Chapter 16 Summary

  1. Sexual disorders are common. Among women, the most frequent problems are a lack of interest in sex, difficulty experiencing orgasm, and a lack of vaginal lubrication. Among men, the commonest problems are premature ejaculation, anxiety about performance, and a lack of interest in sex. Sexual dysfunctions are clinical problems requiring treatment only if they cause distress. Treatment may involve some combination of drugs, psychotherapy, and sex therapy exercises. Sensate focus is a commonly recommended set of exercises.
  2. The causes of premature ejaculation, a very common sexual dysfunction, are poorly understood. A man who ejaculates prematurely may be helped by sex therapy exercises in which he learns to maintain himself at a medium level of arousal for extended periods of time. Premature ejaculation can also be treated with selective serotonin reuptake inhibitors (SSRIs).
  3. Many conditions can lead to problems with penile erection, including smoking, use of alcohol and certain prescription or recreational drugs, diabetes, cardiovascular disease, spinal cord injury, and prostate surgery. Among psychological factors that may impair erectile function, performance anxiety is probably the most important. Treatment of erectile dysfunction can include alleviation of the underlying disorder, psychotherapy, or the use of a drug such as Viagra. Among the nondrug treatments available are vacuum devices and penile implants.
  4. Difficulty in reaching ejaculation or orgasm is fairly uncommon in men but may be caused by certain drugs, such as SSRIs. It may be treated by changing or adding drugs or by sensate-focus exercises in which the man and his partner progressively explore each other’s bodies while avoiding performance demands.
  5. Female sexual arousal disorder refers to difficulties with vaginal lubrication or engorgement or with clitoral erection. Insufficient lubrication is common, especially after menopause; it can be dealt with by the use of lubricants. Hormone replacement often restores physiological arousal in postmenopausal women. Sex therapy exercises may be helpful.
  6. In women, painful coitus (dyspareunia) can result from a wide variety of biological causes, including developmental malformations, scars, vaginal atrophy, infections, allergies, and insufficient lubrication. It can often be treated by correction of the underlying condition. In vaginismus, coitus is not possible, due to some combination of pelvic muscle spasm and pain or fear of pain. It is treated by psychotherapy and sex therapy exercises, including the use of vaginal dilators.
  7. Many women have problems with orgasm. Some have never experienced it, and some do not experience it during partnered sex or during coitus. A biological cause for orgasmic dysfunction cannot usually be identified. Sex therapy for anorgasmia may include a program of directed masturbation or sensate-focus exercises. A woman may be helped to experience orgasm during partnered sex or coitus by adding effective clitoral stimulation, trying different positions, or extending the duration of the sexual interaction. It may also be helpful to address relationship problems.
  8. Excessive sexual desire or behavior (hypersexuality) in either sex can be caused by neurological damage, various mental illnesses, or certain drugs. Hypersexuality may include frequently repeated and seemingly involuntary involvement in masturbation, partnered sex, pornography use, telephone sex, and the like. Such behaviors may be classed as compulsive disorders, and like other such disorders, they often respond well to SSRIs. The use of the term “sexual addiction” to describe these conditions is controversial.
  9. Lack of interest in sex (hypoactive sexual desire disorder) is more common among women than among men. Sex hormone levels strongly influence sexual desire. In men, lack of interest in sex often responds to treatment with androgens. In women, it may respond to estrogens, androgens, or a combination of the two. Androgen treatment can cause unwanted or harmful side effects in both sexes, however, and the benefits may be limited, especially in women. Sex therapy may help people with low desire “let go” of thought patterns that interfere with sexual pleasure, such as a perceived obligation to ensure their partner’s satisfaction. The efficacy of sex therapy in the treatment of hypoactive sexual desire disorder needs to be objectively tested. Lack of sexual desire needs to be evaluated in a broad context, which includes not just medical problems but also psychological, relationship, and socioeconomic issues.