Problems with sexual function can adversely affect an individual’s mood, interpersonal relationships and general well-being.
Sexual problems are defined as difficulty during any stage of the sexual act that prevents the individual or couple from enjoying sexual activity. Sexual difficulties may begin early in a person's life, or after an individual has previously enjoyed a satisfying sex life. A problem may develop 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.
Physical factors contributing to sexual problems include:
Drugs of abuse, such as alcohol, nicotine, narcotics, stimulants.
Medications, e.g., antihypertensives, antihistamines, and particularly drugs used to treat depression (SSRI antidepressants)
Cancer drugs (e.g., cytotoxic chemotherapy, aromatase inhibitors)
Disease such as diabetes, cardiovascular disorders, neuropathy, multiple sclerosis, cancer
Endocrine disorders (thyroid, pituitary, or adrenal gland problems)
Hormonal deficiencies (low testosterone associated with aging, estrogen deficiency associated with menopause)
Emotional factors affecting sex include both interpersonal problems (marital or relationship problems, or lack of trust and open communication between partners) and psychological problems within the individual (depression, sexual fears or guilt, or past sexual trauma.)
Sexual dysfunctions are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders. Sexual desire disorders (decreased libido) may be caused by a decrease in the normal production of testosterone (in both men and women), which is often age-related. Other causes may be aging, fatigue, pregnancy, and 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. Psychiatric conditions, such as depression and anxiety, can also cause decreased libido.
Sexual arousal disorders previously known as frigidity in women and impotence in men, are now known as erectile dysfunction (ED), and female sexual arousal disorder (FSAD). For both men and women, these conditions may appear 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.
As mentioned above, there may be medical causes for these disorders. Chronic disease may also contribute to these difficulties, as well as the nature of the relationship between partners. As the success of the PDE5 inhibitors (i.e., Viagra, Cialis) attests, many erectile disorders in men may be primarily physical conditions, although they often have psychological ramifications.
Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder occurs in both women and men, although more frequently among women. Again, the SSRI antidepressants are frequent culprits –- these may 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, which interferes with intercourse). Dyspareunia may be caused by insufficient lubrication (vaginal dryness). 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 may also cause dryness, as can fear and anxiety about sex.
It is unclear exactly what causes vaginismus, but it is thought that the cause is multifactorial. Another female sexual pain disorder is called vulvodynia or vulvar vestibulitis. In this condition, women experience burning pain during sex which may be related to problems with the skin in the vulvar and vaginal areas. There are numerous theories about cause, but none have been definitively proven.
Sexual dysfunction is more common in people who abuse alcohol and drugs. It is also more likely in people suffering from diabetes, cardiovascular disorders, and degenerative neurological disorders. Ongoing psychological problems, difficulty maintaining relationships, or chronic disharmony with the current sexual partner may also interfere with sexual function. Partner openness and the ability to freely communicate desires and preferences greatly facilitate sexual relations.
People who are experiencing sexual problems and are victims of sexual trauma, such as sexual abuse or rape at any age, are urged to seek psychiatric consultation. Individual counseling with an expert in trauma may prove beneficial in allowing sexual abuse victims to overcome sexual difficulties and enjoy voluntary sexual experiences with a chosen partner.
There are various approaches to the treatment of sexual dysfunction depending on the nature of the underlying problem. Medical conditions 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.
Basically, however, there are two major approaches to treating sexual dysfunctions: pharmacologically with drugs, and psychotherapeutically through various psychological or sex therapies. For men who have difficulty attaining an erection, all of the PDE5 inhibitors (i.e.,Viagra, Levitra, Cialis), which increase blood flow to the penis, have proven very helpful, with success rates approaching 70%. A caution involves male patients on nitrates for coronary heart disease who should not take these drugs. Second line drug approaches involving direct injections into the penis of the drug alprostadil, or its delivery through a penile suppository, are also effective, although they carry with them a certain level of discomfort. Mechanical aids (e.g., vacuum chambers) and penile surgical implants represent a third level option for men who do not respond to drug treatments.
Women with vaginal dryness and pain on intercourse may be helped with lubricating gels and locally applied estrogen hormone creams, and – in cases of menopausal women – with hormone replacement therapy. In clear cases of androgen insufficiency, women can be prescribed testosterone gels applied locally to restore normal levels of sexual desire.
It is also worth mentioning that quite a few large pharmaceutical companies have investigational drugs for the treatment of female sexual dysfunction in late stages of development, and it is possible to participate in one of the ongoing trials.
Reports on the treatment of Vulvodynia have shown that testosterone cream, biofeedback, low doses of some antidepressants and surgery have all been successful to some degree. Behavioral treatments involving many different techniques to treat problems associated with psychologically based orgasm and sexual arousal disorders have been found successful. Masters and Johnson treatment strategies are among the many behavioral therapies used successfully. Simple, open, accurate, and supportive education about sex and sexual behaviors or responses may be all that is required in some cases, just as some couples may benefit from joint counseling to address interpersonal issues and communication styles. Psychotherapy can also help in some cases to address anxieties, fears, inhibitions, or poor body image.
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