Page 510-535, 25 pages Page 1 of16
Chapter 18: Sexual Disorders
• Definitions of sexual disorders are affected by social and cultural contexts, and sexual dysfunction
exists on a continuum – most have had a sexual problem that goes away in a day or a few months
without treatment, between absolutely great sexual functioning and long-term difficulties which require
• Sexual Disorder: A problem with sexual response that causes the person psychological distress.
There are four categories in the DSM, with desire, arousal, and orgasmic disorders corresponding to the
sexual response cycle.
• These diagnoses have been criticized for their focus on genital responding and neglect of subjective
• Disorders can be lifelong, or primary, and present since the person began sexual functioning (e.g. has
never achieved orgasm). It could also be acquired, or secondary, appearing after a period of normal
• Disorders can be generalized, occurring in all situations, or situational when it occurs in some
situations but not others. For example, they may occur with one partner but not the other, in one location
but not another.
Type of In Men – 18% at some point in life In Women – 28% at some point
Desire Hypoactive sexual desire disorder Hypoactive sexual desire disorder
(HSDD) Sexual aversion disorder
Sexual aversion disorder
Arousal Erectile disorder Female sexual arousal disorder
Orgasmic Premature ejaculation Female orgasmic disorder
Male orgasmic disorder
Sexual Pain Dyspareunia Dyspareunia Vaginismus
Hypoactive Sexual Desire
• Desire encompasses the libido, motivation to seek out sexual stimuli, or general interest in sex. It can
be manifested in sexual thoughts and fantasies, and interest in initiating and participating in sexual
• Hypoactive sexual desire (HSD) is a disorder in which there is a persistent/recurrent deficiency in
interest and responsive desire in sexual activity, including a lack of spontaneous sexual thoughts or
fantasies the judgement of deficiency is made by the clinician, taking into account factors such as age
and context (e.g. length of relationship, previous sexual experience)
• People with HSD typically avoid situations that will evoke sexual feelings: they do not initiate sex, are
not receptive when their partner initiates, and do not feel frustrated if they do not engage in sexual
activity. When they do engage, it may be due to partner pressure or to non-sexual needs such as
• Low sexual desire is the most common sexual issue for women, about 39% with diminished and 10-
15% with no sexual desire. About half as many men as women experience desire problems.
• The problem is often not an individual’s absolute level of sexual desire, but a discrepancy of sexual
desire between partners.
• Cause of lifelong, generalized HSDD is unknown; low levels of hormones may play a role. Acquired
HSDD may be informed by stress and fatigue, depression (anhedonia) , and negative sexual attitudes. Page 510-535, 25 pages Page 2 of16
Sexual Aversion Disorder
• On a continuum with HSDD. In Sexual Aversion Disorder, a person has a strong repulsion against
sexual interaction, involving anxiety, fear or disgust, and actively avoids any kind of genital contact with a
• Sexual aversive disorder may be more prevalent in women than men, and may be related to panic
• Erectile Disorder (ED) is the persistent inability to have or maintain an erection, often meaning the
man cannot engage in sexual intercourse. It may be situational, occurring with a partner but not with
• Around 10% of men have experienced an erection problem within the last year, increasing markedly
between ages 4o and 70. Erectile disorder is the most common disorder for men who seek therapy
• Psychological reactions to ED may be severe, often seen as an embarrassment.
Female Sexual Arousal Disorder
• Female Sexual Arousal Disorder (FSAD): A persistent or recurrent inability to attain or to maintain an
adequate lubrication-swelling response. Occurs in women with a lack of response to sexual stimulation.
Many women do not consider it to be a problem, and thus do not seek treatment (easily alleviated by
• This involves both a psychological component and a physiological component – both by difficulties with
vaginal lubrication and with a women’s subjective sense of arousal.
• Chivers (2010): Agreement between physiological and psychological sexual responses is lower in
women than men – 0.26 agreement in women, and 0.66 in men.
• Many women who report subjective arousal difficulties have physiological arousal at similar levels to
control women, while women who report physiological without psychological arousal do have lower
vaginal lubrication. This suggests there may be different subtypes of FSAD.
• Problems with lubrication particularly increase after menopause, and is not a sexual disorder. The use
of commercial lubricants can help with this problem.
DSM5: Sexual Interest/Arousal Disorder (SIAD)
• SIAD: Lack of sexual interest or arousal of at least 6 months, with at least 3 indicators. Absent or
o Frequency or intensity of interest in sexual activity
o Frequency or intensity of sexual/erotic thoughts or fantasies
o Initiation of sexual activity, and is typically unreceptive to a partner’s attempts to initiate
o Frequency or intensity of sexual excitement/pleasure during sexual activity on all or almost all
(above 75% of) sexual encounters
o Sexual interest/arousal from any internal or external sexual/erotic cues
o Frequency or intensity of genital and/or nongenital sensations during sexual activity on all or
almost all encounters
o The problem causes clinically significant distress or impairment
• Sexual desire and arousal disorders were merged in DSM5 for women, due to criticism of the linear
step-by-step progression of the sexual response cycle
• Many women experience desire after the sexual encounter has begun (responsive desire), rather than
at the beginning as a prerequisite for one’s sexual response
Orgasmic Disorders Page 510-535, 25 pages Page 3 of16
Premature (Rapid) Ejaculation
• Premature ejaculation occurs when a man ejaculates too soon, and feels he cannot control the timing
of his ejaculation. In some cases ejaculation occurs before penetration occurs at all, and in other cases
the man is able to delay the orgasm to some extent but not long enough to his or his partner’s
• Clinicians must take into account factors that affect duration of the excitement phase, such as: age,
novelty of the sexual partner or situation, and recent frequency of sexual activity
• In practice it is difficult to specify when an ejaculation is considered “premature” or “too soon”. Kaplan
believed the key was the absence of voluntary control, and is based on self-definition if the man
finds his lack of ejaculatory control is concerning or affecting his relationship.
• Poor ejaculatory control is a common problem reported by 24% of men. 60% of men who seek
treatment for sexual problems report premature ejaculation. Average time to ejaculation around 8
minutes, with 17% reporting ejaculating under 2 minutes.
• However, female partners are less likely to see their rapid ejaculation as a problem compared to the
men themselves. PE is associated with lower sexual satisfaction for the men but not their partners, and is
not associated with relationship satisfaction for either partner.
• PE can cause a man to become anxious about his sexual competence, and may create relationship
friction – societal concept of a competent lover as someone who can postpone ejaculation and “satisfy”
• One may internalize PE, believe one is unworthy of relationships and stop dating entirely.
• Men may use some strategies for dealing with PE, such as using desensitizing creams, or most
commonly to think of distracting thoughts during sex to remove attention from the sensations. These
o Sex negative, e.g. thinking of an unattractive public figure
o Sex positive, e.g. visualizing a past episode of prolonged intercourse
o Non-sexual and negative, e.g. thinking of a sad event
o Sex neutral, e.g. counting backwards from 100
o Sexually incongruous, e.g. thinking of your grandmother or church
• The sex positive alternative is recommended to both delay ejaculation and help partners remain in the
moment. Can also focus on sensations and use the stop/start technique to maintain arousal at
• May have a learned component with rushed masturbation during youth, as a form of conditioning
Male Orgasmic Disorder
• Male orgasmic disorder is the opposite of rapid ejaculation, where one is persistently unable to
orgasm or orgasm is greatly delayed despite adequate erection and stimulation. About 5% prevalence; in
the most common version, the man is incapable of orgasm during intercourse but may be able to from
hand or mouth stimulation.
• Some react negatively to this condition, seeing their partner’s inability to orgasm as a personal rejection
or intercourse may become painful due to its long duration. Some men adopt the practice of faking
Female Orgasmic Disorder
• Female orgasmic disorder is a sexual disorder in which the woman is unable to orgasm, following a
normal sexual excitement phase. Diagnosis based on clinician’s judgement that the woman’s orgasmic
capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual
stimulation she receives
• A common pattern is situational orgasmic disorder, in which the woman may have orgasms when
masturbating but not when being stimulated by a partner. Page 510-535, 25 pages Page 4 of16
• Most common complaint from women who seek sex therapy; 11% prevalence in Canadian women,
especially among younger women.
• Around 21% report they do not usually orgasm during intercourse. Social scripts of the “right” way to
have sex with penile-vaginal intercourse and the “right” way to achieve orgasm may pathologize women’s
variations in orgasm response. Some experts consider situational orgasmic disorder to be well within the
normal range of female sexual response – a matter of adequate stimulation, not dysfunctional sexual
• Nevertheless, if a woman is truly distressed by her inability to orgasm it may be appropriate to provide
therapy even if she would not meet the criteria for a disorder. Must clarify difference in dissatisfaction in
sexual responding from an overly idealistic sexual script
Sexual Pain Disorders
• “Normal” causes of occasional pain during sex: deep penetration with cervical contact, certain
positions, vaginal dryness and friction
• Dyspareunia: Painful intercourse, can occur for both women and men. Occasional pain during
intercourse is common particularly for girls between ages 12 and 19 who are engaging in intercourse, but
persistent dyspareunia is not.
• In women, the pain may be felt in the vagina, around the introitus and clitoris, or deep in the pelvis; it
may be generalized or localized to a particular area and the pain can also differ in terms of quality and
intensity. Some describe a burning sensation, others a sharp pain or ache.
• Conditions that can cause this pain include: infections, skin conditions, fissures, and nervous system
disorders. These may resolve themselves fairly easily with medial solutions; however, some suffer from
chronic genital pain without an apparent physiological cause.
• Most of these women also experience pain in non-sexual situations involving the genitals, such as
sports or inserting a tampon.
• Dyspareunia significantly decreases one’s enjoyment of the sexual experience, and frequently causes
problems with arousal and orgasm.
• Some experts argue that just because pain interferes with sexual activity, this does not make it a sexual
disorder – should be classified by its location rather than the activity it affects. This is particularly true as
this pain often occurs in non-sexual situations.
• These experts argue painful intercourse should be reclassified and treated as a pain disorder, where
psychological and cognitive factors such as fear of pain would be targeted in treatment.
• Vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible
findings or a specific, clinically identifiable, neurologic disorder.
• Location may be localized or generalized. Temporal nature includes being provoked (wearing tight
pants, horseback riding), unprovoked, or mixed.
• Provoked Vestibulodynia (PVD): Pain in the area surrounding the entrance of the vagina (i.e. the
vestibule), occurring as a result of contact to the area, which can be either sexual and/or non-sexual.
Pain is described as burning, stabbing, and sharp (vs. deep, dull, aching). There is sometimes redness in
the vestibule. 12% prevalence.
• Generalized Vulvodynia (GVD): Unprovoked pain extending over a large region of the vulva.
Described as a constant low-grade burning or itching. Can be exacerbated by prolonged contact. 5-6%
• Mixed Presentation: Unprovoked pain that occurs any time, and provoked pain during sexual activity
or contact. Page 510-535, 25 pages Page 5 of16
• Most believe vulvodynia is a chronic pain condition, with heightened nerve sensitivity in both genital and
non-genital areas (pressure threshold detection test), and similar brain activation patterns to
• Sexual pain vs. pain during sex:
Patient presents with distressing genital pain experienced primarily during intercourse
Sexual Dysfunction Suspected Diagnosis Pain Condition
1. Sexual issues, including Focus of Questions 1. Pain: Many methods of assessing
relationship factors + abuse experience of pain
history 2. Psychological factors
2. Psychological factors such as 3. Sexual issues
depression and anxiety
Lifelong or acquired Information Gathered Anatomical region
Partner factors Temporal characteristics and pattern
Relationship factors Patient’s statement of intensity
Psychosocial factors Time since onset of pain
Medical factors Potential etiology
Psychosexual disorder Implied Direction of Pain and important psychosexual
• Possible etiologies: nervous system disorder, genetic predisposition to sensitivity, pelvic floor muscles
that are very tense and tight, psychological factors such as rumination and catastrophization, yeast
infections leaving unresolved pain, medications including antibiotics, hormonal contraceptives, or other
drugs affecting genital tissue, and physical injury. Research shows that history of abuse or dysfunctional
relationships not always present.
• Impact on Mental Health: Particularly difficult in a relationship where one wants to fulfill the sexual
component. A chronic pain condition is extremely debilitating. Can affect a woman’s self-esteem, and be
• Physical Health: Barrier to engaging in exercise or activities like cycling and horseback riding. May also
be a problem at work, especially for women with GVD who cannot sit for long periods of time.
• Can affect a woman’s self-concept if they are unable to engage in activities, relationships, and work
the way they are used to.
• Vaginismus is a sexual disorder in which there is persistent difficulties to allow vaginal entry of a penis,
a finger, and/or any object, despite the woman’s expressed wish to do so. Often involves a spastic
contraction of the muscles of the outer third of the vagina. In some cases it is so severe that penetration
• There is variability in involuntary pelvic muscle contraction, phobic avoidance, and anticipation, fear,
and experience of pain.
• Vaginismus is often related to dyspareunia, where if attempted intercourse is painful it may result in
spasms that close off the entrance to the vagina.
• Women with vaginismus have greater muscle tension, lower muscle strength, and greater fear and
avoidance of intercourse than women with other forms of dyspareunia.
• Psychotherapies targeting phobias can be adapted, as well as education, relaxation exercises, and
Diagnosis & Treatment Page 510-535, 25 pages Page 6 of 16
• DSM-5: “Genito-pelvic pain/penetration disorder” for people with difficulties with vaginal penetration
during intercourse, marked vulvovaginal or pelvic pain, fear or anxiety about the pain, and tensing or
tightening of pelvic floor muscles during attempted penetration for > 6 months.
• Cotton Swab Test: Palpate the vulvar area with a cotton swab, applying light pressure to the labia
majora, labia minora, and vulvar vestibule. The patient rates pain on scale from 0 (no pain) to 10 (most
pain I’ve ever felt)
• Pain Assessment Model: Assessing impact of pain on 6 areas:
o Physiologic: Duration, location Sensory: Descriptive of type of pain
o Affective: Mood or anxiety-related factors Cognitive: Catastrophizing, ruminating
o Sociocultural: Impact on relationships Behavioural: Strategies employed to deal
• Psychotherapy: Coping techniques to decrease experience of pain. Include pain-focused CBT,
mindfulness-based cognitive therapy encouraging focus on accepting pain and their body, sex or couples
• Pelvic Floor Physiotherapy: Biofeedback with electrodes attached to pelvic floor muscles and learning
relaxation and control over them, electrical stimulation to decrease muscle tension, manual techniques
such as massage and dilation treatment
• Medication: More for GVD than PVD. Include antidepressants, topical preparations like steroids, and
injectable medication like lidocaine
• Surgery: Excision of the affected area, such as the vaginal mucosa in the vestibular area to remove the
over-sensitive nerves. Often report decreased pain, but unsure about impact on sexual functioning and
• Alternative: Acupuncture, hypnosis, and tender-point stimulation
WHAT CAUSES SEXUAL DISORDERS?
• Biopsychosocial Model: A general model that argues that physical, psychological, and social factors
all contribute to the development and maintenance of sexual disorders.
• Physical factors include organic factors, such as disease or injury, and drugs
• Diseases of the heart, circulatory system, and vascular pathologies can all cause problems in the blood
vessels supplying the penis, and thus produce erection problems – arteries must allow a great deal of
blood flow in, and veins must constrict to prevent outflow
• ED is thus associated with diabetes (35% incidence in diabetic men), and in many cases ED may be
the earliest symptom of a developing case of diabetes
• Hypogonadism with an underfunctioning of the testes, and thus lowered testosterone levels, can be a
cause. Hyperprolactinemia with excessive production of prolactin is also a cause
• Any disease or injury that damages the lower part of the spinal cord may cause ED, since this is where
the erection reflex centre is located. Finally, prostate surgery may cause ED
• Most sexual disorders, including ED, result from interplay between organic and psychological causes.
For example, a man with circulatory problems may have erection problems, and development of
anxieties about maintaining erections will worsen the problem
• PE is more often caused by psychological factors, although in some men it may be due to a
malfunctioning of the ejaculatory reflex causing a physiological hypersensitivity, or an infection like
prostatitis or multiple sclerosis affecting the nervous system Page 510-535, 25 pages Page 7 of 16
• Sociobiologists argue that rapid ejaculation may have been selected for during evolution, as those who
copulate and ejaculate rapidly would be able to reproduce with females without them escaping, and
would be less likely to be attacked by other males during copulation
• In chimpanzees, the average time from intromission to ejaculation is 7 seconds, despite engaging in
lengthy courtship and foreplay behaviours
Male Orgasmic Disorder
• Male orgasmic disorder may be associated with multiple sclerosis, spinal cord injury, and prostate injury
• Hypogonadism, thyroid disorders, pituitary conditions (hyperprolactinemia), prostate surgery, etc.
• Most commonly due to psychological factors
Female Orgasmic Disorder
• May be caused by severe illness, general ill health, extreme fatigue, or injury to the spinal cord
• Most commonly due to psychological factors
• Organic factors include:
o Disorders of the vaginal entrance such as irritated remnants of the hymen or painful scars from
an episiotomy or sexual assault
o Disorders of the vagina such as allergic reactions to spermicidal creams or latex, a thinning of
the vaginal walls with age, or scarring from hysterectomies
o Pelvic disorders such as pelvic inflammatory disease, endometriosis, tumours, cysts, or tearing
of the uterine ligaments
• In uncircumcised men, a penis which is not washed thoroughly under the foreskin may collect smegma
and cause infections. An allergic reaction to spermicide or latex may also be involved.
• Prostate problems can cause pain during intercourse or on ejaculation.
• Can be caused by painful intercourse and associated organic factors, but more often due to
psychological or interpersonal factors
• Short-Term Pharmacological Effects: At high doses, alcohol acts as a depressant and sexual arousal
is markedly depressed in both men and women.
• Expectancy Effects: Many expect alcohol will loosen them up, making them more sexually uninhibited.
This expectancy effect increases physiological arousal; this only works at low doses.
• Long-Term Effects of Abuse: Alcoholics frequently have sexual disorders such as ED, orgasmic
disorder, and loss of desire. This may be due to disturbances in sex hormone production due to atrophy
of the testes or liver damage. Chronic abuse also negatively affects interpersonal relationships.
Illicit or Recreational Drugs
• Although marijuana is believed to have aphrodisiac effects, little well-conducted research supports this.
Often users report it increases sexual desire and makes sexual interactions more pleasurable.
• However, marijuana may contribute to risky sexual behaviour such as unprotected sex. Chronic users
often report decreased sexual desire and orgasmic disorder.
• Cocaine is said to enhance sexual experiences by increasing desire, enhancing sensuality, and delay
orgasm. However, chronic use is associated with sexual disorders; the most negative effects occur
among those who regularly inject the drug. The crack cocaine epidemic often involves the exchange of
sex for drugs. Page 510-535, 25 pages Page 8 of16
• Stimulant drugs such as amphetamines are associated with more desire and orgasm control. Injection
of amphetamines can cause what some describe as a total-body orgasm.
• Crystal methamphetamine may particularly cause users to engage in risky sexual behaviour of
unprotected sex with multiple partners.
• Opiates and narcotics like morphine and heroin have strong suppression effects on sexual response
• Drugs used to treat psychological disorders alter CNS functioning, which can affect sexual functioning.
For example, drugs to treat schizophrenia may cause delayed or “dry” orgasms.
• SSRIs are associated with desire, arousal, and delayed orgasm problems; this occurs in between 30-
60% of SSRI users. On the other hand, SSRIs may be used to treat premature ejaculation. Some
antidepressants like bupropion (Wellbutrin) have fewer sexual side effects.
• Antihypertensive drugs can cause erection problems, as well as anti-epileptic drugs
• Predisposing Factors are experiences people have had in the past that affect their current sexual
• Maintaining Factors are ongoing life circumstances, personal characteristics, and lovemaking patterns
that inhibit sexual response
Maintaining Psychological Causes
• 1) Myths or Misinformation: Incorrect beliefs about sex or lack of information. For example, some
couples seek sex therapy due to a woman’s failure to orgasm but are unaware of the location of the
clitoris or its proper stimulation. Misinformation can lead to a sexual script that does not fully enhance
sexual arousal and pleasure, or cause anxiety and worry. This can be treated with simple educational
• 2) Negative Attitudes: Negativity about sex, one’s own body, or partner’s body. For example, belief
that “good” people do not enjoy sex or that one is fat and unworthy of sexual pleasure.
• 3) Anxiety or Inhibition: Anxiety can be caused by negative or traumatic experiences in the past, such
as child sexual abuse. It can also be caused by fear of failure, or fear of unable to perform; this can
create a vicious circle of self-fulfilling prophecy in which fear of failure produces a failure, which produces
• Dual control model with processes of excitation (respond to sexual stimuli with arousal) and inhibition
(inhibiting sexual arousal). People low