Perspectives on Sexual Dysfunction Disorders

There are many factors that may result in a person experiencing sexual dysfunction. These may result from emotional or physical causes. Emotional factors include interpersonal or psychological problems, which can be the result of depression, sexual fears or guilt, past sexual trauma, and sexual disorders, among others.

Sexual dysfunction is especially common among people who have anxiety disorders. Ordinary anxiousness can obviously cause erectile dysfunction in men without psychiatric problems, but clinically diagnosable disorders such as panic disorder commonly cause avoidance of intercourse and premature ejaculation. Pain during intercourse is often a comorbidity of anxiety disorders among women. Therefore,  clinicians are careful not to rule out the fact that there may be physiological causes of these dysfunctions as well.

The Biological Model

Physical factors that can lead to sexual dysfunctions include the use of drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs. Excessive use of alcohol or use of other recreational drugs may cause sexual dysfunction, either by a direct effect on the penile neurovascular system or by causing increased secretion of prolactin, reduction in the production of testosterone, or both. Many medications are commonly associated with sexual dysfunction, including diuretics, antipsychotics, antidepressants, benzodiazepines, buspirone, lithium, disulfiram, oral contraceptives, etc.

For women, almost any physiological change that affects the reproductive system—premenstrual syndrome, pregnancy, the postpartum period, and menopause—can have an adverse effect on libido. A common physiological culprit of anorgasmia is menopause, where one in three women report problems obtaining an orgasm during sexual stimulation following menopause.

For men, diseases such as cardiovascular disease, multiple sclerosis, kidney failure, vascular disease, and spinal cord injury are the source of erectile dysfunction. Historically attributed to psychological causes, new theories suggest that premature ejaculation may have an underlying neurobiological cause that may lead to rapid ejaculation.^[1]

The Psychodynamic Model

Psychological factors associated with sexual dysfunction can be divided into three categories: predisposing factors, precipitating factors, and maintaining factors. Predisposing factors include things like trauma, inadequate sexual information, disturbed family relationships, or insecurities. Precipitating factors include unreasonable or negative expectations, lack of harmony in the relationships, infidelity, or depression. Maintaining factors may include any of those same issues, just maintained over a longer time period.^[2].

The Sociocultural Model

Cultural and societal myths surrounding sex may also cause sexual dysfunctions. For example, some people erroneously learn that men always think about sex, the man should be the leader, penis size is important, couples must have frequent sex, or sex happens automatically. Other myths perpetuate about orgasms and when they happen, supposed dangers of masturbation, circumcision, and more.^[3]

In the context of heterosexual relationships, one of the main reasons for the decline in sexual activity among these couples is the male partner experiencing erectile dysfunction. This can be very distressing for the male partner, causing poor body image, and it can also be a major source of low desire for these men. In aging women, it is natural for the vagina to narrow and become atrophied. If a woman has not been participating in sexual activity regularly (in particular, activities involving vaginal penetration) with her partner, if she does decide to engage in penetrative intercourse, she will not be able to immediately accommodate a penis without risking pain or injury. This can turn into a vicious cycle, often leading to female sexual dysfunction.

According to Emily Wentzell, American culture has anti-aging sentiments that have caused sexual dysfunction to become “an illness that needs treatment” instead of viewing it as the natural part of the aging process it is. Not all cultures seek treatment; for example, a population of men living in Mexico often accept erectile dysfunction as a normal part of their maturing sexuality.^[4]

Female Sexual Dysfunction

Several theories have looked at female sexual dysfunction, from medical to psychological perspectives. Three social psychological theories include the self-perception theory, the overjustification hypothesis, and the insufficient justification hypothesis:

• Self-perception theory: people make attributions about their own attitudes, feelings, and behaviors by relying on their observations of external behavior and the circumstances in which those behaviors occur.
• Overjustification hypothesis: when an external reward is given to a person for performing an intrinsically rewarding activity, the person’s intrinsic interest will decrease.
• Insufficient justification: based on the classic cognitive dissonance theory (inconsistency between two cognitions or between a cognition and a behavior will create discomfort), this theory states that people will alter one of the cognitions or behaviors to restore consistency and reduce distress.

The importance of how a woman perceives her behavior should not be underestimated. Many women perceive sex as a chore as opposed to a pleasurable experience, and they tend to consider themselves sexually inadequate, which in turn does not motivate them to engage in sexual activity. Several factors influence a women’s perception of her sexual life. These factors can include race, gender, ethnicity, educational background, socioeconomic status, sexual orientation, financial resources, culture, and religion. Cultural differences are also present in how women view menopause and its impact on health, self-image, and sexuality. A study has found that African-American women are the most optimistic about menopausal life, Caucasian women are the most anxious, Asian women are the most inhibited about their symptoms, and Hispanic women are the most stoic.

About one-third of the women experienced sexual dysfunction, which may lead to women’s loss of confidence in their sexual lives. Since these women had sexual problems, their sexual lives with their partners became a burden without pleasure, and eventually, they may completely lose interest in sexual activity. Some of the women found it hard to be aroused mentally; however, some had physical problems. Several factors can affect female dysfunction, such as situations in which women do not trust their sex partners. The environment where sex occurs is crucial, since being in an extremely public or extremely private place may make some women feel uncomfortable. Inability to concentrate on the sexual activity due to a bad mood or burdens from work may also cause a woman’s sexual dysfunction.^[5]

Treating Sexual Dysfunction Disorders

Cognitive sexual therapy (CST) is a cognitive-behavioral integrative psychotherapy aimed specifically to address and treat SDs, articulating evidence-based clinical interventions to scientific understandings of human sexuality. In a cognitive sexual therapy (CST) perspective, distorted sexual cognitions, allied to individuals’ misinterpretations of sexual demands, directly affect emotional, physiological, and behavioral regulation in sexual situations. In this sense, restructuring central and intermediate cognitive processes is essential to foster the acquisition of sexual skills and to promote the development of a more adapted sexual repertoire. Thus, cognitions are understood as mediating factors to be modified, aiming sexual skills implementation and emotional regulation during sexual encounters.

Sexual scripts are ideas of how males and females are supposed to interact with each other, including how each gender should behave in sexual or romantic situations. Being able to flexibilize sexual scripts and behaviors leads to better adaptation to physiological, environmental, and relational changes that negatively impact sexuality over the life cycle, contributing to booster sexual satisfaction even in the presence of sexual function disturbances. The focus of cognitive sexual therapy (CST) interventions is to aid patients and partners towards the development of more flexible and adaptable sexual cognitions and behavioral patterns. CST could permit a regain in sexual function and satisfaction during and after treatment with psychotropic medication, lessen the negative impact of sexual adverse effects in quality of life and therefore, increase adherence and therapeutic effects of pharmacotherapy. Although the theoretical rationale supporting this proposal is evidence-based, feasibility, efficacy, treatment modalities, and procedural aspects of the intervention remain to be empirically tested.

Figure 1. Sex therapy, at any age, often involves sensate-focused touching.

Sex Therapy

Sex therapy is a strategy for the improvement of sexual function and treatment of sexual dysfunction including premature ejaculation or delayed ejaculation, erectile dysfunction, lack of sexual interest or arousal, and painful sex. It includes dealing with problems imposed by atypical sexual interests (paraphilias); gender dysphoria and being transgender; highly overactive libido or hypersexuality; a lack of sexual confidence; recovering from sexual abuse, such as rape or sexual assault; and sexual issues related to aging, illness, or disability.

It can include sensate focus, communication, and fantasy exercises as well as psychodynamic therapy. Sensate focus is a sex therapy technique introduced by the Masters and Johnson team. It works by refocusing the participants on their own sensory perceptions and sensuality, instead of goal-oriented behavior focused on the genitals and penetrative sex. Sensate focus has been used to treat problems with body image, erectile dysfunction, orgasm disorders, and lack of sexual arousal.

The exercises are conducted by the couple at home between therapy sessions. Although the couple are nude and touching each other during the exercises, they are instructed to abstain from sexual intercourse during or close to the sessions. Both participants are instructed instead to focus on their own varied sense experience, instead of focusing on performance or orgasm. Initially, the emphasis is on touching in a mindful way for oneself without regard for sexual response or pleasure for oneself or one’s partner. In the second stage, they still abstain from intercourse and use touch to learn about their bodies and to identify what is pleasurable. Eventually, further stages lead again to intercourse, with the focus on learning about the partner’s body.

Taking about sex can be embarrassing for both the clinician and the patients, so it is important for the clinician to reassure the patient of confidentiality. Treatment plans will vary depending on the condition. For example, sexual desire disorders have no particular treatment plan and do not generally respond well to psychotherapy.^[6] Some therapies, like treating vaginismus, include sex education and information to help the patient come to relax or to overcome negative preconceived notions about sex. Relaxation training may be helpful in these instances. Generally, several types of psychoterapies may be used in sex therapy, including psychodynamic, rational emotive therapy, CBT, or behavioral therapies such as systematic desensitization, and Masters and Johnson’s behavioral therapy techniques (which focus on talk therapy with a couple making behavioral changes together that they work on as homework assignments following a therapy session).