Sexual problems are defined as difficulty during any stage of the sexual act (which includes desire, arousal, orgasm, and resolution) that prevents the individual or couple from enjoying sexual activity.

Sexual difficulties may begin early in a person's life, or they may develop after an individual has previously experienced enjoyable and satisfying sex. A problem may develop gradually 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.

Emotional factors affecting sex include both interpersonal problems and psychological problems within the individual. Interpersonal problems include marital or relationship problems, or lack of trust and open communication between partners. Personal psychological problems include depression, sexual fears or guilt, or past sexual trauma.

Physical factors contributing to sexual problems include:

• Drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives (medicines that lower blood pressure), antihistamines, and some psychotherapeutic (drugs that treat psychological problems such as depression) drugs
• Injuries to the back
• An enlarged prostate gland
• Problems with blood supply
• Nerve damage (as in spinal cord injuries)
• Disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis)
• Failure of various organs (such as the heart and lungs)
• Endocrine disorders (thyroid, pituitary, or adrenal gland problems)
• Hormonal deficiencies (low testosterone, estrogen, or androgens)
• Some birth defects

Sexual dysfunction disorders are generally classified into 4 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 estrogen (in women) or testosterone (in both men and women). 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 were previously known as frigidity in women and impotence in men. These have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity is now described as any of several specific problems with desire, arousal, or anxiety.

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.

There may be medical causes for these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease may also contribute to these difficulties, as well as the nature of the relationship between partners. As the success of Viagra attests, many erectile disorders in men may be primarily physical, not psychological conditions.

Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder occurs in both women and men. 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) 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 may 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 may be related to problems with the skin in the vulvar and vaginal areas. The cause is unknown.

Sexual dysfunctions are more common in the early adult years, with the majority of people seeking care for such conditions during their late 20s through 30s. 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 may also interfere with sexual function.

PREVENTION

Open, informative, and accurate communication regarding sexual issues and body image between parents and their children may prevent children from developing anxiety or guilt about sex, and may help them develop healthy sexual relationships.

Review all medications, both prescription and over-the-counter, for possible side effects that relate to sexual dysfunction. Avoiding drug and alcohol abuse will also help prevent sexual dysfunction.

Couples who are open and honest about their sexual preferences and feelings are more likely to avoid some sexual dysfunction. One partner should, ideally, be able to communicate desires and preferences to the other partner.

People who are victims of sexual trauma, such as sexual abuse or rape at any age, are urged to seek psychiatric advice. 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.

SYMPTOMS

• Men or women:
  • Lack of interest in sex (loss of libido)
  • Inability to feel aroused
  • Pain with intercourse (much less common in men than women)
• Men :
  • Inability to attain an erection
  • Inability to maintain an erection adequately for intercourse
  • Delay or absence of ejaculation, despite adequate stimulation
  • Inability to control timing of ejaculation
• Women:
  • Inability to relax vaginal muscles enough to allow intercourse
  • Inadequate vaginal lubrication before and during intercourse
  • Inability to attain orgasm
  • Burning pain on the vulva or in the vagina with contact to those areas

CALL YOUR HEALTH CARE PROVIDER IF...

Call for an appointment with your health care provider if sexual problems persist and are a concern.

SIGNS AND TESTS

Specific physical findings and testing procedures depend on the form of sexual dysfunction being investigated. In any case, a complete history and physical examination should be done to:

• Identify predisposing illness or conditions
• Highlight possible fears, anxieties, or guilt specific to sexual behaviors or performance
• Uncover any history of prior sexual trauma

A physical examination of both the partners should include the whole body and not be limited to the reproductive system.

TREATMENT

Treatment depends on the cause of the sexual dysfunction. Medical causes 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.

For men who have difficulty attaining an erection, the medication sildenafil (Viagra), which increases blood flow to the penis, may be very helpful, though it must be taken 1 to 4 hours prior to intercourse.

Men who take nitrates for coronary heart disease should not take sildenafil. Mechanical aids and penile implants are also an option for men who cannot attain an erection and find sildenafil isn't helpful.

Women with vaginal dryness may be helped with lubricating gels, hormone creams, and -- in cases of premenopausal or menopausal women -- with hormone replacement therapy. In some cases, women with androgen deficiency can be helped by taking testosterone.

Vulvodynia can be treated with testosterone cream, with use of biofeedback and with low doses of some antidepressants which also treat nerve pain. Surgery has not been successful.

Behavioral treatments involve many different techniques to treat problems associated with orgasm and sexual arousal disorders. Self-stimulation and the Masters and Johnson treatment strategies are among the many behavioral therapies used.

Simple, open, accurate, and supportive education about sex and sexual behaviors or responses may be all that is required in many cases. Some couples may benefit from joint counseling to address interpersonal issues and communication styles. Psychotherapy may be required to address anxieties, fears, inhibitions, or poor body image.

PROGNOSIS AND OUTCOME

The prognosis (probable outcome) depends on the form of sexual dysfunction. In general, the probable outcome is good for physical dysfunctions resulting from treatable or reversible conditions. It should be noted, however, that many organic causes do not respond to medical or surgical treatments.

In functional sexual problems resulting from either relationship problems or psychological factors, the prognosis may be good for temporary or mild dysfunction associated with temporary stress or lack of accurate information. However, those cases associated with chronically-poor relationships or deep-seated psychiatric problems typically do not have positive outcomes.

COMPLICATIONS

Some forms of sexual dysfunction may cause infertility.

Persistent sexual dysfunction may cause depression in some individuals. The importance of the disorder to the individual (and couple, when applicable) needs to be determined. Sexual dysfunction that is not addressed adequately may lead to conflicts or potential breakups.