Sexual
problems are defined as difficulty during any stage of the sexual act (which includes
desire, arousal, orgasm, and resolution) that prevents the individual or couple
from enjoying sexual activity.
Information
Sexual
difficulties can begin early in a person's sex life or they may develop after
an individual has previously experienced enjoyable and satisfying sex. A problem
may develop gradually over time, or may occur suddenly as a total or partial inability
to participate in one or more stages of the sexual act. The causes of sexual difficulties
can be physical, psychological, or both.
Emotional
factors affecting sex include both interpersonal problems (such as marital/relationship
problems, or lack of trust and open communication between partners) and psychological
problems within the individual (depression, sexual fears or guilt, past sexual
trauma, and so on).
Physical
factors include drugs (alcohol, nicotine, narcotics, stimulants, antihypertensives,
antihistamines, and some psychotherapeutic drugs); injuries to the back, problems
with an enlarged prostate gland, problems with blood supply, nerve damage (as
in spinal cord injuries); or disease (diabetic neuropathy, multiple sclerosis,
tumors, and, rarely, tertiary syphilis); failure of various organ systems (such
as the heart and lungs); endocrine disorders (thyroid, pituitary, or adrenal gland
problems); hormonal deficiencies (low testosterone, estrogen, or androgens); and
some birth defects.
Sexual
dysfunction disorders are generally classified into four categories: sexual desire
disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders.
Sexual
desire disorders or decreased libido can be caused by a decrease in normal estrogen
(in women) or testosterone (in both men and women) production. Other causes may
be aging, fatigue, pregnancy, medications -- the SSRI anti-depressants which include
fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are well known
for reducing desire in both men and women -- or psychiatric conditions, such as
depression and anxiety.
Sexual
arousal disorders were previously known as frigidity in women and impotence in
men, though these have now been replaced with less judgmental terms. Impotence
is now known as erectile dysfunction, and frigidity has been replaced with a number
of terms describing specific problems with, for example, desire or arousal.
For
both men and women, these conditions can manifest as an aversion to, and avoidance
of, sexual contact with a partner. In men, there may be partial or complete failure
to attain or maintain an erection, or a lack of sexual excitement and pleasure
in sexual activity.
There
may be medical causes to these disorders, such as decreased blood flow or lack
of vaginal lubrication. Chronic disease can also contribute, as well as the nature
of the relationship between the partners. As the success of Viagra attests, most
erectile disorders in men are primarily physical, not psychological conditions.
Orgasm
disorders are a persistent delay or absence of orgasm following a normal sexual
excitement phase. The disorder can occur in both women and men. Again, the SSRI
antidepressants are frequent culprits -- these can delay the achievement of orgasm
or eliminate it entirely.
Sexual
pain disorders affect women almost exclusively and are known as dyspareunia (painful
intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal
wall that interferes with intercourse). Dyspareunia may be caused by insufficient
lubrication (vaginal dryness) in women.
Poor
lubrication may result from insufficient excitement and stimulation, or from hormonal
changes caused by menopause, pregnancy, or breast-feeding. Irritation from contraceptive
creams and foams can also cause dryness, as can fear and anxiety about sex.
It
is unclear exactly what causes Vaginismus, but it is thought that past sexual
trauma (such as rape or abuse) may play a role. Another female sexual pain disorder
is called vulvodynia or vulvar vestibulitis. In this condition, women experience
burning pain during sex which seems to be related to problems with the skin in
the vulvar and vaginal areas. The cause is unknown.
Sexual
dysfunctions are more common in the early adult years, with the majority of people
seeking care for such conditions during their late twenties through thirties.
The incidence increases again in the geriatric population, typically with gradual
onset of symptoms that are associated most commonly with medical causes of sexual
dysfunction.
Sexual
dysfunction is more common in people who abuse alcohol and drugs. It is also more
likely in people suffering from diabetes and degenerative neurological disorders.
Ongoing psychological problems, difficulty maintaining relationships or chronic
disharmony with the current sexual partner can also interfere with sexual function.
PREVENTION
Open,
informative, and accurate communication regarding sexual issues and body image
between parents and their children may prevent children from developing anxiety
or guilt about sex and helps them develop healthy sexual relationships.
Review
all medications, both prescription and over-the-counter, for possible side effects
that relate to sexual dysfunction. Avoiding drug and alcohol abuse will also help
prevent sexual dysfunction.
Couples
who are open and honest about their sexual preferences and feelings are more likely
to avoid some sexual dysfunction. If your partner doesn't know what you want,
he or she can't give it to you.
People
who are victims of sexual trauma, such as sexual abuse or rape at any age, are
recommended to seek psychiatric advice. Individual conseling with an expert in
trauma may prove beneficial in allowing them to overcome their sexual difficulties
and enjoy voluntary sexual experiences with a partner of their choice.
SYMPTOMS
men
or women: lack of interest or desire in sex (loss of libido) inability
to feel aroused pain with intercourse (much less common in men than women)
men : inability to attain an erection inability to maintain an erection
adequately for intercourse delay or absence of ejaculation, despite adequate
stimulation inability to control timing of ejaculation women: inability
to relax vaginal muscles enough to allow intercourse inadequate vaginal lubrication
preceding and during intercourse inability to attain orgasm burning pain
on the vulva or in the vagina with contact to those areas SIGNS AND TESTS
Specific
physical findings and testing procedures depend on the form of sexual dysfunction
being investigated. In any case, a complete history and physical examination should
be done to identify predisposing illness or conditions; highlight possible fears,
anxieties, or guilt specific to sexual behaviors or performance; and elicit any
history of prior sexual trauma. A physical examination of both the partners should
include all systems and not be limited to the reproductive system.
TREATMENT
Treatment
measures depend on the cause of the sexual dysfunction. Medical causes that are
reversible or treatable are usually managed medically or surgically. Physical
therapy and mechanical aides may prove helpful for some people experiencing sexual
dysfunction due to physical illnesses, conditions, or disabilities.
For
men who have difficulty attaining an erection, the medication sildenafil (Viagra),
which increases blood flow to the penis, can be very helpful, though it must be
taken 1 to 4 hours prior to intercourse.
Men
who take nitrates for coronary heart disease should not take sildenafil. Mechanical
aids and penile implants are also an option for men who cannot attain an erection
and find sildenafil isn't helpful.
Women
with vaginal dryness can be helped with lubricating gels, hormonal creams, and
in cases of premenopausal or menopausal women with hormone replacement therapy.
In some cases, women with androgen deficiency can be helped by taking testosterone.
Vulvodynia
can be treated with testosterone cream, with use of biofeedback and with low doses
of some antidepressants which also treat nerve pain. Surgery has not been successful.
Behavioral
treatments involve many different techniques to treat problems associated with
orgasm and sexual arousal disorders. Self-stimulation and the Masters and Johnson
treatment strategies are only two of many behavioral therapies used.
Simple,
open, accurate, and supportive education about sex and sexual behaviors or responses
may be all that is required in many cases. Some couples may benefit from joint
counseling to address interpersonal issues and communication styles. Psychotherapy
may be required to address anxieties, fears, inhibitions, or poor body image.
PROGNOSIS
AND OUTCOME
The
prognosis (probable outcome) depends on the form of sexual dysfunction. In general,
the probable outcome is good for physical (organically caused) dysfunctions resulting
from treatable or reversible conditions. It should be noted, however, that many
organic causes do not respond to medical or surgical treatments.
In
functional sexual problems resulting from either relationship problems or psychological
factors, the prognosis may be good for temporary or mild dysfunction associated
with situational stressors or lack of accurate information. However, those cases
associated with chronically poor-functioning relationships or deep-seated psychiatric
problems typically do not have positive outcomes.
COMPLICATIONS
Some
forms of sexual dysfunction may cause infertility.
Persistent
sexual dysfunction may cause depression in some individuals. The importance of
the disorder to the individual (and couple, when applicable) needs to be determined.
Sexual dysfunction that is not addressed adequately may lead to conflicts or potential
breakups.
CALL
YOUR HEALTH CARE PROVIDER IF
Call
for an appointment with your health care provider if symptoms of sexual dysfunction
persist and are a concern.
Last
Reviewed: 9/9/2002 by Angela Smyth, M.D., Department of Psychiatry, University
of Chicago, Chicago, IL. Review provided by VeriMed Healthcare Network.
