Synonyms

Sexual dysfunction

Definition

Sexual functioning is characterized by absence of difficulty moving through the stages of sexual desire, arousal, and orgasm, as well as subjective satisfaction with the frequency and outcome of individual and partnered sexual behavior.

Description

Sexual functioning is an important aspect of quality of life. Our understanding of sexual functioning is influenced by not only the current state of medical knowledge but also the social values upheld in our culture. Healthy sexual functioning is characterized by a lack of pain or discomfort during sexual activity and a lack of physiological difficulty moving through the three-phase sexual response cycle of desire, arousal, and orgasm. In addition, sexual functioning is indicated by subjective feelings of satisfaction with the frequency of sexual desire and sexual behavior, as well as subjective pleasure during individual and partnered sexual activity.

Kaplan’s three-phase model is the basis for current models of healthy sexual response. The desire phase consists of sexual fantasies and desire to engage in sexual behavior. The arousal phase involves subjective feelings of pleasure along with physiological changes conducive to sexual intercourse. Males experience penile tumescence and erection, and females experience pelvic vasocongestion and vaginal lubrication. The orgasm phase consists of peak feelings of sexual pleasure and a release of sexual tension. Males ejaculate semen, whereas females experience contractions of the outer vaginal wall; additionally, in both males and females, the anal sphincter contracts. Individuals may experience physiological and/or psychological difficulties at any or all of the three phases of sexual response. A resolution period, characterized by relaxation and, for males, a refractory period, follows orgasm.

Etiology of Sexual Dysfunction

The etiology of sexual problems is often a complex combination of biological/medical, psychological, and social factors. For example, the sexual dysfunction may be secondary to a chronic health condition or psychotropic medication. In other cases, performance anxiety, low mood, or previous traumatic experiences may impair sexual functioning. Moreover, conflicts within a relationship as well as within the larger sociocultural context may affect an individual’s sexual functioning. Due to the variety of potential predisposing, precipitating, and maintaining factors, clinicians are encouraged to take a biopsychosocial approach to assessment and treatment of problems in sexual functioning.

Sexual Dysfunction Disorders

Consistent with the medical model of disease, most research and scholarship focuses on sexual dysfunction rather than healthy sexual functioning. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2000) describes nine main disorders of sexual dysfunction, which are grouped into four categories: desire, arousal, orgasm, and pain. All nine disorders share some common diagnostic criteria: the dysfunction is persistent and recurrent; the dysfunction is not substance-induced, due to a general medical condition, or part of another Axis I mental disorder; and the dysfunction causes clinically significant distress or interpersonal difficulty. Sexual dysfunctions are also classified according to their onset (lifelong or acquired), context (generalized or situational), and etiology (due to psychological factors or due to combined psychological and medical factors). Additional diagnostic options include sexual dysfunction due to a general medical condition, substance-induced sexual dysfunction, and sexual dysfunction not otherwise specified.

Desire disorders are characterized by lack of interest in sex, absence of sexual fantasies and sexual behavior, or fear of sexual contact. In hypoactive sexual desire disorder, there is a low level of sexual fantasy and desire for sex. In sexual aversion disorder, genital sexual contact is feared and actively avoided.

Arousal disorders are characterized by difficulty attaining or maintaining sexual arousal. Male erectile disorder is the most researched type of sexual dysfunction and receives the most media attention, particularly since the advent of Sildenafil (Viagra) in 1998. Erectile dysfunction is the inability to maintain an erection adequate for sexual penetration until completion of sexual activity. Female sexual arousal disorder is the inability to attain or maintain vaginal lubrication until completion of sexual activity.

Orgasm disorders are characterized by delay in or absence of orgasm on one extreme, or, on the other extreme, by occurrence of orgasm before the individual wants. In female orgasmic disorder and male orgasmic disorder, orgasm is delayed or absent despite normal sexual arousal and sufficient sexual stimulation. Premature ejaculation describes the occurrence of ejaculation with minimal stimulation before, upon, or soon after penetration and before the individual wants to orgasm.

Sexual pain disorders are characterized by genital pain that is not due to a general medical condition. In dyspareunia, which affects both males and females, genital pain occurs during sex. In vaginismus, involuntary muscle spasms of the vagina prevent penetration or may cause pain if it is attempted.

Prevalence of Sexual Dysfunction

Epidemiological surveys suggest problems with sexual functioning are common among the general population. For example, prevalence rates of premature ejaculation, erectile dysfunction, and female orgasmic disorder are 5%, 5%, and 10%, respectively, among community samples (Wincze & Carey, 2001). Symptoms that do not meet full diagnostic criteria for a sexual dysfunction disorder are likely much more common. Patients struggling with sexual health problems may be reluctant to seek medical consultation due to embarrassment or privacy concerns. Many health care providers are also uncomfortable discussing sexuality, so patients’ sex-related questions and concerns may be neglected in clinical settings.

Assessment of Sexual Functioning

Clinicians are advised to employ multimethod assessment of sexual functioning by including medical, psychosocial, and psychophysiological components. All three perspectives provide valuable information that aids in diagnosing sexual dysfunction, hypothesizing the etiology of the problem, and developing an appropriate treatment plan.

A medical evaluation is an essential piece of the sexual functioning assessment. A general physical examination allows for biological causes (e.g., general medical conditions, such as diabetes or cancer, as well as other vascular, neurologic, or hormonal conditions) to be ruled out. A gynecological or urological exam ensures no anatomical complications. Physical symptoms, such as bleeding or pain, can also be addressed. Medical providers should attend to any notable medical history (e.g., surgeries) as well as any prescription medications or substance use that may affect sexual functioning.

For the psychosocial evaluation, an interview is essential to learn about the onset, frequency, intensity, and duration of the presenting complaint(s). In addition, clinicians should assess pertinent areas including family history, adolescence, significant relationships in adulthood, sexual history, and sexual abuse or trauma. Although an individual patient may present with sexual complaints, difficulties with sexual functioning are often better understood in the context of the individual’s sexual relationship. In many cases (e.g., when working with a patient who is married or in a committed relationship), involving the patient’s sexual partner in the psychosocial evaluation (with the patient’s permission) facilitates a better resolution. It is often advisable to interview the patient’s sexual partner separately to find out more about the presenting complaint. A joint interview with the patient and his or her partner also provides additional insight into the couple’s interaction style, relationship quality, and non-sex-related problems that may cause interpersonal tension. For some patients, self-administered questionnaires may be used to supplement the psychosocial interview. Questionnaires may provide an easier method whereby to disclose sensitive information compared to a face-to-face interview.

The third potential component of the evaluation is psychophysiological assessment. Depending on the presenting complaint, psychophysiological measures can be quite helpful in differential diagnosis. For example, nocturnal penile tumescence is the gold standard for differential diagnosis for male patients with erectile dysfunction. Inability to obtain erections during sleep indicates a medical cause, whereas ability to maintain erections during sleep suggests a psychosocial cause.

Treatment of Sexual Dysfunction

Often the first therapeutic intervention occurs during the comprehensive assessment. During the psychosocial and medical evaluations, clinicians normalize the patient’s problem, provide information, and correct misunderstandings. Formal treatment plans will depend on the presumed cause of the sexual dysfunction. Medical treatments include options such as pharmacotherapy (e.g., Viagra for erectile dysfunction), gels and creams (e.g., lubricating gels to compensate for problems with female arousal), hormone replacement therapy (e.g., testosterone to increase sexual desire), and surgery (e.g., penile implants to treat organic erectile dysfunction). Psychological treatments include psychoeducation about healthy sexual functioning, behaviorally focused sex therapy with the patient or the patient and his or her partner (e.g., using the stop-start technique to treat premature ejaculation), interpersonally focused couples therapy with the patient and his or her partner (e.g., working on trust or communication), or more traditional individual therapy with the patient (e.g., treating mood, anxiety, or trauma symptoms).

Cross-References

Sexual Behavior