Sexual dysfunction

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Sexual dysfunction
SpecialtyPsychiatry Edit this on Wikidata

Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, preference, arousal or orgasm. A thorough sexual history and assessment of general health and other sexual problems (if any) are very important. Assessing (performance) anxiety, guilt, stress and worry are integral to the optimal management of sexual dysfunction. When a sexual problem is managed inappropriately or sub-optimally, it is very likely that the condition will subside immediately but re-emerge after a while [citation needed]. When this cycle continues, it strongly reinforces failure which may eventually cause one to not want to seek further treatment and experience symptoms all their life. It is important to get a thorough assessment from professionals and therapists who are qualified to manage sexual problems [citation needed]. Internet-based information is good for gaining knowledge about sexual functioning and sexual problems but not for self-diagnosis and/or self-management[citation needed].

Categories

Sexual dysfunction disorders may be classified into four categories: sexual desire disorders, arousal disorders, orgasm disorders and pain disorders.

Sexual desire disorders

Main article: Hypoactive sexual desire disorder

Sexual desire disorders or decreased libido are characterised by a lack or absence for some period of time of sexual desire or libido for sexual activity or of sexual fantasies. The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may have started after a period of normal sexual functioning or the person may always have had no/low sexual desire.

The causes vary considerably, but include a possible decrease in the production of normal estrogen in women or testosterone in both men and women. Other causes may be aging, fatigue, pregnancy, medications (such as the SSRIs) or psychiatric conditions, such as depression and anxiety.[1] Loss of libido from SSRIs usually reverses after SSRIs are discontinued, but in some cases it does not. This has been called PSSD; however, this is not a classification that would be found in any current medical text. While a number of causes for low sexual desire are often cited, only some of these have ever been the object of empirical research. Many rely entirely on the impressions of therapists.[2]

Sexual arousal disorders

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 themselves 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.

Erectile dysfunction

Main article: Erectile dysfunction

Erectile dysfunction or impotence is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. There are various underlying causes, such as damage to the nervi erigentes which prevents or delays erection, or diabetes as well as cardiovascular disease, which simply decreases blood flow to the tissue in the penis, many of which are medically reversible.

The causes of erectile dysfunction may be psychological or physical. Psychological erectile dysfunction can often be helped by almost anything that the patient believes in; there is a very strong placebo effect. Physical damage is much more severe. One leading physical cause of ED is continual or severe damage taken to the nervi erigentes. These nerves course beside the prostate arising from the sacral plexus and can be damaged in prostatic and colo-rectal surgeries.

Due to its embarrassing nature and the shame felt by sufferers, the subject was taboo for a long time, and is the subject of many urban legends. Folk remedies have long been advocated, with some being advertised widely since the 1930s. The introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (trade name Viagra), in the 1990s caused a wave of public attention, propelled in part by the news-worthiness of stories about it and heavy advertising.

It is estimated that around 30 million men in the United States suffer from Erectile Dysfunction.[3] However, social stigma, low health literacy and social taboos lead to under reporting which makes an accurate prevalence rate hard to determine.

The Latin term impotentia coeundi describes simple inability to insert the penis into the vagina. It is now mostly replaced by more precise terms.

Premature ejaculation

Main article: Premature ejaculation

Premature ejaculation is when ejaculation occurs before the partner achieves orgasm, or a mutually satisfactory length of time has passed during intercourse. There is no correct length of time for intercourse to last, but generally, premature ejaculation is thought to occur when ejaculation occurs in under 2 minutes from the time of the insertion of the penis.[4] For a diagnosis, the patient must have a chronic history of premature ejaculation, poor ejaculatory control, and the problem must cause feelings of dissatisfaction as well as distress the patient, the partner or both.[5]

Historically attributed to psychological causes, new theories suggest that premature ejaculation may have an underlying neurobiological cause which may lead to rapid ejaculation.[6]

Orgasm disorders

Main article: Anorgasmia

Orgasm disorders are persistent delays or absence of orgasm following a normal sexual excitement phase. The disorder can have physical, psychological, or pharmacological origins. SSRI antidepressants are a common pharmaceutical culprit, as they can delay orgasm or eliminate it entirely.

See also: Post-SSRI sexual dysfunction

Sexual pain disorders

Sexual pain disorders affect women almost exclusively and are also known as dyspareunia (painful intercourse) or 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.

Uncommon sexual disorders in men

Erectile dysfunction from vascular disease is usually seen only amongst elderly individuals who have atherosclerosis. Vascular disease is common in individuals who have diabetes, peripheral vascular disease, hypertension and those who smoke. Any time blood flow to the penis is impaired, erectile dysfunction is the end result.

Hormone deficiency is a relatively rare cause of erectile dysfunction. In individuals with testicular failure like in Klinefelter syndrome, or those who have had radiation therapy, chemotherapy or childhood exposure to mumps virus, the testes may fail and not produce testosterone. Other hormonal causes of erectile failure include brain tumors, hyperthyroidism, hypothyroidism or disorders of the adrenal gland.[7]

Structural abnormalities of the penis like Peyronie's disease can make sexual intercourse difficult. The disease is characterized by thick fibrous bands in the penis which leads to a deformed-looking penis.[8]

Drugs are also a cause of erectile dysfunction. Individuals who take drugs to lower blood pressure, uses antipsychotics, antidepressants, sedatives, narcotics, antacids or alcohol can have problems with sexual function and loss of libido.[9]

Priapism is a painful erection that occurs for several hours and occurs in the absence of sexual stimulation. This condition develops when blood gets trapped in the penis and is unable to drain out. If the condition is not promptly treated, it can lead to severe scarring and permanent loss of erectile function. The disorder occurs in young men and children. Individuals with sickle-cell disease and those who abuse certain medications can often develop this disorder.[10]

Causes

There are many factors which may result in a person experiencing a sexual dysfunction. These may result from emotional or physical causes.

Sexual dysfunction may arise from emotional factors, including interpersonal or psychological problems. Interpersonal problems may arise from marital or relationship problems, performance anxiety, or from a lack of trust and open communication between partners, and psychological problems may be the result of depression, sexual fears or guilt, past sexual trauma, sexual disorders,[11] among others.

Sexual dysfunction is especially common among people who have anxiety disorders. Ordinary anxiousness can obviously cause erectile dysfunction in men without psychiatric problems, but clinically diagnosable disorders such as panic disorder commonly cause avoidance of intercourse and premature ejaculation. Pain during intercourse is often a comorbidity of anxiety disorders among women.[1]

Sexual activity may also be impacted by physical factors. These would include use of drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs.[12] For women, almost any physiological change that affects the reproductive system—premenstrual syndrome, pregnancy, postpartum, menopause—can have an adverse effect on libido.[12] Injuries to the back may also impact sexual activity, as would problems with an enlarged prostate gland, problems with blood supply, nerve damage (as in spinal cord injuries). Disease, such as diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis may also impact on the activity, as would 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.

List of disorders

Physical or psychological sexual disorders under the DSM

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders lists the following sexual dysfunctions:

Additional DSM sexual disorders that are not sexual dysfunctions include:

Other sexual problems

Treatment for males

Since in many men the cause of sexual dysfunction is related to anxiety about performance, psychotherapy can help. Situational anxiety arises from an earlier bad incident or lack of experience. This anxiety often leads to development of fear towards sexual activity and avoidance. In return evading leads to a cycle of increased anxiety and desensitization of the penis.[13] In some cases, erectile dysfunction may be due to marital disharmony. Marriage counseling sessions are recommended in this situation.

Lifestyle changes such as discontinuing smoking, drug or alcohol abuse can also help in some types of erectile dysfunction.[14] Several medications like Viagra, Cialis and Levitra have become available to help people with erectile dysfunction. These medications do work in about 60% of men. In the rest, the medications may not work because of wrong diagnosis or chronic history.

Another type of medication that is effective in roughly 85% of men is called intracavernous pharmacotherapy — used by companies such as Boston Medical Group, Performance Medical Centers and independent doctors — and involves injecting a vasodilator drug directly into the penis in order to stimulate an erection.[15] This method has an increased risk of priapism if used in conjunction with other treatments, and localized pain.[5]

Treatment for females

Although there are no approved pharmaceuticals for addressing female sexual disorders, several are under investigation for their effectiveness.[16] A vacuum device is the only approved medical device for arousal and orgasm disorders. It is designed to increase blood flow to the clitoris and external genitalia.[16] Women experiencing pain with intercourse are often prescribed pain relievers or desensitizing agents. Others are prescribed lubricants and/or hormone therapy.[16] Many patients with female sexual dysfunction are often also referred to a counselor or therapist for psychosocial counseling.[16]

Clinical studies

In modern times, the genuine clinical study of sexual problems is usually dated back no further than 1970 when Masters and Johnson's Human Sexual Inadequacy was published. It was the result of over a decade of work at the Reproductive Biology Research Foundation in St. Louis, involving 790 cases. The work grew from Masters and Johnson's earlier Human Sexual Response (1966).

Prior to Masters and Johnson the clinical approach to sexual problems was largely derived from the thinking of Freud. It was held with psychopathology and approached with a certain pessimism regarding the chance of help or improvement. Sexual problems were merely symptoms of a deeper malaise and the diagnostic approach was from the psychopathological. There was little distinction between difficulties in function and variations nor between perversion and problems. Despite work by psychotherapists such as Balint sexual difficulties were crudely split into frigidity or impotence, terms which too soon acquired negative connotations in popular culture.

The achievement of Human Sexual Inadequacy was to move thinking from psychopathology to learning, only if a problem did not respond to educative treatment would psychopathological problems be considered. Also treatment was directed at couples, whereas before partners would be seen individually. Masters and Johnson saw that sex was a joint act. They believed that sexual communication was the key issue to sexual problems not the specifics of an individual problem. They also proposed co-therapy, a matching pair of therapists to the clients, arguing that a lone male therapist could not fully comprehend female difficulties.

The basic Masters and Johnson treatment program was an intensive two week program to develop efficient sexual communication. Couple-based and therapist led the program began with discussion and then sensate focus between the couple to develop shared experiences. From the experiences specific difficulties could be determined and approached with a specific therapy. In a limited number of male only cases (41) Masters and Johnson had developed the use of a female surrogate, an approach they soon abandoned over the ethical, legal and other problems it raised.

In defining the range of sexual problems Masters and Johnson defined a boundary between dysfunction and deviations. Dysfunctions were transitory and experienced by the majority of people, dysfunctions bounded male primary or secondary impotence, premature ejaculation, ejaculatory incompetence; female primary orgasmic dysfunction and situational orgasmic dysfunction; pain during intercourse (dyspareunia) and vaginismus. According to Masters and Johnson sexual arousal and climax are a normal physiological process of every functionally intact adult, but despite being autonomic it can be inhibited. Masters and Johnson treatment program for dysfunction was 81.1% successful.

Despite the work of Masters and Johnson the field in the US was quickly overrun by enthusiastic rather than systematic approaches, blurring the space between 'enrichment' and therapy. Although it has been argued that the impact of the work was such that it would be impossible to repeat such a clean experiment.

See also

2

References

  1. ^ a b Coretti G and Baldi I (August 1, 2007). "The Relationship Between Anxiety Disorders and Sexual Dysfunction". Psychiatric Times. 24 (9).
  2. ^ Maurice, William (2007): “Sexual Desire Disorders in Men.” in ed. Leiblum, Sandra: Principles and Practice of Sex Therapy (4th ed.) The Guilford Press. New York
  3. ^ NIH. Consensus Development Panel on Impotence. Impotence. Journal of the American Medical Association. 1993;270: 83 - 90
  4. ^ Waldinger M.D.,Berenden H.H., Blok B.F., et al. Premature Ejaculation and Serotengeric Anti-depressants - Induced Delayed Ejaculation: The Involvement of the Serotonergic System. Behavioural Brain Res. 1998;92(2): 111-118
  5. ^ a b Diaz V.A. & Close J.D. Male Sexual Dysfunction Primary Care 2010;37(3): 473 - 489.'
  6. ^ Lauman E.O., Nicolosi, A., Glasser D.B., et al. Sexual Problems among women and men aged 40 to 80 years: Prevalence and Correlates Identified in a GLobal Study of Sexual Attitudes and Behaviours. Internation Journal of Impotence Research. 2005;7(1): 39 - 57.
  7. ^ Strange sexual disorders Ask Men. Retrieved on February 18, 2010
  8. ^ Analysis of abnormal sexual disturbances 2010-02-18[unreliable medical source?]
  9. ^ Gupta, A; Chaudhry, M; Elewski, B (2003). "Tinea corporis, tinea cruris, tinea nigra, and piedra". Dermatologic Clinics. 21 (3): 395–400, v. doi:10.1016/S0733-8635(03)00031-7. PMID 12956194.
  10. ^ A study on Priapism eMedicine. Retrieved on 2010-02-18
  11. ^ Michetti, P M; Rossi, R; Bonanno, D; Tiesi, A; Simonelli, C (2005). "Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile dysfunction (ED)". International Journal of Impotence Research. 18 (2): 170–4. doi:10.1038/sj.ijir.3901386. PMID 16151475.
  12. ^ a b Saks BR (April 15, 2008). "Common issues in female sexual dysfunction". Psychiatric Times. 25 (5).
  13. ^ How to Get Rid of Sexual Disorders and Dysfunction Online guide against depression. Retrieved on 2010-02-18
  14. ^ Merck Sharpe & Dohme. "Male genital and sexual disorders" 2010-02-18.
  15. ^ Rodríguez Vela, L; Moncada Iribarren, I; Gonzalvo Ibarra, A; Sáenz de Tejada y Gorman I (1998). "Treatment of erectile dysfunction using intracavernous pharmacotherapy". Actas urologicas espanolas. 22 (4): 291–319. PMID 9658642.
  16. ^ a b c d Amato P, MD. An update on therapeutic approaches to female sexual dysfunction [1]. 2007. Retrieved August 14, 2008.

Further reading

External links

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