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Common Sexual Dysfunctions
 In
diagnosis and history taking, it is important to remember that each dysfunction
covered in this course can be lifelong (has always been
present), acquired (has not always been present), situational
(occurs in some situations and not others), or generalized (occurs
regardless of the situation). The following list, while far from exhaustive,
describes common sexual dysfunctions, their possible causes, and treatments.
Note: Sexual
dysfunctions should be assessed objectively and managed according to the
cause—not according to the status, orientation, or age of the affected
client. The range of dysfunction encountered among adolescents, older
clients, unmarried adults, homosexuals, and bisexuals is the same as that
found among married heterosexual adults of reproductive age. If you feel
unable to provide professional, impartial services to particular clients,
refer the clients to another provider, if possible.
Sexual
desire changes over the course of our lives, and occasional loss of desire
in either sex is not uncommon. In ISD, however, there is persistent loss
of desire that disrupts sexual relationships. It is characterized by diminished
sexual attraction, decreased sexual activity, few or no sexual dreams
or fantasies, and diminished attention to erotic material by one or both
partners. ISD is the most common presenting sexual dysfunction in women
and is less commonly reported in men. Female sexual arousal disorder
(FSAD) is the name for persistent or recurrent inability to
achieve or maintain an adequate lubrication-swelling response. (A woman
with FSAD may or may not find enjoyment in physical contact.)
Causes of ISD:
- Contributing factors to
ISD include hormone deficiencies, depression, alcoholism, liver or kidney
disease, and chronic illness, as well as the side effects of drugs (e.g.,
antihypertensives and antidepressants). Psychological contributing factors
include stress, relationship problems, sexual trauma, major life changes,
and the pairing of negative memories with sexual interactions.
- In women. Testosterone
plays a vital role in women’s sexual desire. Reduction in testosterone
(e.g., due to removal of ovaries, chemotherapy, menopause) can be treated
through supplementation of the hormone. Life events affecting hormonal
patterns (though not fully understood) include premenstrual tension,
childbirth, pregnancy, and menopause.
- In men. Sexual
desire in men can be inhibited by many physical and psychological factors.
In the presence of testosterone deficiency, signs and symptoms include
loss of facial and body hair, decrease in lean muscle mass, fatigue,
loss of energy or lethargy, and erectile dysfunction (ED).
Treatment of ISD:
- ISD can be difficult to
treat. Replacement therapy is indicated if testosterone deficiency is
the cause of ISD. Determine if there are any relationship, situational,
or physical or psychological issues that may be contributing to the
loss of desire. (If the cause is psychological, most studies of outcome
indicate that response to psychological interventions for ISD is very
poor.)
- Treat or refer the client
to a sex therapist, urologist, or other appropriate specialist on the
basis of the underlying cause, if possible.
Dyspareunia is a condition
in women characterized by recurrent genital pain with sexual activity.
Pain usually occurs with penetration but can occur during nonpenetrative
genital stimulation as well. The pain can be superficial (at the vaginal
opening) or deep inside the vagina. Repeated pain can create a negative
cycle, leading to avoidance of sexual activity, lack of arousal, anorgasmia,
and ISD. Symptoms may include burning, itching, stinging, or inflammation
in any area of the perineum.
Causes of dyspareunia:
- The main causes are vulvovaginitis,
genital herpes, atrophic vulvitis, urethral problems, episiotomy, radiation
vaginitis, and sexual trauma, as well as inadequate lubrication or topical
irritants such as spermicides or latex.
- Deep pelvic pain is often
associated with thrusting by the partner that hits an ovary during sexual
intercourse, pelvic inflammatory disease (PID), pelvic or abdominal
surgery, postoperative adhesions, endometriosis, genital or pelvic tumors,
irritable bowel syndrome, urinary tract infection, and ovarian cysts.
Dyspareunia can also have psychological causes.
Treatment of dyspareunia:
- Considerations involve
identifying and treating any physical causes for pain. If the dyspareunia
is of a psychological nature, refer the client to a provider with a
background in sex therapy or psychology, if possible.
Vaginismus is a condition
in women characterized by difficulty in achieving penetration or discomfort
during penetration due to involuntary contractions of vaginal muscles.
Some women’s symptoms are so severe that they avoid any sexual contact;
others may have satisfying sexual experiences through extensive foreplay
leading to orgasm without penetration.
Causes of vaginismus:
- Vaginismus is often the
result of physical or sexual abuse that causes a phobic reaction at
the prospect of vaginal penetration.
- Other causes may include
painful first intercourse, relationship problems, fear of pregnancy,
rape, religious orthodoxy, or the woman’s belief that her vagina
is too small. It has been suggested that a woman experiencing psychological
conflict may indirectly express anger toward her partner by closing
off her vagina.
Treatment of vaginismus:
- Refer the client to a provider
with a background in sex therapy or psychology, if possible. The approach
to treatment is called “cognitive behavioral” therapy, consisting
of a program with specific exercises for relaxing the muscles around
the vagina and systematic desensitization of the vagina. The woman learns
to control her vaginal muscle spasm while gently introducing inserters
of gradually increasing size into her vagina. The success rate is fairly
high for women who complete the program.
Anorgasmia is a condition
in women characterized by a persistent or recurrent delay in or absence
of orgasm following a normal sexual excitement or plateau stage. Affected
women may have strong sexual desire, adequate arousal during the excitement
stage, and pleasure with vaginal penetration but are unable to experience
orgasm, even with adequate stimulation. (Note: Women are often misdiagnosed
as anorgasmic if they are not able to experience an orgasm through penile-vaginal
intercourse. A woman is not anorgasmic if she can achieve orgasm through
means other than penile-vaginal stimulation.)
Causes of anorgasmia:
- These include anger and
hostility toward one's partner, ineffective sexual technique, anxiety,
familial or religious teachings that discourage sexual stimulation,
and strong fear of loss of control over feelings and behavior.
- Anorgasmia can be experienced
where communication between partners is poor and where the sexual or
emotional needs of the anorgasmic partner are not satisfied.
Treatment of anorgasmia:
- Refer the client (and partner,
if applicable) to a sex therapist, where possible. Individual and couple
work is focused on treating the fear or phobia of orgasm or loss of
control, resolution of conflicts, and increasing stimulation. Couple
work involves sexuality education, addressing sexual myths, and developing
a greater understanding of the anorgasmic partner’s needs.
Premature ejaculation is a
condition in men characterized by persistent or recurrent ejaculation
with minimal sexual stimulation before, on, or shortly after penetration
and before the person wishes it. PE occurs when a man is unable to exert
reasonable voluntary control of his ejaculatory response and is unaware
of erotic sensations leading to the “point of inevitability”
and ejaculation. PE is most common among younger men and men with limited
sexual experience. The condition is often associated with performance
anxiety.
Causes of PE:
- Causes are rarely physical.
Some infections of the urethra and prostate, neglected gonorrhea, and
overly tight foreskin have been considered as possible physical causes.
- More commonly, the affected
man has not learned to recognize the sensory feedback that indicates
ejaculation is imminent. This is common among men who have taught themselves
to ignore this sensory feedback and “think of other things”
as a means of avoiding ejaculation before they are satisfied or before
their partner is satisfied.
Treatment of PE:
- Interventions may include
psychological approaches aimed at reducing anxiety, special techniques
to improve ejaculatory control (such as the “pause and squeeze”
technique), and drug therapy with the use of formulations that delay
ejaculation, thereby improving sexual satisfaction in the client and
his partner.
- Refer the client to a sex
therapist, psychologist, or urologist, if possible.
Male orgasmic disorder is
persistent or recurrent involuntary delay in orgasm and ejaculation or
the inability of the man to have orgasm. (Note: This is sometimes confused
with retrograde ejaculation—a condition in which the man ejaculates
into his bladder instead of out through the urethra. Retrograde
ejaculation is common in gay men and may be related to fears of infection
believed to be brought on by “safer sex” campaigns.)
Causes and treatment of male orgasmic
disorder:
- The cause is rarely physical
and rather is associated with a traumatic sexual experience, strict
religious upbringing, hostility, overcontrol, or lack of trust.
- Psychological exploration
and counseling is the indicated treatment.
ED (also known as impotence)
is the persistent or recurrent inability in men to attain an erection
or to maintain an erection until completion of sexual activity. (Note:
Occasional inability to achieve erection may cause undue stress and result
in performance anxiety, which affects future functioning and creates a
cycle of impotence. Occasional impotence is common; this is usually situational
and is not considered dysfunctional.) Erectile dysfunction, usually
of an organic type, is being seen increasingly in those with late stage
HIV. It is not yet clear whether ED is an effect of the virus or of the
antiviral drugs used to treat infection.
Causes of ED:
- Drugs, alcohol, diabetes,
Parkinson’s disease, multiple sclerosis, HIV, other diseases, and
spinal cord lesions can cause ED.
- Approximately one-third
of cases are psychological, one-third physical, and the remaining third
have a mix of both causes.
- Performance anxiety is
often associated with ED.
Treatment of ED:
- Where possible, refer the
client to a sex therapist, psychologist, or urologist. As part of treatment,
both partners should be counseled about the risks involved in some treatment
approaches.
- Approaches to treatment
depend on the cause of the dysfunction and commonly include intracavernosal
injection (with Papaverine, Alprostadil, Vasoactive intestinal polypeptide,
or combinations of these); intraurethral pellets (prostaglandin); oral
medications (Yohimbine, Sildenafil [Viagra]); hormonal treatment (testosterone,
in the presence of low levels); surgical interventions; and psychological
therapy.
- One approach to ED includes
the use of vacuum devices (manual or battery operated) that involve
placing the penis is a plastic tube with suction, thus drawing venous
blood into the penis to create an erection. Once the penis is erect,
a rubber constriction ring is placed at the base of the penis to prevent
the erection from being lost, thus allowing sexual intercourse. However,
tissue damage may result using this method if the erection is maintained
for more than 30 minutes.
- Surgical interventions
for the insertion of an inflatable penile prosthetic can allow erection
sufficient for sexual intercourse. These prostheses are used with men
who have had pelvic surgery, diabetes, or atherosclerosis; they can
also be used for conditions such as Peyronie’s disease (which is
characterized by a hard fibrous formation in the penile tissue layer
causing curvature of the penis on erection and sometimes pain, making
sexual intercourse difficult or impossible). Risks associated with the
surgical procedure include infection, trauma to the urethra, compression
or damage to the blood vessels in the penis, and drooping of the glans.
© 2007 EngenderHealth
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