Reading: Introduction to Sexual Dysfunctions and Sexual Dysfunction Disorders

We first look into the four proposed categories of sexual dysfunction disorders: sexual desire disorders, arousal disorders, orgasm disorders and pain disorders as well as some proposed biological and psychological causes of these disorders. Sexual dysfunction among men and women is specifically studied in the fields of andrology and gynecology respectively.

There are several disorders related to sexual dysfunctions outlined in the DSM-5. These include

• delayed ejaculation,
• erectile disorder,
• female orgasmic disorder,
• female sexual interest/arousal disorder,
• genito-pelvic pain/penetration disorder,
• male hypoactive sexual desire disorder,
• premature ejaculation,
• substance or medication-induced sexual dysfunction, or
• other and unspecified sexual dysfunction.

We will not go into exhaustive detail about each disorder, but you should be familiar with the basic descriptions of each. They are summarized in the table below.

Sexual Desire Disorders

Sexual desire disorders or decreased libido are characterized by a lack or absence for some period of time of sexual desire or libido for sexual activity. The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may have started after a period of normal sexual functioning or the person may always have had no or low sexual desire. The causes vary considerably, but include a possible decrease in the production of normal estrogen in women or testosterone in both men and women. Other causes may be aging, fatigue, pregnancy, medications (such as SSRIs), or psychiatric conditions, such as depression and anxiety.

Hypoactive Sexual Desire Disorder

Figure 1. In some cases, HSDD may put a strain on relationships.

Hypoactive sexual desire disorder (HSDD) is considered a sexual dysfunction and is characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician.

In the DSM-5, hypoactive sexual desire disorder (HSDD) was split into male hypoactive sexual desire disorder and female sexual interest/arousal disorder. Hypoactive sexual desire disorder (HSDD) was first included in the DSM-3 under the name inhibited sexual desire disorder, but the name was changed in the DSM-3-R. Other terms used to describe the phenomenon include sexual aversion and sexual apathy. More informal or colloquial terms are frigidity and frigidness.

There are various subtypes. HSDD can be general (general lack of sexual desire) or situational (still has sexual desire but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or lifelong (the person has always had no/low sexual desire.) 

For HSDD to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), or some other medical condition. A person with male hypoactive sexual desire disorder or female sexual interest/arousal disorder will not start or respond to their partner’s desire for sexual activity.

Male Hypoactive Sexual Desire Disorder (MHSDD)

In the DSM-5, male hypoactive sexual desire disorder is characterized by “persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity,” as judged by a clinician with consideration for the patient’s age and cultural context.

Female Sexual Interest/Arousal Disorder (FSIAD)

Female sexual interest/arousal disorder is defined as a “lack of, or significantly reduced, sexual interest/arousal,” manifesting through at least three of the following symptoms: no or little interest in sexual activity, no or few sexual thoughts, no or few attempts to initiate sexual activity or respond to partner’s initiation, no or little sexual pleasure/excitement in 75–100% of sexual experiences, no or little sexual interest in internal or external erotic stimuli, and no or few genital/nongenital sensations in 75–100% of sexual experiences.

Diagnosing HSDD

For both diagnoses, symptoms must persist for at least six months, cause clinically significant distress, and not be better explained by another condition. Simply having lower desire than one’s partner is not sufficient for a diagnosis. Self-identification of a lifelong lack of sexual desire as asexuality precludes diagnosis.

Low sexual desire alone is not equivalent to HSDD because of the requirement in HSDD that the low sexual desire causes marked distress and interpersonal difficulty and because of the requirement that the low desire is not better accounted for by another disorder in the DSM or by a general medical problem. It is therefore difficult to say exactly what causes HSDD. It is easier to describe, instead, some of the causes of low sexual desire. 

Etiology of HSDD

The cause of lifelong/generalized HSDD is unknown. In the case of acquired/generalized low sexual desire, possible causes include various medical/health problems, psychiatric problems, low levels of testosterone or high levels of prolactin. One theory suggests that sexual desire is controlled by a balance between inhibitory and excitatory factors. This is thought to be expressed via neurotransmitters in selective brain areas. A decrease in sexual desire may therefore be due to an imbalance between neurotransmitters with excitatory activity like dopamine and norepinephrine and neurotransmitters with inhibitory activity, like serotonin. Low sexual desire can also be a side effect of various medications. In the case of acquired/situational HSDD, possible causes include intimacy difficulty, relationship problems, sexual addiction, and chronic illness of the partner. The evidence for these is somewhat in question. Some claimed causes of low sexual desire are based on empirical evidence. However, some are based merely on clinical observation. In many cases, the cause of HSDD is simply unknown.

Research has not yet examined factors associated with FSIAD and there has been little investigation of the impact of individual factors, notably stress, levels of fatigue, gender identity, health, and other individual attributes and experiences, such as dysfunctional sexual beliefs that may affect sexual desire or response. However, researchers have investigated a number of causes and consequences of low sexual interest in women and low sexual arousal. These elements are broken down into biological factors including medical health, hormones, and medications, and psychological factors including stress, relationships, comorbid mental illness, and history of sexual abuse.^[2]

Sexual Arousal Disorders

Sexual arousal disorders were previously known as frigidity in women and impotence in men, though these have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity has been replaced with a number of terms describing specific problems that can be broken down into four categories. These four categories, as described by the DSM are lack of desire, lack of arousal, pain during intercourse, and lack of orgasm. For both men and women, these conditions can manifest themselves 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 physiological origins to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease can also contribute as well as the nature of the relationship between the partners.

Erectile Disorder

Figure 2. Physical damage as a cause of erectile dysfunction is more severe than psychological causes.

Men with erectile disorder cannot attain or maintain an erection during sexual activity that is sufficient to allow them to initiate or maintain sexual activity. Erectile dysfunction or impotence is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. There are various underlying causes, such as damage to the nervi erigentes, which prevents or delays erection, or diabetes as well as cardiovascular disease, which simply decreases blood flow to the tissue in the penis, many of which are medically reversible.

The causes of erectile dysfunction may be psychological or physical. Psychological erectile dysfunction can often be helped by almost anything that the patient believes in; there is a very strong placebo effect. Physical damage is much more severe. One leading physical cause of erectile dysfunction is continual or severe damage taken to the nervi erigentes. These nerves course beside the prostate arising from the sacral plexus and can be damaged in prostatic and colorectal surgeries. Diseases are also common causes of erectile dysfunction; especially in men. Diseases such as cardiovascular disease, multiple sclerosis, kidney failure, vascular disease, and spinal cord injury are the source of erectile dysfunction.

Due to its embarrassing nature and the shame felt by sufferers, the subject was taboo for a long time and is the subject of many urban legends. Folk remedies have long been advocated, with some being advertised widely since the 1930s. The introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (trade name Viagra), in the 1990s caused a wave of public attention, propelled in part by the news-worthiness of stories about it and heavy advertising.

It is estimated that around 30 million men in the United States and 152 million men worldwide suffer from erectile dysfunction. However, social stigma, low health literacy, and social taboos lead to underreporting,which makes an accurate prevalence rate hard to determine.

Orgasm Disorders

Ejaculatory and orgasmic disorders are common male sexual dysfunctions. The DSM-5 specifically mentions delayed ejaculation and premature ejaculation (PE), although there are others that may include anejaculation (inability to orgasm), or retrograde ejaculation (where some of the semen travels back to the bladder), or anorgasmia (persistent inability or struggle to orgasm).

Delayed Ejaculation

Delayed ejaculation is a man’s inability for or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation. Generally, a man can reach orgasm within a few minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not have orgasms at all or cannot have an orgasm until after prolonged intercourse which might last for 30–45 minutes or more. In most cases, delayed ejaculation presents the condition in which the man can climax and ejaculate only during masturbation, but not during sexual intercourse. It is the least common of the male sexual dysfunctions, and can result as a side effect of some medications. In one survey, 8% of men reported being unable to achieve orgasm over a two-month period or longer in the previous year.

Delayed ejaculation can be mild (men who still experience orgasm during intercourse, but only under certain conditions), moderate (cannot ejaculate during intercourse but can during fellatio or manual stimulation), severe (can ejaculate only when alone), or most severe (cannot ejaculate at all). All forms may result in a sense of sexual frustration.

Medical conditions that can cause delayed ejaculation include hypogonadism, thyroid disorders, pituitary disorders such as Cushing’s disease, prostate surgery outcome, and drug and alcohol use. Difficulty in achieving orgasm can also result from pelvic surgery that involved trauma to pelvic nerves responsible for orgasm. Some men report a lack of sensation in the nerves of the glans penis, which may or may not be related to external factors, including a history of circumcision. Delayed ejaculation is a possible side effect of certain medications, including selective serotonin reuptake inhibitors (SSRIs); opiates such as morphine, methadone, or oxycodone; many benzodiazepines such as Valium; certain antipsychotics; and antihypertensive.

Psychological and lifestyle factors have been discussed as potential contributors, including insufficient sleep, distraction due to worry, distraction from the environment, anxiety about pleasing their partner, and anxiety about relationship problems.

Premature Ejaculation

Premature ejaculation (PE) is a prevalent sexual dysfunction in men characterized as a persistent and undesirable premature ejaculation that occurs around one minute or less of vaginal penetration and must be experienced in almost all or all (75–100%) occasions during partnered sexual activity. Premature ejaculation (PE) often occurs when a man experiences orgasm and expels semen within a few moments of beginning sexual activity and with minimal penile stimulation. PE has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax, and (historically) ejaculatio praecox. 

There is no correct length of time for intercourse to last, but generally, premature ejaculation is thought to occur when ejaculation occurs in around one minute or less from the time of the insertion of the penis. Because of the variability in time required to ejaculate and in partners’ desired duration of sex, exact prevalence rates of PE are difficult to determine. For a diagnosis, the patient must have a chronic history of premature ejaculation (at least six months), poor ejaculatory control, and the problem must cause feelings of dissatisfaction as well as distress for the patient, the partner, or both.

Historically attributed to psychological causes, new theories suggest that premature ejaculation may have an underlying neurobiological cause that may lead to rapid ejaculation. The nucleus paragigantocellularis of the brain has been identified as having involvement in ejaculatory control. Scientists have long suspected a genetic link to certain forms of premature ejaculation. However, studies have been inconclusive in isolating the gene responsible for lifelong PE. Other researchers have noted that men who have premature ejaculation have a faster neurological response in the pelvic muscles. 

Premature ejaculation can be diagnosed as either lifelong (primary) or acquired (secondary), with acquired PE developing at some point in life after previous normal experiences. Acquired PE may be due to situational factors such as performance anxiety, relationship problems, or some ailments more comment in older men, such as prostatitis, hyperthyroidism, or diabetes.^[3]

Female Orgasmic Disorder

Sexual Pain Disorders

Sexual pain disorders affect women almost exclusively and are also known as dyspareunia (painful intercourse) or vaginismus (an involuntary spasm of the muscles of the vaginal wall that interferes with intercourse).

Genito-Pelvic Pain/Penetration Disorder (GPPPD)

Genito-pelvic pain/penetration disorder (GPPPD) is a new diagnosis included in the DSM-5, which merged the revised definitions of both female sexual dysfunctions dyspareunia and vaginismus.

At least one of the following persistent or recurrent criteria characterizes GPPPD: (1) difficulties with vaginal penetration during intercourse, (2) genito-pelvic pain during vaginal intercourse or penetration attempts, (3) fear or anxiety associated with genito-pelvic pain or vaginal penetration, or (4) tightness of the pelvic floor muscles during attempted vaginal penetration. One or more of these symptoms have to be present for at least six months and must cause clinically significant distress. GPPPD can be classified as either lifelong or acquired and, depending on the level of distress, as mild, moderate, or severe. The fusion of vaginismus and dyspareunia under a new classification and set of criteria was due to the significant overlap in clinical presentation and exceeding difficulties to distinguish between the two reliably.

Etiology of Genito-Pelvic Pain/Penetration Disorder (GPPPD)

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 breastfeeding. Irritation from contraceptive creams and foams can 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 seems to be related to problems with the skin in the vulvar and vaginal areas. The cause is unknown.

The prevalence of GPPPD has not been ascertained due to the novel criteria set. Reported prevalence rates in the general population vary between three and 25% for dyspareunia and 0.4 and 6.6% for vaginismus. Prevalence estimates are heterogeneous due to varying diagnostic criteria, assessment methods, study design, and sample characteristics.

The burden of suffering associated with GPPPD and linked conditions such as vulvodynia and provoked vestibulodynia is high as symptoms have a detrimental impact on physiological and psychological health, and relational well-being. Vulvodynia is chronic pain in the vulva, the area on the outside of a woman’s genitals. It is usually described as a sensation of burning, stinging, itching, or rawness. Vestibulodynia is chronic pain and discomfort that occurs in the area around the opening of the vagina, inside the inner lips of the vulva. This area is known as the vestibule.

GPPPD has been shown to have a negative effect on the woman’s overall quality of life, with 60% of women reporting that the disorder compromised their ability to enjoy life. Moreover, it has been linked to depression and anxiety disorder. GPPPD symptoms are often comorbid with a wide range of other sexual dysfunctions and reduced sexual behavior. Many women with GPPPD also experience problems when using tampons or during gynecological examinations. GPPPD has been shown to contribute to declines in self-esteem and feelings of femininity and is associated with a negative body and genital self-image. It can pose a considerable burden on a couple’s relationship, especially if they would like to have children.^[6]