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. The World Health Organization defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
What causes Sexual Problems?
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, narcotic analgesics, stimulants, antihypertensives (medicines that lower blood pressure), antihistamines, and some psychotherapeutic drugs (drugs that treat psychological problems such as depression )
- 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 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.
Types of Sexual Problems
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 female sexual dysfunction, a term that covers a range 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 erectile dysfunction treatments show, 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.
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)
- 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
- 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
Specific physical findings and testing procedures depend on the form of sexual dysfunction being investigated. A complete history is usually taken and a physical examination performed to:
- Identify predisposing illnesses 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.
Call your doctor if:
Call for an appointment with your health care provider if sexual problems persist and are a concern.
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 phosphodiesterase type 5 inhibitors (PDE-5 inhibitors) such as sildenafil (Viagra), tadalafil (Cialis), avanafil (Stendra), or vardenafil (Levitra, Staxyn) are commonly used for erectile dysfunction. PDE-5 inhibitors increase blood flow to the penis, and can be taken 15 minutes to 4 hours prior to intercourse (depending upon the drug). Cialis can be given on a daily basis without regard for sexual activity timing, but it is given at a lower dose. The American College of Physicians (ACP) recommends that selection of a PDE-5 inhibitor be patient-specific, taking into consideration cost and insurance coverage, ease of use, onset of action and duration, and side effects and possible drug interactions.
Men who take nitrates for coronary heart disease should NOT take PDE-5 inhibitors. Mechanical aids and penile implants are also an option for men who cannot attain an erection and who find that PDE-5 inhibitors are not helpful.
Other options besides PDE-5 inhibitors are available. Testosterone may be prescribed by either skin patch or injection, especially if the problem is related to age. "Low-T" has been promoted as a common male problem for older men, but testosterone replacement can be linked with serious side effects. A 2016 study published in the New England Journal of Medicine suggested that testosterone therapy may restore some sexual desire and function in older men whose natural hormone levels have declined, but testosterone therapy is not an appropriate therapy for erectile dysfunction alone. Testosterone didn't improve vitality or physical function in men 65 or older. The studies did not show significant health risks over a year; however, health experts and the FDA are concerned that long-term use of testosterone could boost a man's risk of prostate cancer, heart attack, or stroke.
Alprostadil (Caverject, Edex) injected (intracavernous injection) or inserted as pellets, improves blood flow to the penis. This technique is usually more effective than medications taken by mouth.
For some patients, a vacuum pump or penile prosthesis (implant) may also be recommended or required.
Yohimbe (or yohimbine) has been promoted as a "natural" alternative for impotence in men. Yohimbe comes from bark from a West African tree. The bark is rich in the alkaloid yohimbine and has been used as an aphrodisiac in traditional medicine.
In the US, yohimbine is available by prescription as a dietary supplement. Yohimbine acts to block the alpha-2-adrenergic receptors in the corpus cavernosum, increasing blood flow to the penis. Alpha-2-blocker activity can occur in the CNS, as well. A number of studies have reported an effect greater than placebo in treating erectile dysfunction in men; however, results were mixed and studies were not always of high quality.
Many experts do not recommend the use of yohimbine supplements due to questionable studies and high success rates with PDE-5 inhibitors. Serious side effects, such as irregular or fast heart beat, kidney toxicity and failure, seizure, heart attack, and a severe case of Raynaud's phenomenon have been reported with yohimbine products. Other side effects might include nausea, vomiting, headache, sweating and psychiatric effects.
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.
Ospemifene (Osphena) is a medication approved in 2013 for painful sex in women (dyspareunia). Ospemifene is an oral selective estrogen receptor modulator (SERM), with tissue‐specific estrogenic agonist/antagonist effects. Basically, ospemifene acts on some tissues like an estrogen and on other tissues like an anti-estrogen. Other drugs on the U.S. market that are in the same class include tamoxifen, toremifene, and raloxifene, but they do not work specifically on vaginal tissues. Vaginal tissues and linings may thin just prior to, or during menopause. Vaginal secretions may decline making sex very painful. Topical estrogen treatments, such as topical cream, tablet, or the vaginal ring have been used effectively for this condition. Ospemifene is the first non‐estrogen treatment approved for moderate- to-severe dyspareunia in women with menopause‐related vulvar and vaginal atrophy. However, ospemifene may increase the risk of developing endometrial hyperplasia, a condition that may lead to cancer of the uterus. If a women's uterus has not been removed, her doctor may prescribe a progestin to use while taking ospemifene.
In August 2015, the FDA approved Addyi (flibanserin) for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. Addyi was the first approved medication for HSDD, and works in the brain as a multifunctional serotonin agonist antagonist (MSAA). Addyi was originally developed as an antidepressant. While Addyi showed modest benefit in clinical trials, its side effects, including fainting with alcohol use, prompted many labeling restrictions: a Boxed Warning, a REMS plan, required certification for prescribers and pharmacies, and a Patient-Provider Agreement Form. Addyi is given nightly as a 100 milligram bedtime dose. Addyi should not be used in liver disease, with alcohol, and with many prescription drugs. Experts recommend that you stop taking the drug if you don't notice an boost in your sex drive after 2 months.
Selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction is a common problem, occurring in up to 50 percent of patients. Sexual problems can include decreased libido in women and men, lowered sexual arousal, inability to orgasm in women, and increased ejaculation latency (time taken to ejaculate during vaginal penetration) in men. Initial options are to wait for 6 to 8 weeks to determine if sexual dysfunction will reverse on its own (watchful waiting), or to lower the dose, but these options are not often effective. Patients who respond to the antidepressant therapy and have moderate sexual dysfunction can augment their SSRI with bupropion (women) or a phosphodiesterase-5 inhibitor (men with erectile dysfunction). Another option is to switch antidepressants from the original SSRI to bupropion, mirtazapine, or even a trial of a different SSRI. Sexual dysfunction due to SSRIs appears to worsen with higher doses.
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.
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.
- The World Health Organization (WHO). Sexual and Reproductive Health. Defining sexual health. Accessed 6/10/2016 at http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/
- Elkinson S, Yang LP . Ospemifene: first global approval. Drugs 2013. 73:605‐12. doi: 10.1007/s40265‐013‐0046‐y. Accessed 6/10/2016.
- Qaseem A, Snow V, Denberg TD, at al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2009;151(9):639. Accessed Accessed 6/10/2016 at http://annals.org/article.aspx?articleid=745155
- FDA Approves Addyi. Drugs.com. August 18, 2015. Accessed 6/10/2016 at https://www.drugs.com/newdrugs/fda-approves-addyi-flibanserin-hypoactive-sexual-desire-disorder-premenopausal-women-4248.html
- Testosterone Therapy May Boost Sex Drive in Older Men. Drugs.com. Feb. 17, 2016. Accessed 6/10/2016 at https://www.drugs.com/news/testosterone-therapy-may-boost-sex-drive-older-men-60177.html