The nosological system for sexual disorders incorporated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) characterizes sexual dysfunction as disturbances in sexual response denned to include four phases: desire, excitement, orgasm, and resolution. This classification, psychophysiologically based and oriented towards sexual performance, does not fully encompass the experiences and problems of the aging male. Aging is mostly neglected in DSM-IV as an associated feature of sexual dysfunction and its subjective aspects, which become more salient as age progresses. However, a significant improvement in the DSM-IV edition should be recognized. The diagnostic criteria for sexual dysfunction now require that the disturbance causes marked distress or interpersonal difficulties (Table 8.1). Consequently, age-related declines in a man's sexual function may not be categorized as dysfunctional unless they are problematic for the individual or his partner.

Sexual problems and concerns, not classifiable as dysfunctional according to DSM-IV diagnostic categories, are highly prevalent in the aging population. Their importance as a source of dissatisfaction and as a determinant of help-seeking behavior has been frequently ignored. The large body of data on sexual problems in the aging male is remarkable for its almost exclusive focus on erectile disorders. Regrettably, the health-care delivery system in the Western world tends to focus on the functional decrements in erectile capacity with limited attention given to underlying individual and interpersonal difficulties. In this chapter we shall summarize information from selected surveys, representative samples of the community at large and clinical populations. Among the latter we shall describe our clinical experience over a 17-year span at the Human Sexuality Program at Mount Sinai Medical Center.