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Sexual Dysfunction Explained


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Sexual dysfunction or sexual malfunction  (see also sexual function) refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm.


Categories

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


Sexual desire disorders

Sexual desire disorders or decreased libido can be caused by a decrease production of normal estrogen in women or testosterone in both men and women.  Other causes may be ageing, fatigue, pregnancy, medications (such as the SSRIs) or psychiatric conditions, such as depression and anxiety.  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.


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.  Unlike disorders of orgasm, as the success of sildenafil (Viagra) attests, most erectile disorders in men are primarily physical conditions.


Orgasm disorders

Orgasm disorders are persistent delays or absence of orgasm following a normal sexual excitement phase.  The disorder can occur in both women and men.  The SSRI antidepressants may be the reason for the disorder, as they can delay orgasm or eliminate it entirely.


Sexual pain disorders

Sexual pain disorders affect women almost exclusively and are 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.


General

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.


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, 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, among others.

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.  Injuries to the back may also impact sexual activity, aswould problems with an enlarged prostate gland, problems with blood supply, nerve damage (as in spinal cord injuries).  Disease, such as diabetic neuropathy, multiple sclerosis, tumours, 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.


Symptoms

Psychological sexual disorders

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

01)  Hypoactive sexual disorder (see also asexuality)

02)  Beastiality

03)  Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse)

04)  Female sexual arousal disorder (failure of normal lubricating arousal response)

05)  Male erectile disorder

06)  Female orgasmic disorder (see Anorgasmia)

07)  Male orgasmic disorder (see Anorgasmia)

08)  Premature ejaculation

09)  Dyspareunia

10)  Vaginismus

11)  Secondary sexual dysfunction

12)  Paraphilias

13)  PTSD due to genital mutilation or childhood sexual abuse


Other sexual disorders

Sexual dissatisfaction (non-specific)

01)  Anorgasmia

02)  Impotence

03)  Sexually transmitted diseases

04)  Delay or absence of ejaculation, despite adequate stimulation

05)  Inability to control timing of ejaculation

06)  Inability to relax vaginal muscles enough to allow intercourse

07)  Inadequate vaginal lubrication preceding and during intercourse

08)  Burning pain on the vulva or in the vagina with contact to those areas

09)  Unhappiness or confusion related to sexual orientation

10)  Transsexual and transgender people may have sexual problems (pre or post surgery)
       though actually being transgendered or transsexual is not a sexual problem in itself.

11)  Persistent sexual arousal syndrome

12)  Post SSRI Sexual Dysfunction

13)  Sexual addiction

14)  Hypersexuality

15)  Female genital cutting


Other related problems

01)  Infertility

02)  Paraphilia


Treatment for females

Although there are no approved pharmaceuticals for addressing female sexual disorders, several are under investigation for their effectiveness.  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. Women experiencing pain with intercourse are often prescribed pain relievers or desensitising agents.  Others are prescribed lubricants and/or hormone therapy.  Many patients with female sexual dysfunction are often also referred to a counsellor or therapist for psychosocial counselling.

A manual physical therapy, the Wurn Technique, which is designed to reduce pelvic and vaginal adhesion, may also be beneficial for women experiencing sexual pain and dysfunction.  In a controlled study, Increasing orgasm and decreasing intercourse pain by a manual physical therapy technique, twenty-three (23) women reporting painful intercourse and/or sexual dysfunction received a 20-hour program of manipulative physical therapy.  The results were compared using the validated Female Sexual Function Index, with post-test vs. pretest scores.  Results of therapy showed improvements in all six recognised domains of sexual dysfunction.  The results were significant (P </= .003) on all measures, with individual measures and P-values as follows: desire (P < .001), arousal (P = .0033), lubrication (P < .001), orgasm (P < .001), satisfaction (P < .001), and pain (P < .001). A second study to improve sexual function in patients with endometriosis showed similar statistical results.


Clinical studies

The earliest attempts at treating sexual dysfunctions, especially erectile dysfunction, date back to Muslim physicians and pharmacists in the medieval Islamic world.  They were the first to prescribe medication for the treatment of this problem, and they developed several methods of therapy for this issue, including a single-drug therapy method where a drug was prescribed and a 'combination method of either a drug or food.'  Most of these drugs were oral medication, though a few patients were also treated through topical and transurethral means.  Sexual dysfunctions were being treated with clinically tested drugs in the Islamic world since the 9th century until the 16th century by a number of Muslim physicians and pharmacists, including Muhammad ibn Zakariya Razi, Thabit bin Qurra, Ibn Al-Jazzar, Avicenna (The Canon of Medicine), Averroes, Ibn al-Baitar, and Ibn al-Nafis (The Comprehensive Book on Medicine).

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 and vice versa.

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 over-run by ethusiastic 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.


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