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Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm. To maximize the benefits of medications and behavioral techniques in the management of sexual dysfunction it is important to have a comprehensive approach to the problem. A thorough sexual history and assessment of general health and other sexual problems (if any) are very important. Assessing (performance) anxiety, guilt (associated with masturbation in many South-Asian men), stress and worry are integral to the optimal management of sexual dysfunction. When a sexual problem is managed inappropriately or sub-optimally, it is very likely that the condition will subside immediately but re-emerge after a while. When this cycle continues, it strongly reinforces failures that eventually make individuals not to access any help and suffer it all their life. So, it is important to get a thorough assessment from professionals and therapists who are qualified to manage sexual problems. Internet-based information is good for gaining knowledge about sexual functioning and sexual problem but not for self-diagnosis and/or self-management.

What is sexual dysfunction?

When you have problems with sex, doctors call it “sexual dysfunction”. Both men and women can have it. There are 4 kinds of sexual problems.

• Desire disorders – When you are not interested in having sex or have less desire for sex than you used to.
• Arousal disorders – When you don’t feel a sexual response in your body or you cannot stay sexually aroused.
• Orgasmic disorders – When you can’t have an orgasm or you have pain during orgasm.
• Sexual pain disorders – When you have pain during or after sex. Desire disorders (Hypoactive Sexual Desire Disorder)

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 or of sexual fantasies. 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/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 the SSRIs) or psychiatric conditions, such as depression and anxiety. Loss of libido from SSRIs usually reverses after SSRIs are discontinued, but in some cases it does not.

Arousal disorders

• Sexual arousal disorders were previously known as frigidity in women and impotence in men. 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 medical causes 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.

Orgasm disorder (Anorgasmia)

• Orgasm disorders are persistent delays or absence of orgasm following a normal sexual excitement phase. The disorder can have physical, psychological, or pharmacological origins. SSRI antidepressants are a common pharmaceutical culprit, as they can delay orgasm or eliminate it entirely.

Sexual pain disorders

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

Causes: There are many factors which may result in a person experiencing a sexual dysfunction. These may result from emotional or physical causes.

• Sexual dysfunction may arise from emotional factors, including interpersonal or psychological problems. Interpersonal problems may arise from marital or relationship problems, or from a lack of trust and open communication between partners, and psychological problems may be the result of depression, sexual fears or guilt, past sexual trauma, 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 co-morbidity of anxiety disorders among women.
• Sexual activity may also be impacted by physical factors. These would include use of drugs, such as alcohol, nicotine, narcotics, stimulants, anti-hypertensives, antihistamines, and some psychotherapeutic drugs. For women, almost any physiological change that affects the reproductive system – premenstrual syndrome, pregnancy, postpartum, menopause – can have an adverse effect on libido. Injuries to the back may also impact sexual activity, as would problems with an enlarged prostate gland, problems with blood supply, nerve damage (as in spinal cord injuries). Disease, such as diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis may also impact on the activity, as would failure of various organ systems (such as the heart and lungs), endocrine disorders (thyroid, pituitary, or adrenal gland problems), hormonal deficiencies (low testosterone, estrogen, or androgens), and some birth defects.

What causes sexual dysfunction?

Many things can cause problems in your sex life. Certain medicines (such as oral contraceptives and chemotherapy drugs), diseases (such as diabetes or high blood pressure), excessive alcohol use or vaginal infections can cause sexual problems. Depression, relationship problems or abuse (current or past abuse) can also cause sexual dysfunction. You may have less sexual desire during pregnancy, right after childbirth or when you are breastfeeding. After menopause many women feel less sexual desire, have vaginal dryness or have pain during sex due to a decrease in estrogen (a hormone in the body). The stresses of everyday life can also affect your ability to have sex. Being tired from a busy job or caring for young children may affect your sexual desire. You may also be bored by a long-standing sexual routine.

How do I know if I have a problem?

Up to 70% of couples have a problem with sex at some time in their relationships. Most women will have sex that doesn’t feel good at some point in her life. This doesn’t necessarily mean you have a sexual problem.If you don’t want to have sex or it never feels good, you might have a sexual problem. Discuss your concerns with your doctor. Remember that anything you tell your doctor is private and that your doctor can help you find a reason and possible treatment for your sexual dysfunction.

What can I do?

If desire is the problem, try changing your usual routine. Try having sex at different times of the day, or try a different sexual position.Arousal disorders can often be helped if you use a vaginal cream or sexual lubricant for dryness. If you have gone through menopause, talk to your doctor about taking estrogen or using an estrogen cream.If you have a problem having an orgasm, you may not be getting enough foreplay or stimulation before actual intercourse begins. Extra stimulation (before you have sex with your partner) with a vibrator may be helpful. You might need rubbing or stimulation for up to an hour before having sex. Many women don’t have an orgasm during intercourse. If you want an orgasm with intercourse, you or your partner may want to gently stroke your clitoris. Masturbation may also be helpful, as it can help you learn what techniques work best for you.If you’re having pain during sex, try different positions. When you are on top, you have more control over penetration and movement. Emptying your bladder before you have sex, using extra lubrication or taking a warm bath before sex all may help. If you still have pain during sex, talk to your doctor. He or she can help you find the cause of your pain and decide what treatment is best for you.

Can medicine help?

If you have gone through menopause or have had your uterus and/or ovaries removed, taking the hormone estrogen may help with sexual problems. If you’re not already taking estrogen, ask your doctor if this is an option for you.You may have heard that taking sildenafil (Viagra) or the male hormone testosterone can help women with sexual problems. There have not been many studies on the effects of Viagra or testosterone on women, so doctors do not know whether these things can help or not. Both Viagra and testosterone can have serious side effects, so using them is probably not worth the risk.

What else can I do?

Learn more about your body and how it works. Ask your doctor about how medicines, illnesses, surgery, age, pregnancy or menopause can affect sex. Practice “sensate focus” exercises where one partner gives a massage, while the other partner says what feels good and requests changes (example: “lighter”, “faster”, etc.). Fantasizing may increase your desire. Squeezing the muscles of your vagina tightly (called Kegel exercises) and then relaxing them may also increase your arousal. Try sexual activity other than intercourse, such as massage, oral sex or masturbation.

What about my partner?

Talk with your partner about what each of you like and dislike, or what you might want to try. Ask for your partner’s help. Remember that your partner may not want to do some things you want to try, and you may not want to try what your partner wants. You should respect each other’s comforts and discomforts. This helps you and your partner have a good sexual relationship. If you feel you can’t talk to your partner, your doctor or a counselor may be able to help you.If you feel like your partner is abusing you, tell your doctor

How can my doctor help?

Your doctor can suggest ways to treat your sexual problems or can refer you to a sex therapist or counselor if needed.

Treatment for females

Although there are no approved pharmaceuticals for addressing female sexual disorders, several are under investigation for their effectiveness. A vacuum device is the only approved medical device for arousal and orgasm disorders. It is designed to increase blood flow to the clitoris and external genitalia. Women experiencing pain with intercourse are often prescribed pain relievers or desensitizing agents. Others are prescribed lubricants and/or hormone therapy. Many patients with female sexual dysfunction are often also referred to a counselor or therapist for psychosocial counseling.Sexual dysfunction in males

Erectile dysfunction

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, 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 impotence 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. These nerves course besides the prostate gland arising from the sacral plexus and can be damaged in prostatic and colo-rectal surgeries. The introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (Viagra), in the 1990s caused a wave of public attention, propelled in part by the news-worthiness of stories about it and heavy advertising. Uncommon sexual disorders in men Erectile dysfunction from vascular disease is usually seen only amongst elderly individuals who have atherosclerosis. Vascular disease is common in individuals whom have diabetes, peripheral vascular disease, hypertension and those who smoke. Any time blood flow to the penis is impaired, erectile dysfunction is the end result. Hormones deficiency is a relatively rare cause of erectile dysfunction. In individuals with testicular failure like Klinefelter’s syndrome, or those who have had radiation therapy, chemotherapy or childhood exposure to mumps virus, the testes may fail and not produce testosterone. Structural abnormalities of the penis like Peyronie’s disease can make sexual intercourse difficult. The disease is characterized by thick fibrous bands in the penis which leads to a deformed-looking penis. Drugs are also a cause of erectile dysfunction. Individuals who take drugs to lower blood pressure, uses antipsychotics, antidepressants, sedatives, narcotics, antacids or alcohol can have problems with sexual function and loss of libido. Priapism is a painful erection that occurs for several hours and occurs in the absence of sexual stimulation. This condition develops when blood gets trapped in the penis and is unable to drain out. If the condition is not promptly treated, it can lead to severe scarring and permanent loss of erectile function. The disorder occurs in young men and children. Individuals with sickle-cell disease and those who abuse certain medications can often develop this disorder

Treatment for males

Since in many men the cause of sexual dysfunction is related to anxiety about performance, psychotherapy can help. Situational anxiety arises from an earlier bad incident or lack of experience. This anxiety often leads to development of fear towards sexual activity and avoidance. In return evading leads to a cycle of increased anxiety and desensitization of the penis. In some cases, erectile dysfunction may be due to marital disharmony. Marriage counseling sessions are recommended in this situation. Lifestyle changes such as discontinuing smoking, drug or alcohol abuse can also help in some types of erectile dysfunction. Several medications like Viagra, cialis and Levitra have become available to help people with erectile dysfunction. These medications do work in about 60% of men. In the rest, the medications may not work because of wrong diagnosis or chronic history. Another type of medication that is effective in roughly 85% of men is called intracavernous pharmacotherapy involves injecting a vasodilator drug directly into the penis in order to stimulate an erection.