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. Information
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:
o Lack of interest in sex (loss of libido)
o Inability to feel aroused
o Pain with intercourse (much less common in men than women)
• Men :
o Inability to attain an erection
o Inability to maintain an erection adequately for intercourse
o Delay or absence of ejaculation, despite adequate stimulation
o Inability to control timing of ejaculation
• Women:
o Inability to relax vaginal muscles enough to allow intercourse
o Inadequate vaginal lubrication before and during intercourse
o Inability to attain orgasm
o 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.
Are Women Less Satisfied With Their Care Than Men?
Early on in my residency, a fellow surgeon-in-training revealed that she was switching fields. Her real love was not general surgery, she explained, but urology.
As she recounted the steps leading to her decision to focus on diseases of the urinary tract, I couldn’t help wondering about her future practice. She might see an occasional woman or child; but most of her patients would be men.
I shared these thoughts with her, and she laughed. “Male patients have different expectations than female patients,” she said. “Somehow, I think I’m a better fit as a doctor for men.”
It wasn’t the first time a colleague had made a sweeping generalization about patient care, but what struck me was how boldly she had emphasized differences between men and women. As medical students we were taught to care for all patients equally, and as young practicing doctors, most of us assumed that at least as far as gender was concerned, that meant treating everyone the same.
It turns out that my colleague was onto something.
In a study published this year in the journal Health Services Research, researchers analyzed the results of a survey that asked nearly two million patients how they felt about their hospitalization. Known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or Hcahps (pronounced “H-caps”), and administered to patients within six weeks of discharge, the survey consists of 27 questions about topics ranging from communication with nurses and doctors and responsiveness of hospital staff to general cleanliness and noise levels. When the researchers divided the questionnaire results by the patients’ sex, they discovered that men tended to be more positive over all about their hospital experiences. Women were less satisfied with staff responsiveness, their discussions with nurses, communication about medications and discharge plans and the general conditions of the hospital. Among men and women who were older or felt sicker, these differences were even more pronounced.
“What patients require when they are ill and feeling vulnerable is not the same,” said Marc N. Elliott, the study’s lead author and a senior statistician at the RAND Corporation in Santa Monica, Calif. “What’s becoming clear is that we are not meeting the needs of female patients.”
In some cases the extent to which male and female patients differed in their satisfaction levels was substantial, surprising even the researchers. “There was a fairly consistent gender gap,” Dr. Elliott said. “But some of the differences were on the same magnitude as what you might see among patients from different ethnic groups or widely disparate socioeconomic backgrounds.”
One of the more marked differences was the amount of information about medications or discharge plans that patients needed to feel sufficiently informed. Women generally wanted more information than they received, while men were satisfied with what they were told. There were also considerable disparities between men and women regarding cleanliness, with women inclined to be less satisfied with the hygiene of hospital surroundings.
The findings from this study underscore how complex addressing quality and patient experience can be. Currently, most health care improvement efforts tend to treat patients as a monolithic group. It’s an oversight that can be attributed, at least in part, to the relative paucity of research and data on the patient experience.
That situation may change, as the Hcahps survey becomes linked to reimbursement and more hospitals begin administering the questionnaire to their patients. While some hospital administrators and clinicians are concerned about this prospect, Dr. Elliott and his colleagues believe their study is an indication of what this survey could help to do. By offering patients an opportunity to express their opinions, Hcahps might uncover issues that have gone unnoticed.
“Patients are hesitant to tell us what they are feeling because they don’t want to be seen as confrontational,” Dr. Elliott said. “To make substantial improvements, we need to get at that information.”
He added: “Real quality improvement is not one-size-fits-all.”
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