Sexual dysfunction

Sexual dysfunction can be classified into four categories: sexual desire disorders, arousal disorders, orgasm disorders, and pain disorders. Dysfunction among men and women are studied in the fields of andrology and gynecology respectively. Sexual desire disorders Sexual desire disorders or decreased libido are characterized by a lack of sexual desire, libido for sexual activity, or sexual fantasies for some time. The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may start after a period of normal sexual functioning, or the person may always have had an absence or a lesser intensity of sexual desire. The causes vary considerably but include a 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 SSRIs), or psychiatric conditions, such as depression and anxiety. While many causes of low sexual desire are cited, only a few of these have ever been the object of empirical research. 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 that can be broken down into four categories as described by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: lack of desire, lack of arousal, pain during intercourse, and lack of orgasm. 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 physiological origins to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease and the partners' relationship can also contribute to dysfunction. Additionally, postorgasmic illness syndrome (POIS) may cause symptoms when aroused, including adrenergic-type presentation: rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness, and fatigue. From the onset of arousal, symptoms can persist for up to a week in patients. The cause of this condition is unknown; however, it is believed to be a pathology of either the immune system or autonomic nervous systems. It is defined as a rare disease by the National Institute of Health, but the prevalence is unknown. It is not thought to be psychiatric in nature, but it may present as anxiety relating to coital activities and may be incorrectly diagnosed as such. There is no known cure or treatment. Erectile dysfunction Erectile dysfunction (ED), or impotence, is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. There are various underlying causes of ED, including damage to anatomical structures, psychological causes, medical disease, and drug use. Many of these causes are medically treatable. Psychogenic ED is defined as ED primarily due to psychological disease or interpersonal factors. Chronic psychological Psychogenic erectile dysfunction (ED) is characterized by difficulty achieving or maintaining an erection primarily due to psychological or interpersonal factors. Factors such as performance anxiety, relationship distress, or ongoing stress can initially lead to temporary erectile difficulties. If these psychological factors persist over time, they may contribute to physiological changes in vascular and neural pathways, potentially resulting in chronic erectile dysfunction. Psychogenic ED is also strongly associated with depression or low mood, and addressing the underlying psychological or mental health conditions is recommended for effective management. Medical conditions are also common causes of erectile dysfunction. Diseases such as cardiovascular disease, multiple sclerosis, kidney failure, vascular disease, and spinal cord injury can cause erectile dysfunction. It is estimated that around 30 million men in the United States and 152 million men worldwide have erectile dysfunction. However, social stigma, low health literacy, and social taboos lead to under reporting which makes an accurate prevalence rate hard to determine. ED from vascular disease is seen in individuals who have atherosclerosis. Vascular disease is common in individuals who smoke or have diabetes, peripheral vascular disease, or hypertension. Cardiovascular disease can decrease blood flow to penile tissues, making it difficult to develop or maintain an erection. Drugs are also a cause of erectile dysfunction. Individuals who take drugs that lower blood pressure, antipsychotics, antidepressants, sedatives, narcotics, antacids, or alcohol can have problems with sexual function and loss of libido. Hormone deficiency is a relatively rare cause of erectile dysfunction. In individuals with testicular failure, as in Klinefelter syndrome, or those who have had radiation therapy, chemotherapy, or childhood exposure to the mumps virus, the testes may fail to produce testosterone. Other hormonal causes of erectile failure include brain tumors, hyperthyroidism, hypothyroidism, or adrenal gland disorders. Orgasm disorders Anorgasmia Anorgasmia is classified as persistent delays or absence of orgasm following a normal sexual excitement phase in at least 75% of sexual encounters. 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. A common physiological cause of anorgasmia is menopause; one in three women report problems obtaining an orgasm during sexual stimulation following menopause. 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 two minutes from the time of the insertion of the penis. 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 for the patient, the partner, or both. Premature ejaculation has historically been attributed to psychological causes, but newer theories suggest that premature ejaculation may have an underlying neurobiological cause that may lead to rapid ejaculation. Post-orgasmic disorders Post-orgasmic disorders cause symptoms shortly after orgasm or ejaculation. Post-coital tristesse (PCT) is a feeling of melancholy and anxiety after sexual intercourse that lasts for up to two hours. Sexual headaches occur in the skull and neck during sexual activity, including masturbation, arousal or orgasm. In men, post orgasmic illness syndrome (POIS) causes severe muscle pain throughout the body and other symptoms immediately following ejaculation. These symptoms last for up to a week. Some doctors speculate that the frequency of POIS "in the population may be greater than has been reported in the academic literature", and that many with POIS are undiagnosed. POIS may involve adrenergic symptoms: rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness, and fatigue. The etiology of this condition is unknown; however, it is believed to be a pathology of either the immune system or autonomic nervous systems. It is defined as a rare disease by the NIH, but the prevalence is unknown. It is not thought to be psychiatric in nature, but it may present as anxiety relating to coital activities and thus may be incorrectly diagnosed as such. There is no known cure or treatment. Peyronie's disease has no certain cause, but the leading hypothesis is that it arises from dysregulated wound healing in response to chronic microtrauma of the erect penis. Risk factors include age, genetics, minor trauma (potentially during cystoscopy or transurethral resection of the prostate), chronic systemic vascular diseases, diabetes, smoking, and alcohol consumption. == Causes ==

There are many factors which may result in a person experiencing a sexual dysfunction. These may result from emotional or physical causes. Emotional factors include interpersonal or psychological problems, which include depression, sexual fears or guilt, past sexual trauma, and sexual disorders. Sexual dysfunction is especially common among people who have anxiety disorders. Pain during intercourse is often a comorbidity of anxiety disorders among women. Physical factors that can lead to sexual dysfunctions include the use of drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs. For women, almost any physiological change that affects the reproductive system—premenstrual syndrome, pregnancy and the postpartum period, and menopause—can have an adverse effect on libido. With SSRI medication Sexual problems are common with SSRIs, which can cause anorgasmia, erectile dysfunction, diminished libido, genital numbness, and sexual anhedonia (pleasureless orgasm). Poor sexual function is also one of the most common reasons people stop the medication. In some cases, symptoms of sexual dysfunction may persist after discontinuation of SSRIs. This combination of symptoms is sometimes referred to as post-SSRI sexual dysfunction. Pelvic floor dysfunction Pelvic floor dysfunction can be an underlying cause of sexual dysfunction in both women and men, and is treatable by pelvic floor physical therapy, a type of physical therapy designed to restore the health and function of the pelvic floor and surrounding areas. Female sexual dysfunction Several theories have looked at female sexual dysfunction, from medical to psychological perspectives. Three social psychological theories include: the self-perception theory, the overjustification hypothesis, and the insufficient justification hypothesis: • Self-perception theory: people make attributions about their own attitudes, feelings, and behaviours by relying on their observations of external behaviours and the circumstances in which those behaviours occur • Overjustification hypothesis: when an external reward is given to a person for performing an intrinsically rewarding activity, the person's intrinsic interest will decrease • Insufficient justification: based on the classic cognitive dissonance theory (inconsistency between two cognitions or between a cognition and a behavior will create discomfort), this theory states that people will alter one of the cognitions or behaviours to restore consistency and reduce distress The prevalence of sexual dysfunction in women is not well known due to a paucity of epidemiological studies, inconsistent criteria for sexual dysfunction across different studies and incomplete recruitment, with studies often excluding women who were without a partner or who were sexually inactive. However, based on incomplete population based studies from the United States, Europe and Australia, unspecified arousal dysfunction (in which a woman is unable to achieve desirable genital or non-genital sexual arousal despite adequate stimulation and desire) was present in 3-9% of women aged 18–44, 5-7.5% aged 45–64 and 3-6% in women older than 65. Anorgasmia with distress (in which women were unable to achieve an orgasm) was present in 7-8% of women younger than 40, 5-7% aged 40–64 and 3-6% of those older than 65. Sexual assault has been associated with excessive menstrual bleeding, genital burning, and painful intercourse (attributable to disease, injury, or otherwise), medically unexplained dysmenorrhea, menstrual irregularity, and lack of sexual pleasure. Physically violent assaults and those committed by strangers were most strongly related to reproductive symptoms. Multiple assaults, assaults accomplished by persuasion, spousal assault, and completed intercourse were most strongly related to sexual symptoms. Assault was occasionally associated more strongly with reproductive symptoms among women with lower income or less education, possibly because of economic stress or differences in assault circumstances. Associations with unexplained menstrual irregularity were strongest among African American women; ethnic differences in reported circumstances of assault appeared to account for these differences. Assault was associated with sexual indifference only among Latinas. Menopause The most prevalent of female sexual dysfunctions that have been linked to menopause include lack of desire and libido; these are predominantly associated with hormonal physiology. Specifically, the decline in serum estrogens causes these changes in sexual functioning. Androgen depletion may also play a role, but current knowledge about this is less clear. The hormonal changes that take place during the menopausal transition have been suggested to affect women's sexual response through several mechanisms, some more conclusive than others. Aging in women Whether or not aging directly affects women's sexual functioning during menopause is controversial. However, many studies have demonstrated that aging has a powerful impact on sexual function and dysfunction in women, specifically in the areas of desire, sexual interest, and frequency of orgasm. The primary predictor of sexual response throughout menopause is prior sexual functioning, Testosterone levels in women at age 60 are on average about half of what they were before the women were 40. Although this decline is gradual for most women, those who have undergone bilateral oophorectomy experience a sudden drop in testosterone levels, as the ovaries produce 40% of the body's circulating testosterone. Sexual desire has been related to three separate components: drive, beliefs and values, and motivation. Particularly in postmenopausal women, drive fades and is no longer the initial step in a woman's sexual response. ==Diagnosis==

List of disorders DSM The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders lists the following sexual dysfunctions: • Hypoactive sexual desire disorder (see also asexuality, which is not classified as a disorder) • Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse) • Female sexual arousal disorder (failure of normal lubricating arousal response) • Male erectile disorder • Female orgasmic disorder (see anorgasmia) • Male orgasmic disorder (see anorgasmia) • Premature ejaculation • Dyspareunia • Vaginismus Additional DSM sexual disorders that are not sexual dysfunctions include: • Paraphilias • PTSD due to genital mutilation or childhood sexual abuse Other sexual problems • Sexual dissatisfaction (non-specific) • Lack of sexual desire • Anorgasmia • Impotence • Sexually transmitted infections • Delay or absence of ejaculation, despite adequate stimulation • Inability to control timing of ejaculation • Inability to relax vaginal muscles enough to allow intercourse • Inadequate vaginal lubrication preceding and during intercourse • Burning pain on the vulva or in the vagina with contact to those areas • Unhappiness or confusion related to sexual orientation • Transsexual and transgender people may have sexual problems before or after surgery. • Persistent sexual arousal syndrome • Sexual addiction • Hypersexuality • All forms of female genital cutting • Post-orgasmic diseases, such as Dhat syndrome, PCT, POIS, and sexual headaches. • Hard flaccid syndrome ==Treatment==

Males Several decades ago, the medical community believed most sexual dysfunction cases were related to psychological issues. Although this may be true for a portion of men, the vast majority of cases have now been identified to have a physical cause or a correlation. If the sexual dysfunction is deemed to have a psychological component or cause, psychotherapy can help. Situational anxiety arises from an earlier bad incident or lack of experience, and often leads to development of fear towards sexual activity and avoidance which enters a cycle of increased anxiety and desensitization of the penis. In some cases, erectile dysfunction may be due to marital disharmony. Marriage counseling sessions are recommended in this situation. Lifestyle changes such as discontinuing tobacco smoking or substance use can also treat some types of ED. Several oral medications like Viagra, Cialis, and Levitra have become available to alleviate ED and have become first line therapy. These medications provide an easy, safe, and effective treatment solution for approximately 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, which involves injecting a vasodilator drug directly into the penis to stimulate an erection. This method has an increased risk of priapism if used in conjunction with other treatments, and localized pain. When conservative therapies fail, are an unsatisfactory treatment option, or are contraindicated for use, the insertion of a penile implant may be selected by the patient. Technological advances have made the insertion of a penile implant a safe option for the treatment of ED, which provides the highest patient and partner satisfaction rates of all available ED treatment options. Pelvic floor physical therapy has been shown to be a valid treatment for men with sexual problems and pelvic pain. The 2020 guidelines from the American College of Physicians support the discussion of testosterone treatment in adult men with age-related low levels of testosterone who have sexual dysfunction. They recommend yearly evaluation regarding possible improvement and, if none, to discontinue testosterone; intramuscular treatments should be considered rather than transdermal treatments due to costs and since the effectiveness and harm of either method is similar. Testosterone treatment for reasons other than possible improvement of sexual dysfunction may not be recommended. Females In 2015, flibanserin was approved in the US to treat decreased sexual desire in women. While it is effective for some women, it has been criticized for its limited efficacy, and has many warnings and contraindications that limit its use. Flibanserin was found to increase pleasurable sexual experiences by 0.5 events per month in trials. Possible side effects include dizziness, drowsiness, nausea and fatigue. Counselling for female sexual dysfunction, including sexual counselling, cognitive behavioral therapy, body awareness counselling, and couples counselling have been found to be helpful. Androgen therapy for hypoactive sexual desire disorder has a small benefit but its safety is not known. It is more commonly used among women who have had an oophorectomy or are in a postmenopausal state. However, like most treatments, this is also controversial. One study found that after a 24-week trial, women taking androgens had higher scores of sexual desire compared to a placebo group. As with all pharmacological drugs, there are side effects in using androgens, which include hirsutism, acne, polycythaemia, increased high-density lipoproteins, cardiovascular risks, and endometrial hyperplasia. Alternative treatments include topical estrogen creams and gels that can be applied to the vulva or vagina area to treat vaginal dryness and atrophy. ==Research==

In modern times, clinical study of sexual problems is usually dated back no earlier 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 Sigmund Freud. It was held to be 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 viewpoint. 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 acquired negative connotations in popular culture. Human Sexual Inadequacy moved thinking from psychopathology to learning; psychopathological problems would only be considered if a problem did not respond to educative treatment. Treatment was directed at couples, whereas before partners would be seen individually. Masters and Johnson believed that sex was a joint act, and that sexual communication was the key issue to sexual problems, not the specifics of an individual problem. They also proposed co-therapy, with a pair of therapists to match 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. The program is couple-based and therapist-led, and began with discussion and 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 developed the use of a female surrogate, which was 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 most people, and included male primary or secondary impotence, premature ejaculation, and 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 they can be inhibited despite being autonomic responses. Masters and Johnson's treatment program for dysfunction was 81.1% successful. Despite Masters and Johnson's work, sexual therapy in the US was overrun by enthusiastic rather than systematic approaches, blurring the space between "enrichment" and therapy. == See also ==