What is sexual dysfunction?

Causes and Symptoms

It is evident from the term performance anxiety that sexual anxiety is more easily recognized when it involves performance (that is, erections and orgasms) than when it involves subjective arousal. The most extreme example of this way of thinking is the familiar notion that women do not experience performance anxiety because it is only men who have to perform. When researchers searched for a corresponding term that refers not to performance but to subjectively felt arousal, they devised the oxymoronic-sounding term pleasure anxiety. Performance anxiety refers to the fear of not being able to perform, while pleasure anxiety refers to the fear of feeling pleasure. Sex therapists have traditionally been much more concerned with the fear of not being able to perform.

To explain this blind spot in the field, it is clear that, historically, lack of desire has been considered a female disorder, whereas lack of performance has been considered a male disorder. From the male-identified point of view, the failure to perform is relatively understandable; it is often treated with humor, sympathy, or indulgence. Traditionally, however, the same indulgence has not been extended toward a woman when she cannot fulfill the role expected of her.

If there are any doubts that frigidity is a more accusatory term than impotence, the latter as a diagnostic term retains its currency, whereas the former has largely been dropped. Researchers William H. Masters and Virginia E. Johnson were the first authorities to drop the term frigidity, and as a result of their influence it is rarely used in the field of sex therapy and research. It is still used, however, in the psychoanalytic literature.

The category of inhibited sexual desire in the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders: DSM-III (3d ed., 1980) indicated the difficulty in finding a nonjudgmental means of referring to the lack of erotic arousal: The term inhibition implies that the conditions for desire are present but that desire is being withheld. One of the implied accusations in the term frigidity is that the woman who does not experience erotic arousal is a cold, unfeeling, or withholding person. The work group on psychosexual disorders for the revision of the DSM-III-R published in 1987 first recognized this difficulty and recommended that “inhibited sexual desire” be renamed “hypoactive sexual desire disorder,” arguing that this more awkward term is necessary because it reflects greater neutrality in terms of etiology. In DSM-5 (2013), several updates have been made to terms and criteria for sexual dysfunctions, including the addition of gender-specific dysfunctions such as male hypoactive sexual desire disorder, erectile disorder, female sexual interest/arousal disorder, and female orgasmic disorders. The criteria for all sexual disorders in DSM-5 have been updated to include a minimum duration of six months and more precise severity criteria.

In the 1970s researchers noted that the diagnosis of low sexual desire among couples seeking help with sexual dysfunction increased from approximately one-third of couples in the early 1970s to more than one-half of couples by the early 1980s. Men as well as women were identified with low sexual desire, or frigidity. Most of the knowledge of the causes of low sexual desire is based on clinical experience, rather than on more empirical and objective research. It has become clear that there is no single cause for low sexual desire. Rather, many cases involve several causal factors working simultaneously.

Virtually every standard work on sexual dysfunction lists religious orthodoxy as a major cause of sexual dysfunction. Some patients suffer from low sexual desire because they essentially lack the capacity for play (the obsessive-compulsive personality). Specific sexual phobias or aversions also may cause low sexual desire. Men with low desire almost uniformly have some degree of aversion to the vagina and female genitals. Women who have been sexually molested as children, or raped as adults, often have specific aversion reactions.

Some patients fear that if they allow themselves to feel any sexual desire at all, they will lose all control over themselves and begin acting out sexually in ways that would have disastrous consequences. Fear of pregnancy is often a “masked” cause of low sexual desire among women. Depression, hormonal issues, the side effects of medication, relationship problems, lack of attraction to one’s partner, fear of closeness, and an inability to fuse feelings of love and sexual desire are among the many causes of low sexual desire in both men and women.

With regard to impotence, although the exact number is not known, it has been estimated that there are approximately ten million men in the United States suffering from impotence. In the past, it was thought that psychogenic causes accounted for 90 percent of impotence, with only 10 percent attributable to medical or postsurgical diseases, so-called physical or organic impotence. As medical knowledge increased, in the early 1990s it was estimated that medical or organic causes accounted for 50 to 70 percent of all patients suffering from impotence.

Until the 1980s, it was difficult to determine whether any given patient was impotent as a result of psychogenic causes or physical, organic ones. The availability of blood tests to measure hormone levels and of penile tumescence sleep laboratory testing now allows for accurate determination of the true cause of impotence in patients. Yet even when it is attributable to organic causes, impotence has significant psychological implications.

Impotence can be defined as the persistent inability to attain and maintain a rigid penis adequate for penetration and successful completion of intercourse. There are two types of impotence: primary and secondary. Primary impotence is the term used to describe the male who has never been able to achieve an
erection adequate for sexual intercourse. This is a relatively rare condition. Except in very unusual circumstances that might have involved a surgical procedure on the penis during childhood, primary impotence is not caused by any physical defect but instead has a psychologic basis. Men with primary impotence are most often found to have had a severely repressive childhood. These patients generally exhibit considerable conflict in their relationships with women and have hostile or fearful attitudes toward females.

The majority of men with impotence have secondary impotence; that is, at one time in their lives they were capable of full erections and intercourse but have subsequently lost that ability. In the 1980s, other medical terms for impotence came into common use, such as
erectile dysfunction
. As in the case of frigidity, the word impotence has had negative connotations.

Diabetes mellitus
is a rather common organic medical problem accounting for impotence in many men. It has been estimated that 50 percent of men who have had diabetes for twenty years become impotent. It is thought that diabetes results in impotence by causing neuropathy or malfunction of the nerves, as well as narrowing of the blood vessels. Arteriosclerosis, or hardening of the arteries, causes a narrowing of the blood vessels. Many patients who have
arteriosclerosis involving the aorta or smaller blood vessels that supply blood to the penis will experience impotence.

Chronic kidney failure,
cirrhosis (chronic liver
disease), neurological diseases such as
Parkinson’s disease and
multiple sclerosis, malfunction of the spinal cord (such as
spina bifida or spinal cord injury), and low levels of
testosterone are also frequent organic causes of impotence. Masters and Johnson have stated that
alcoholism is the second most common cause of impotence. Pelvic fractures and trauma, radiation therapy, radical pelvic surgery (including removal of the prostate, bladder,
or rectum), and aortic aneurysm repair can cause nerve and blood vessel injuries that can result in impotence and/or problems with ejaculation. Penile cancer, Peyronie’s disease (curvature of the penis as a result of scar tissue formation), and priapism (prolonged erection of the penis) are also causes of organic impotence. It has been reported that prescription drugs may account for 25 percent of patients with impotence. By far the most common group of drugs resulting in impotence are those taken for treatment of hypertension, or high blood pressure
.

Treatment and Therapy

There are several difficulties inherent in devising a treatment program for low sexual desire. While most of the behavioral exercises devised by Masters and Johnson may enhance arousal and orgasm, they often fail in increasing sexual desire or motivation, since they were not designed to deal specifically with low sexual desire. A second problem is that many cases of low sexual desire not only are quite complex but are diverse in apparent etiology and maintenance factors as well. Each case of low desire must be examined on its own terms, and treatment must be tailored to the specific needs of the individual.

Behavior therapy and social learning theory contributed most of the effective techniques that constituted sex therapy in the 1980s. Other therapeutic approaches, however, have been used as adjunct techniques or proposed alternatives. One broad-spectrum approach attempts to integrate interventions from many theoretical orientations into a comprehensive treatment program, while remaining sensitive to the need to fine-tune the program to the individual.

The first step in this broad-spectrum approach is experiential/sensory awareness. Many patients with low sexual desire are unable to verbalize their feelings and are often unaware of their responses to situations involving sexual stimulation. The goal of this phase of therapy is to help patients recognize, using bodily cues, when they are experiencing feelings of anxiety, pleasure, anger, or disgust.

The second stage is the insight phase of therapy, in which patients, with the help of the therapist, attempt to learn and understand what is causing and maintaining their low desire. Frequently, patients with low sexual desire have misconceptions and self-defeating attitudes about the cause of the problem. Patients are helped to reformulate attitudes about the cause of the problem in a way that is conducive to therapeutic change.

The third stage, the cognitive phase of therapy, is designed to alter irrational thoughts that inhibit sexual desire. Patients are helped to identify self-statements that interfere with sexual desire. They are helped to accept the general assumption that their emotional reactions can be directly influenced by their expectations, labels, and self-statements. Patients are taught that unrealistic or irrational beliefs may be the main cause of their emotional reactions and that they can change these unrealistic attitudes. With change, patients can reevaluate specific situations more realistically and can reduce negative emotional reactions that cause low desire.

The final element of this treatment program consists of behavioral interventions. Behavioral assignments are used throughout the therapy process and include basic sex therapy as well as other sexual and nonsexual behavior procedures. Behavioral interventions are used to help patients change nonsexual behaviors that may be helping to cause or maintain the sexual difficulty. Assertiveness training, communication training, and skill training in negotiation are examples of such behavioral interventions.

The treatment of psychogenic impotence includes supportive psychotherapy and behavior-oriented tasks. If, during the course of evaluation, symptoms of depression such as loss of libido and appetite or sleep difficulties are present without a physical basis, the patient is often treated with an antidepressant medication. As mental depression lessens, sexual interest and potency will often return. Depression is the most common mental disorder detected when impotent patients undergo psychological studies.

There are certain causes of organic impotence that may be reversible with appropriate therapy. The alcoholic patient, for example, may regain his potency if his drinking problem can be resolved. The heavy cigarette smoker may similarly experience improvement in his general health and regain erections following cessation of smoking. Patients with newly discovered
diabetes mellitus and high blood sugars may regain their erections following control of their diabetes with insulin, diet, or oral medications. This improvement will not be seen, however, in those individuals with long-standing diabetes who lose their erections.

Treatment programs for organic impotence are geared toward the problems of each individual and are often age-dependent. From 1980 to 1990, there were major advances not only in the diagnosis but also in the treatment of erectile insufficiency; moreover, many of those major treatment advances were nonsurgical. As a result of these nonsurgical advances and their positive rate of success, men often are encouraged to begin their treatment program with the most conservative technique possible. It has been estimated that approximately 90 percent of patients with erectile insufficiency are adequately treated with one of the following(conservative) medical programs: oral medication, self-injection, and vacuum tumescence devices.

Often the first step to medical management of erectile dysfunction is oral medication. Generally, these medications cause smooth muscle relaxation, thereby enhancing the blood flow into the penis. The drug Viagra (sildenafil), introduced in 1998, allows sufficient blood flow for an erection over a four- to five-hour period. Viagra boasted a success rate of almost 80 percent and was immediately in great demand. Dangerous side effects were noted, however, when sildenafil is used in conjunction with nitroglycerin or long-acting nitrates in any form. These nitrate medications in combination with sildenafil produce significant blood pressure drops and are dangerous, especially to patients with compromised cardiac status. Soon after its introduction, concerns arose over the misuse of Viagra to enhance sexual performance instead of to treat impotence. Drugs similar to sildenafil, which are classified as phosphodiesterase V (PDE V) inhibitors, are new to the market. These drugs facilitate erectile function by stimulating the relaxation of smooth muscle tissue in the erectile bodies of
the penis. This relaxation allows rapid blood flow into the penis and facilitates erectile function in men with erectile dysfunction. Additional drugs, including tadalafil (Cialis) and vardenafil (Levitra), have been approved for the treatment of erectile dysfunction in certain markets. Other agents, including apomorphine (Uprima), will stimulate central nervous system functions, providing improved erectile function. Uprima, which has been approved by the FDA Advisory Panel, is the first agent to act on the central nervous system to improve erectile dysfunction. Medications to increase sexual desire are also being investigated by various pharmaceutical companies in conjunction with the Food and Drug Administration (FDA).

Penile injection with drugs is a treatment for male impotence that was popularized in 1982 by Ronald Virag of Paris. Penile injection with vasoactive compounds to effect an erection, however, had not yet been approved by the FDA in the United States by the late 1990s. Thus patients were required to sign a legal release of liability if this method of treatment was chosen.

In the 1990s, there were approximately eighty thousand males using self-injection therapy (for the treatment of erectile impotence) in the United States. This method of treatment has gained much international acceptance and continues to be the focus of much clinical and laboratory research. This technique is relatively painless and quick, producing results in ten to twenty minutes. Treatment is initiated by administering a test dose of the medication. During this initial stage of treatment, the medication dosage level is adjusted. The patient is then taught the injection technique, given instructions on how to care for the medication and equipment, and given an assessment of erectile response. This method is considered simple, safe, and highly successful (with a success rate of approximately 75 to 80 percent). The major complications are priapism and penile scarring, which occurs in 1 to 2 percent of cases.

Another nonsurgical option available is vacuum tumescence therapy. This device enables the patient to attain penile enlargement and rigidity by inducing blood flow into the penile shaft. Once the blood flow is induced by the creation of a vacuum, it is trapped by the use of an occlusive device applied at the base of the penis. Although it produces a successful erection in approximately 75 percent of cases, the vacuum tumescence device and the accompanying obstructing rubber occlusive device prevent the ejaculate from being expelled in most cases.

Many men with erectile dysfunction are best treated by surgical reconstruction. This group represents approximately 10 percent of the entire impotent population. Penile
revascularization is one option. The patients who are best treated with penile revascularization are typically men under fifty years of age. Generally, these men are nonsmoking, healthy individuals whose potency problems are caused by a single lesion or injury. The purpose of penile revascularization is to channel more blood into the corpora cavernosa and thereby increase the corpora cavernosa pressure. Pressure can be increased by a variety of methods, including bypass artery-to-artery, bypass artery-to-vein, or closure of specific leaking areas in the corpora cavernosa.

Although available since the mid-1930s, penile prosthetics made their greatest strides after the introduction of synthetic materials (plastics) in the 1950s. Since then, major changes in design, function, and surgical technique have evolved. The prosthetics available by the late twentieth century were of three basic varieties: simple rods, flexible rods, and hydraulic devices (one-piece, two-piece, and multicomponent). Once implanted, prosthetics give the patient a return to “normal erectile dynamics.” Although the tumescence-detumescence cycle is a result of the patient’s prosthesis, sensation, satisfaction, and often even ejaculation remain as they were prior to surgery.

Perspective and Prospects

Anthropologists have found that impotence (erectile dysfunction) and frigidity (inhibited or low sexual desire) have been observed in both primitive and highly developed societies. During most of human history, it was taken for granted that women attain sexual gratification in the same manner as men. Little attention was paid to the failures.

One of the most significant social changes affecting attitudes toward these sexual dysfunctions has been the altered status of women in contemporary society. During the Victorian era, whether they worked or not, women were legally the wards of men and had virtually no civil rights. Many of the Victorian attitudes toward sex—fears, prejudices, taboos, and superstitions—remained powerful influences into the late twentieth century.

Researchers, however, have learned that they cannot understand the problem of impotence in women by comparing it with impotence in men, since the dynamics as well as the treatments for each disorder differ greatly. With the women’s movement and the Masters and Johnson research into human sexuality, the archaic terms impotence and frigidity were called into question. More gender-neutral terms were used, and, particularly in the case of erectile insufficiency, organic as opposed to psychogenic etiologies were acknowledged. By the late twentieth century, erectile insufficiency had become a disorder more often treated by urologists than by psychiatrists.

With this changing attitude toward these sexual dysfunctions among the medical community as well as the public at large, more research was devoted to treating the problems effectively and to reassuring the patients. Age-old stereotypes came under attack, such as the notion that performance anxiety affects only men and that frigidity or low sexual desire is a disorder that affects only women. As more organic etiologies for both erectile dysfunction and low sexual desire are acknowledged, patients feel increasingly comfortable seeking medical attention, and the stigma of sexual dysfunction being purely psychological is slowly beginning to vanish.

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