which seemed to correlate with the onset of his symptoms.

Differential Diagnosis: The differential diagnosis included premature ejaculation, erectile dysfunction, and performance anxiety. The infrequency and irregularity of symptoms were critical factors in ruling out a more specific diagnosis.

Treatment: A multidisciplinary approach involving psychotherapy and behavioral interventions was adopted. Cognitive-behavioral therapy (CBT) sessions were initiated to address his anxiety and stress management. Couples therapy was also recommended to improve communication with his partner and manage the relational aspects of his sexual dysfunction.

Outcome and Follow-Up: Over several months of therapy, Mr. A reported a noticeable improvement in his symptoms. He learned coping strategies to manage his anxiety and stress, which subsequently led to a decrease in the frequency of his sexual dysfunction episodes. His relationship with his partner also improved, as indicated by increased satisfaction and communication during follow-up sessions.

Discussion: This case highlights the complexities in diagnosing and treating Other Specified Sexual Dysfunction. The etiology of these conditions can be multifactorial, necessitating a comprehensive approach to treatment. Psychological factors, particularly stress and anxiety, can play a significant role in the manifestation of these symptoms.

Conclusion: Other Specified Sexual Dysfunction requires a tailored approach to management, considering both the psychological and relational aspects of the individual. Multidisciplinary treatment strategies can effectively manage these conditions, including psychotherapy and behavioral interventions.

Recent Psychology Research Findings

One area of research focuses on the psychological aspects of sexual dysfunction. Stress, anxiety, and depression are frequently found to be associated with various sexual dysfunctions. For instance, a study by Bancroft et al. (2003) examined the impact of mood on sexual response. They found that negative mood states, particularly anxiety and depression, could significantly impair sexual arousal and response, highlighting the importance of psychological factors in sexual health.

Physiological factors also play a critical role in sexual dysfunction. Research has explored how chronic illnesses like diabetes and cardiovascular diseases impact sexual function. A study by Jackson et al. (2010) revealed that men with cardiovascular disease often experienced erectile dysfunction before the onset of their heart conditions. This study underscored the need for cardiovascular evaluation in men presenting with erectile dysfunction, reflecting the interconnected nature of physical health and sexual function.

Lifestyle factors, such as smoking and alcohol use, have been implicated in sexual dysfunction as well. A comprehensive study by Feldman et al. (2000) examined the relationship between lifestyle factors and erectile dysfunction. They found that smoking and excessive alcohol consumption were significantly associated with an increased risk of erectile dysfunction, suggesting that lifestyle modifications could be an integral part of managing sexual dysfunction.

Another important aspect is the impact of medication on sexual function. A review by Balon (2006) analyzed the sexual side effects of psychiatric medications, noting that many commonly prescribed drugs, such as SSRIs and antipsychotics, can lead to sexual dysfunction.

These studies collectively indicate that the etiology and impact of Other Specified Sexual Dysfunction are multifaceted, involving psychological, physiological, lifestyle, and medication-related factors. They emphasize the importance of a holistic approach to assessment and treatment.

Treatment and Interventions

The treatment and interventions for Other Specified Sexual Dysfunction, a category in the DSM-5-TR, are varied and depend on the specific symptoms and underlying causes of the dysfunction. Since this category encompasses a range of sexual dysfunctions that don't meet the criteria for more particular disorders, treatment approaches are often tailored to the individual's unique presentation.

Psychotherapy, particularly cognitive-behavioral therapy (CBT), is a common and effective treatment modality. CBT focuses on identifying and changing negative thought patterns and behaviors that may contribute to sexual dysfunction. A study by McCabe (2001) explored the effectiveness of CBT in treating sexual dysfunctions and found significant improvements in sexual satisfaction and function among participants. This approach often includes education about sexual response and techniques to decrease anxiety related to sexual activity.

Couple's therapy is another important intervention, primarily when the dysfunction affects relationship dynamics. According to a study by Heiman and Meston (1997), couple's therapy aimed at improving communication and increasing intimacy can effectively address the relational aspects of sexual dysfunction. This approach often involves both partners and focuses on improving sexual communication and enhancing emotional intimacy.

Pharmacotherapy can be considered, mainly if there are underlying medical conditions contributing to the sexual dysfunction. For example, PDE5 inhibitors like sildenafil (Viagra) have been used to treat erectile dysfunction. However, the applicability of pharmacotherapy in Other Specified Sexual Dysfunction depends on the specific symptoms and their causes.

Lifestyle modifications are also recommended as part of a comprehensive treatment approach. Addressing factors like obesity, smoking, and excessive alcohol consumption can improve overall health and, by extension, sexual functioning. A study by Esposito et al. (2004) demonstrated that lifestyle changes, including weight loss and increased physical activity, led to improved sexual function in men with erectile dysfunction.

Each treatment approach is chosen based on a thorough assessment of the individual's symptoms, underlying causes, and personal and relational dynamics. The goal is to address not just the symptoms but also the contributing factors to improve overall sexual health and quality of life.

Implications if Untreated

If Other Specified Sexual Dysfunction is left untreated, it can have several implications on an individual's mental health, relationship dynamics, and overall quality of life. The research literature provides insights into these potential consequences.

Mental Health Impact: Sexual dysfunction is strongly linked with mental health issues, particularly depression and anxiety. A study by Atlantis and Sullivan (2012) found that sexual dysfunction could significantly contribute to the development of mental health disorders. Untreated sexual dysfunction can exacerbate feelings of inadequacy and low self-esteem and reduce overall well-being.

Relationship Implications: Sexual dysfunctions can also strain intimate relationships. According to a study by McCabe and Althof (2014), sexual dysfunction can lead to decreased satisfaction in relationships, communication difficulties, and increased stress within partnerships. If untreated, these issues can escalate, potentially leading to more serious relationship problems or breakdowns.

Physical Health Consequences: There is a bidirectional relationship between sexual dysfunction and physical health. For instance, erectile dysfunction has been identified as a predictor of cardiovascular disease in men. A study by Vlachopoulos et al. (2013) showed that erectile dysfunction can be an early marker of vascular disease, underscoring the importance of addressing sexual dysfunction as part of overall health.

Quality of Life: Sexual health is a significant aspect of overall quality of life. A study by Shifren et al. (2008) demonstrated that sexual dysfunction is associated with lower levels of happiness and satisfaction with life. Persistent sexual dysfunction can lead to long-term reductions in quality of life, affecting various aspects of daily functioning.

Social and Psychological Stigma: Additionally, sexual dysfunction often carries social and psychological stigma, which can lead to social withdrawal and exacerbate feelings of isolation and loneliness. This aspect, although less researched, is crucial in understanding the broader implications of untreated sexual dysfunction.

These studies collectively emphasize the importance of treating Other Specified Sexual Dysfunction to prevent these potential adverse outcomes and improve overall well-being.

Summary

Other Specified Sexual Dysfunction presents a particularly challenging area in the field of sexual health due to its complex and multifaceted nature. Diagnosing and treating this disorder can be difficult, as it encompasses a range of symptoms that do not fit neatly into the specific sexual dysfunction categories outlined in the DSM-5-TR. Historically, the understanding and categorization of sexual dysfunctions have evolved, with contemporary perspectives focusing more on inclusivity and compassion. This shift reflects a broader understanding of sexual health as a vital component of overall well-being.

The evolution in the perspective on sexual dysfunctions can be traced back over the past few decades. Initially, the focus was primarily on physiological aspects. Still, over time, there has been a growing recognition of the psychological, relational, and socio-cultural factors that play a crucial role in sexual health. Studies like those by Tiefer (2001) have advocated for a more inclusive and comprehensive approach to understanding sexual dysfunction, one that goes beyond a narrow biomedical perspective.

One of the most significant impacts of Other Specified Sexual Dysfunction is on personal relationships. Research by McCabe (2001) has shown that sexual dysfunction can lead to relationship stress and communication difficulties. This impact extends beyond the bedroom, affecting overall relationship satisfaction and stability.

The disorder also has profound implications for an individual's sense of identity and self-esteem. According to a study by Hartmann et al. (2002), individuals with sexual dysfunction often experience a decrease in self-confidence and an altered sense of self. This change can affect their ability to function in daily life, impacting social interactions, work performance, and overall mental health.

Moreover, the stigma associated with sexual dysfunction can exacerbate these impacts. The social and psychological stigma can lead to feelings of shame and isolation, as highlighted in research by Moreira et al. (2005). This stigma can prevent individuals from seeking help, thus prolonging and intensifying the adverse effects of the dysfunction.

In conclusion, Other Specified Sexual Dysfunction is a complex and multifaceted disorder that can significantly impact an individual's mental health, relationships, and quality of life. The evolving understanding of this disorder reflects a more inclusive and compassionate approach, recognizing the importance of addressing the diverse factors contributing to sexual health.

References

Atlantis, E., & Sullivan, T. (2012). Bidirectional association between depression and sexual dysfunction: A systematic review and meta-analysis. Journal of Sexual Medicine, 9(6), 1497-1507.

Bacon, C. G., Mittleman, M. A., Kawachi, I., Giovannucci, E., Glasser, D. B., & Rimm, E. B. (2003). Sexual function in men older than 50 years of age: Results from the health professionals follow-up study. Annals of Internal Medicine, 139(3), 161-168.

Balon, R. (2006). SSRI-Associated Sexual Dysfunction. American Journal of Psychiatry, 163(9), 1504-1509.

Bancroft, J., & Janssen, E. (2000). The dual control model of male sexual response: A theoretical approach to centrally mediated erectile dysfunction. Neuroscience & Biobehavioral Reviews, 24(5), 571-579.

Bancroft, J., Loftus, J., & Long, J. S. (2003). Distress about sex: A national survey of women in heterosexual relationships. Archives of Sexual Behavior, 32(3), 193-208.

Brotto, L. A. (2010). The DSM diagnostic criteria for sexual aversion disorder. Archives of Sexual Behavior, 39(2), 271-277.

Esposito, K., Giugliano, F., Di Palo, C., Giugliano, G., Marfella, R., D'Andrea, F., ... & Giugliano, D. (2004). Effect of lifestyle changes on erectile dysfunction in obese men: A randomized controlled trial. Journal of the American Medical Association, 291(24), 2978-2984.

Feldman, H. A., Johannes, C. B., Derby, C. A., Kleinman, K. P., Mohr, B. A., Araujo, A. B., & McKinlay, J. B. (2000). Erectile dysfunction and coronary risk factors: Prospective results from the Massachusetts male aging study. Preventive Medicine, 30(4), 328-338.

Hartmann, U., Philippsohn, S., Heiser, K., & Rüffer-Hesse, C. (2002). Low sexual desire in midlife and older women: Personality factors, psychosocial development, present sexuality. Menopause, 9(6), 392-402.

Heiman, J. R., & Meston, C. M. (1997). Empirically validated treatment for sexual dysfunction. Annual Review of Sex Research, 8, 148-194.

Jackson, G., Montorsi, P., Adams, M. A., Anis, T., El-Sakka, A., Miner, M., ... & Sharlip, I. D. (2010). Cardiovascular aspects of sexual medicine. Journal of Sexual Medicine, 7(4 Pt 2), 1608-1626.

Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281(6), 537-544.

Leiblum, S. R., & Chivers, M. L. (2007). Normal and persistent genital arousal in women: new perspectives. Journal of Sex & Marital Therapy, 33(4), 287-300.

Leiblum, S., & Nathan, S. (2001). Persistent sexual arousal syndrome: A newly discovered pattern of female sexuality. Journal of Sex & Marital Therapy, 27(4), 365-380.

Lew-Starowicz, M., & Rola, R. (2013). Sexual dysfunction in patients with neurologic disorders. Neurological Sciences, 34(1), 71-78.

Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O'Muircheartaigh, C. A., & Waite, L. J. (2007). A study of sexuality and health among older adults in the United States. The New England Journal of Medicine, 357(8), 762-774.

Maiorino, M. I., Bellastella, G., & Esposito, K. (2014). Diabetes and sexual dysfunction: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 7, 95-105.

McCabe, M. P. (2001). Cognitive-behavioral therapy for sexual dysfunction. Archives of Sexual Behavior, 30(2), 131-150.

McCabe, M. P. (2001). Psychological and interpersonal dimensions of sexual function and dysfunction. Archives of Sexual Behavior, 30(2), 131-150.

McCabe, M. P., & Althof, S. E. (2014). A systematic review of the psychosocial outcomes associated with erectile dysfunction: Does the impact of erectile dysfunction extend beyond a man's inability to have sex? Journal of Sexual Medicine, 11(2), 347-363.

Metz, M. E., & McCarthy, B. W. (2004). Coping with erectile dysfunction: How to regain confidence and enjoy great sex. New Harbinger Publications.

Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1022 outpatients. Journal of Clinical Psychiatry, 62(Suppl 3), 10-21.

Montorsi, F., Briganti, A., Salonia, A., Rigatti, P., Margonato, A., Macchi, A., Galli, S., & Ravagnani, P. M. (2003). Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease. European Urology, 44(3), 360-365.

Moreira, E. D., Brock, G., Glasser, D. B., Nicolosi, A., Laumann, E. O., Paik, A., ... & Gingell, C. (2005). Help-seeking behaviour for sexual problems: The global study of sexual attitudes and behaviors. International Journal of Clinical Practice, 59(1), 6-16.

Peate, I. (2005). The effects of smoking on the reproductive health of men. British Journal of Nursing, 14(7), 362-366.

Serretti, A., & Chiesa, A. (2009). Treatment-emergent sexual dysfunction related to antidepressants: A meta-analysis. Journal of Clinical Psychopharmacology, 29(3), 259-266.

Shamloul, R., & Ghanem, H. (2013). Erectile dysfunction. Lancet, 381(9861), 153-165.

Shifren, J. L., Monz, B. U., Russo, P. A., Segreti, A., & Johannes, C. B. (2008). Sexual problems and distress in United States women: Prevalence and correlates. Obstetrics & Gynecology, 112(5), 970-978.

Tiefer, L. (2001). A new view of women's sexual problems: Why new? Why now? Journal of Sex Research, 38(2), 89-96.

Vlachopoulos, C., Jackson, G., Stefanadis, C., & Montorsi, P. (2013). Erectile dysfunction in the cardiovascular patient. European Heart Journal, 34(27), 2034-2046.