Sexual Disorders or

Sexual Dysfunction
Linda C. Shafer, M.D.
25 

first to diagnose a sexual problem and can facilitate the

OVERVIEW
transition from inpatient to outpatient care.
A comprehensive psychiatric evaluation of any patient in
the general hospital setting should include close attention
to complaints, impairments, and deviations of sexual function.
EPIDEMIOLOGY AND RISK FACTORS
Although on occasion, sexual problems are the primary Sexual disorders are extremely common. It has been estimated
reason for consultation, more often they may provide that 43% of women and 31% of men in the United States
important clues about an underlying medical or psychologic suffer from sexual dysfunction.2 In addition, lack of sexual
condition. Consider the “difficult” patient on obstetrics who satisfaction is associated with significant emotional (including
repeatedly refuses gynecologic exams, the formerly mild- depression and marital conflict) and physical (e.g., cardio-
mannered elderly gentleman who now shouts obscenities vascular disease and diabetes mellitus) problems.2–4
and gropes at nurses, or the sexually provocative patient Sexual disorders affect individuals across the epidemio-
who evokes strong reactions from the medical team. Could logic spectrum. Risk factors include: female gender, older
the patient on obstetrics have a history of sexual trauma, age, and co-existing psychiatric or medical (e.g., cardiovas-
the elderly man a frontal lobe tumor, or the provocative cular) disease.2–5 It has been estimated that 10% to 54% of
patient a personality disorder? These are a few of many patients do not resume sexual activity after myocardial
examples that serve to highlight the role that understanding infarction (MI); 45% to 100% of patients with uremia or
sexuality plays in caring for patients both compassionately who are undergoing hemodialysis experience low sexual
and effectively. desire; and 26% to 50% of patients with untreated depression
The consulting psychiatrist should also be reminded of experience erectile dysfunction (ED).6
the importance that being able to maintain a healthy sexual Among those with obesity and a sedentary lifestyle, weight
life holds for many patients, regardless of the reason for loss and increased physical activity are associated with
hospitalization. Sexuality may take on even greater signifi- improved sexual function.7,8 The association between race
cance for patients suffering from illness that directly impairs and sexual dysfunction is more variable.2,9 There is a strong
sexual function, because of the difficulties both real and association between ED and vascular diseases.10 In fact, ED
perceived. Psychiatric consultants should be alerted to high may be the presenting symptom of cardiovascular disease.11
rates of sexual problems in patients with chronic diseases ED may be more frequent among individuals with specific
(especially cardiovascular disease, cancer, diabetes, neurologic genetic mutations (e.g., polymorphisms in genes for nitric
problems, end-stage renal disease, and pain). Many chronic oxide synthase) in molecular pathways responsible for
diseases result in depression, which in turn contributes to resisting endothelial dysfunction.12 Sexual trauma for both
decreased sexual desire. Moreover, psychological reactions sexes is associated with long-term negative changes in sexual
to existing illnesses run the gamut, from fear that sex can function.13 A strong association exists between paraphilic
kill (post-myocardial infarction) to distress over low sexual disorders and childhood attention-deficit/hyperactivity
self-image (post-disfiguring surgery), to avoidance of sex, disorder (ADHD), substance abuse, major depression or
to fear of pain during sex, to fear that sexual advances will dysthymia, and phobic disorder.14,15 The prototypical patient
be rejected, all leading to decreased sexual intimacy.1 with a paraphilic disorder is young, white, and male. Anxiety,
When offering suggestions for patient management, such depression, and suicidal thoughts or actions, as well as
as prescribing a new psychotropic medication, care should homosexual or bisexual orientation, are commonly associated
be taken to minimize or treat sexual side effects as much gender dysphoria.16
as is possible. This may also help to improve patient rapport
and compliance. In cases where sexual dysfunction appears
to have a psychological component, or where longer-term
PATHOPHYSIOLOGY
behavioral, psychotherapeutic, or pharmacologic therapy The ability to maintain adequate sexual function depends
may be warranted, referral for outpatient psychiatric care on complex interactions among the brain, peripheral nerves,
can be arranged. The consulting psychiatrist may be the hormones, and the vascular system. Disease states in these
279
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280 Chapter 25     Sexual Disorders or Sexual Dysfunction

systems are associated with sexual dysfunction. However, Kaplan21 modified the Masters and Johnson model
no single comprehensive view has been established. by introducing a desire stage; this model emphasized the
Brain regions involved in sexual arousal include the importance of neuropsychological input in the human sexual
anterior cingulate gyrus, prefrontal cortex, thalamus, response. The Kaplan model consisted of three stages: (1)
temporo-occipital lobes, hypothalamus, and amygdala.17 The desire; (2) excitement/arousal (including an increase in
neurotransmitters dopamine and norepinephrine appear to peripheral blood flow); and (3) orgasm (muscular contraction).
stimulate sexual function, whereas serotonin may inhibit Basson,23 who recognized the complexity of the female
orgasm. Testosterone, estrogen, progesterone, oxytocin, and sexual response, more recently proposed a biopsychosocial
melanocortin hormones have a positive effect on sex, but model of female sexuality that consisted of four overlapping
prolactin is an inhibitor.18 components: (1) biology, (2) psychology, (3) sociocultural
Recent data suggest a central role for nitric oxide (NO) factors, and (4) interpersonal relationships. Notably, this
at the vascular level. In women, NO is thought to control conceptualization suggested that women may be receptive
vaginal smooth muscle tone; higher levels of NO are associ- to, and satisfied with, sex even in the absence of intrinsic
ated with increased vaginal lubrication. In men, NO allows sexual desire if other conditions were met (such as emotional
for increased intrapenile blood flow, which facilitates erection. closeness). The fact that physical measurements of female
NO acts via the generation of cyclic guanosine monophos- arousal (such as increased vaginal secretions) are poorly
phate (cGMP), which has vasodilatory properties. Phos- correlated with sexual satisfaction lends support for Basson’s
phodiesterase type-5 (PDE-5) inhibitors (the prototype of view.
which is sildenafil) act to inhibit the degradation of cGMP, Aging is associated with changes in the normal human
which prolongs the effects of NO.19 Cholinergic fibers, sexual response. Men are slower to achieve erections and
prostaglandin E, vasoactive intestinal peptide (VIP), and require more direct stimulation of the penis to achieve
possibly neuropeptide Y (NPY) and substance P may also erections. Women have decreased levels of estrogen, which
improve vasocongestion.20 leads to decreased vaginal lubrication and narrowing of the
Sexual dysfunction may be best understood by having vagina. Testosterone levels in both sexes decline with age,
knowledge of the stages of the normal sexual response; which may result in decreased libido.24
these vary with age and physical status. Medications, diseases,
injuries, and psychological conditions can affect the sexual
response in any of its component phases, and can lead to
CLINICAL FEATURES AND DIAGNOSIS
different dysfunctional syndromes (Table 25-1).21 Three The newly revised Diagnostic and Statistical Manual of Mental
major models of the human sexual response have been Disorders, 5th edition (DSM-5)25 classifies sexual disorders
proposed. into three major categories. Sexual dysfunction is characterized
Masters and Johnson22 developed the first model of the by a clinically significant disturbance in the ability to respond
human sexual response, consisting of a linear progression sexually or to experience sexual pleasure. Paraphilic disorders
through four distinct phases: (1) excitement (arousal); (2) are characterized by recurrent, intense sexual urges that
plateau (maximal arousal before orgasm); (3) orgasm involve unusual objects or activities and cause personal
(rhythmic muscular contractions); and (4) resolution (return distress or harm to self or others. Gender dysphoria involves
to baseline). Following resolution, a refractory period exists conflict between one’s assigned and experienced genders,
in men. resulting in personal distress or functional impairment.25
The DSM-5 has made substantial changes to the classification
of sexual disorders, as detailed later in this chapter.
TABLE 25-1  Classification of Sexual
The diagnosis of a sexual problem relies upon a thorough
Dysfunctions
medical and sexual history. Physical examination and labora-
IMPAIRED SEXUAL tory investigations may be crucial to identification of organic
RESPONSE PHASE FEMALE MALE causes of sexual dysfunction. Primary psychiatric illness may
Desire Female sexual Male hypoactive present with sexual complaints (Table 25-2).25 However,
interest/arousal sexual desire most sexual disorders have both an organic and a psychologi-
disorder disorder cal component. Physical disorders, surgical conditions (Table
Other specified Other specified 25-3),21 medications, and use or abuse of drugs (Table
sexual sexual 25-4)26–30 can affect sexual function directly or cause second-
dysfunction: dysfunction: ary psychological reactions that lead to a sexual problem.
sexual aversion sexual aversion Psychological factors may predispose, precipitate, or maintain
Excitement Female sexual Erectile disorder a sexual disorder (Table 25-5).31,32
(arousal, vascular) interest/arousal
disorder
Orgasm (muscular) Female orgasmic Delayed APPROACH TO SEXUAL HISTORY-TAKING
disorder ejaculation
The sexual history provides an invaluable opportunity to
Premature
uncover sexual problems (Case 1). Because patients are often
ejaculation
embarrassed to discuss their sexuality with physicians or
Sexual pain Genito-pelvic Other specified
pain/ or unspecified
view sex as outside the realm of medicine, and because
penetration sexual physicians are often reluctant to broach the topic of sex for
disorder dysfunction fear of offending their patients, the need to make sexual
history-taking a routine part of practice is paramount.

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 Chapter 25     Sexual Disorders or Sexual Dysfunction 281

TABLE 25-2  Psychiatric Differential Diagnosis course of the interview, Ms. K revealed that she had been
of Sexual Dysfunction sexually molested by her stepfather beginning at the age
PSYCHIATRIC DISORDER SEXUAL COMPLAINT of 12. She expressed resentment towards her mother, who
“knew what was going on but stood by and did nothing.”
Depression (major Low libido, erectile
After this history was revealed, the goal of the consul-
depression or dysthymic dysfunction
tant was to gain the patient’s trust and give the patient
disorder)
Bipolar disorder (manic Increased libido some control over her situation. The consultant took time
phase) to explain the importance of the pelvic exam and ultra-
Generalized anxiety Low libido, erectile sound in excluding potentially serious conditions. Eventu-
disorder, panic disorder, dysfunction, lack of vaginal ally, the patient agreed to undergo the exams with the
post-traumatic stress lubrication, anorgasmia condition that only female providers be present and that
disorder a small speculum/ultrasound probe be used. With Ms. K’s
Obsessive–compulsive Low libido, erectile permission, the consultant brought Ms. K’s suggestions to
disorder dysfunction, lack of vaginal the team, who agreed with this plan. Ms. K underwent the
lubrication, anorgasmia, exams uneventfully. Her work-up was unrevealing, and
“anti-fantasies” focusing on she was deemed medically safe to discharge home. The
the negative aspects of a consultant checked back frequently during Ms. K’s hospital
partner stay and helped arrange for outpatient psychiatric care.
Schizophrenia Low desire, bizarre sexual
desires
Paraphilic disorder Deviant sexual arousal
Gender dysphoria Dissatisfaction with one’s
own assigned gender and Screening questions include: Are you sexually active? If
sexual phenotype, causing so, with men, women, or both? Is there anything you would
distress and/or harm like to change about your sex life? Have there been any
Personality disorder Low libido, erectile changes in your sex life? Are you satisfied with your present
(passive–aggressive, dysfunction, premature sex life? To maximize its effectiveness, the sexual history
obsessive–compulsive, ejaculation, anorgasmia may be tailored to the patient’s needs and goals. Physicians
histrionic) should recognize that paraphilics are often secretive about
Marital dysfunction/ Varied their activities, in part because of legal and societal implica-
interpersonal problems tions. Patients should be reassured about the confidentiality
Fears of intimacy/ Varied, deep intrapsychic
of their interaction (except in cases where their behavior
commitment issues
requires mandatory legal reporting, e.g., as with child
abuse).33
In taking a sexual history, the consulting psychiatrist
Physicians should always attempt to be sensitive and non- should recognize that chronic illness often contributes to
judgmental in their interviewing technique, moving from sexual dysfunction, whether by direct physical damage or
general topics to more specific ones. Questions about sexual associated psychological effects. Patients with cancer, end-
function may follow naturally from aspects of the medical stage renal disease, coronary artery disease, multiple sclerosis,
history (such as introduction of a new medication, or and diabetes are all at increased risk of sexual problems. To
investigation of a chief complaint that involves a gynecologic explore the role physiologic illness may play in sexual
or urologic problem). dysfunction, consultants should ask questions about diseases,
procedures, and medications that might affect hormone
balance, disrupt normal anatomic genitalia, cause CNS
CASE 1  dysfunction, damage vascular or peripheral nerve supply
to sexual organs, or contribute to pain during sexual
Ms. K, a 28-year-old administrative assistant without a
activity.1
psychiatric history, was admitted with lower abdominal
With Internet pornography and “cybersex” activities now
and pelvic pain of unclear etiology. However, she refused
available on-demand, anytime, psychiatrists should be aware
a pelvic exam and pelvic ultrasound, which were deemed
of increasing patient concerns about “sexual addiction.” The
essential for her work-up. She threatened to leave against
sexual history-taker should feel comfortable exploring, as
medical advice, and psychiatry was consulted to help
needed, the role of the Internet in the patient’s sexual and
elucidate her thought process and capacity to make this
non-sexual functioning and the potential for excessive and/
decision.
or compulsive sexual activities. In fact, a new “hypersexual
On interview, Ms. K was alert, oriented, lucid, and
disorder” was proposed for inclusion in DSM-5, although
irritable. She stated, “The doctors have no right to do this
ultimately not included in the text.34 Yet, the possibility of
to me. It’s my body. They should find another way.” Her
impulsive, excessive sexual behavior causing distress to self
angry words then gave way to tears and sadness. On taking
or others remains. Thus, appropriate screening by a trained
a social and sexual history, Ms. K revealed that she had
clinician is essential. “Hypersexuality” may be a primary
dated briefly several men, but her fears of sexual intimacy
problem. However, if behaviors are new or rapidly escalating,
coupled with her partners’ infidelities and physical and
an underlying medical or neurological problem should be
verbal abuse usually ended her relationships. Over the
first excluded, particularly in the inpatient setting.

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282 Chapter 25     Sexual Disorders or Sexual Dysfunction

TABLE 25-3  Medical and Surgical Conditions Causing Sexual Dysfunctions

ORGANIC DISORDERS SEXUAL IMPAIRMENT
Endocrine
Hypothyroidism, adrenal dysfunction, hypogonadism, diabetes Low libido, (early) erectile dysfunction, decreased vaginal
mellitus lubrication
Vascular
Hypertension, atherosclerosis, stroke, venous insufficiency, sickle Erectile disorder with intact ejaculation and libido
cell disorder
Neurologic
Spinal cord damage, diabetic neuropathy, herniated lumbar disc, Sexual disorder—early sign, low libido (or high libido),
alcoholic neuropathy, multiple sclerosis, temporal lobe epilepsy erectile dysfunction, impaired orgasm
Local Genital Disease
Male: Priapism, Peyronie’s disease, urethritis, prostatitis, hydrocele Low libido, erectile dysfunction
Female: Imperforate hymen, vaginitis, pelvic inflammatory Genito-pelvic pain, low libido, decreased arousal
disease, endometriosis
Systemic Debilitating Disease
Renal, pulmonary, or hepatic diseases, advanced malignancies, Low libido, erectile dysfunction, decreased arousal
infections
Surgical Postoperative States
Male: Prostatectomy (radical perineal), abdominal-perineal bowel Erectile dysfunction, no loss of libido, ejaculatory
resection impairment
Female: Episiotomy, vaginal repair of prolapse, oophorectomy Genito-pelvic pain, decreased lubrication
Male and female: Amputation (leg), colostomy, and ileostomy Mechanical difficulties in sex, low self-image, fear of odor

Physical Examination and DIAGNOSTIC CRITERIA OF SPECIFIC

Laboratory Investigation SEXUAL DISORDERS
Though history-taking is often the most important tool in Male Disorders of Sexual Function
the diagnosis of sexual disorders, the physical examination
may reveal a clear medical or surgical basis for sexual dysfunc- Erectile Disorder
tion. Special attention should be paid to the endocrine, ED (previously referred to as “male erectile disorder” and
neurologic, vascular, urologic, and gynecologic systems. colloquially as “impotence”) is defined as the inability of a
Similarly, laboratory studies may be indicated, depending male to obtain or maintain an erection sufficient to complete
on the degree to which an organic cause is suspected.5,18 sexual activity in more than 75% of sexual encounters.
There is no “routine sexual panel.” Roughly 20–30 million American men suffer from ED;
Screening tests can be guided by the history and physical this symptom accounts for more than 500,000 ambulatory
examination. Tests for systemic illness include: complete care visits to healthcare professionals annually. A number
blood count (CBC), urinalysis, creatinine, lipid profile, of risk factors for ED have been identified (see Table 25-6).
thyroid function studies, and fasting blood sugar (FBS). Between 50% and 85% of cases of ED have an organic basis.
Endocrine studies (including testosterone, prolactin, lutein- Primary (life-long) ED occurs in 1% of men under the age
izing hormone [LH], and follicular stimulating hormone of 35 years. Secondary (acquired) ED occurs in 40% of
[FSH]), can be performed to assess low libido and erectile men over the age of 60 years; this figure increases to 73%
disorder (ED). An estrogen level and microscopic examina- in men who are over 80 years old. ED may be generalized
tion of a vaginal smear can be used to assess vaginal dryness. (i.e., it occurs in all circumstances) or situational (i.e., it
Cervical culture and pap smear can be performed to is limited to certain types of stimulation, situations, and
investigate a diagnosis of dyspareunia. The nocturnal penile partners). ED may be a symptom of a generalized vascular
tumescence (NPT) test is valuable in the assessment of ED. disease and should prompt further investigation.2,10,35 Bicycle
If NPT occurs regularly (as measured by a RigiScan monitor), riding has also been linked to penile numbness (associated
problems with erection are unlikely to be organic. Penile with perineal nerve damage) and to ED (due to decreased
plethysmography is used to assess paraphilias by measurement oxygen pressure in the pudendal arteries), although more
of an individual’s sexual arousal in response to visual and research is needed.36 Depression is a common co-morbidity
auditory stimuli. Genetic or chromosomal testing may be in patients with ED.
pertinent in the evaluation of gender dysphoria with ambigu-
ous genitalia. For example, heritable disorders of abnormal Delayed Ejaculation
sexual development (e.g., congenital adrenal hyperplasia, This disorder (previously referred to as “retarded ejacula-
5-alpha reductase-2 deficiency) are in some cases associated tion”) is defined as a persistent infrequency of, delay in, or
with gender dysphoria later in life.25 absence of ejaculation following normal sexual excitement in

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 Chapter 25     Sexual Disorders or Sexual Dysfunction 283

TABLE 25-4  Drugs and Medicines That Cause TABLE 25-5  Psychological Causes of
Sexual Dysfunction Sexual Dysfunction
DRUG SEXUAL SIDE EFFECT Predisposing Factors
Lack of information/experience
Cardiovascular
Methyldopa Low libido, erectile Unrealistic expectations
dysfunction, anorgasmia Negative family attitudes to sex
Thiazide diuretics Low libido, erectile Sexual trauma: rape, incest
dysfunction, decreased Precipitating Factors
lubrication Childbirth
Clonidine Erectile dysfunction, Infidelity
anorgasmia Dysfunction in the partner
Propranolol, metoprolol Low libido, erectile dysfunction
Maintaining Factors
Digoxin Gynecomastia, low libido,
Interpersonal issues
erectile dysfunction
Family stress
Clofibrate Low libido, erectile dysfunction
Work stress
Psychotropics Financial problems
Sedatives Depression
Alcohol Higher doses cause sexual Performance anxiety
problems Gender dysphoria
Barbiturates Erectile dysfunction
Anxiolytics
Alprazolam, diazepam Low libido, delayed ejaculation
TABLE 25-6  Risk Factors Associated With
Antipsychotics Erectile Dysfunction
Thioridazine Retarded or retrograde
ejaculation Hypertension
Haloperidol Low libido, erectile Diabetes mellitus
dysfunction, anorgasmia Smoking
Risperidone Erectile dysfunction Coronary artery disease
Peripheral vascular disorders
Antidepressants
Blood lipid abnormalities
MAOIs (phenelzine) Erectile dysfunction, retarded
Peyronie’s disease
ejaculation, anorgasmia
Priapism
TCAs (imipramine) Low libido, erectile
Pelvic trauma or surgery
dysfunction, retarded
Renal failure and dialysis
ejaculation
Hypogonadism
SSRIs (fluoxetine, Low libido, erectile
Alcoholism
sertraline) dysfunction, retarded
Depression
ejaculation
Lack of sexual knowledge
Atypical (trazodone) Priapism, retarded or
Poor sexual technique
retrograde ejaculation
Interpersonal problems
Lithium Low libido, erectile dysfunction
Hormones
Estrogen Low libido in men
Progesterone Low libido, erectile dysfunction
be differentiated from retrograde ejaculation, in which the
bladder neck does not close off properly during orgasm,
Gastrointestinal causing semen to spurt backward into the bladder. Delayed
Cimetidine Low libido, erectile dysfunction
ejaculation may also be an unsuspected cause of a couple’s
Methantheline bromide Erectile dysfunction
infertility problems. The male may not have admitted his
Opiates Orgasmic dysfunction lack of ejaculation to his partner.37
Anticonvulsants Low libido, erectile Premature (Early) Ejaculation
dysfunction, priapism
This disorder is defined as recurrent ejaculation with minimal
MAOI, monoamine oxidase inhibitor; SSRI, selective serotonin re-uptake sexual stimulation before, on, or shortly after penetration
inhibitor; TCA, tricyclic antidepressant. (within 1 minute) and before the person wishes it. Early
ejaculation is common and was reported in nearly one-third
at least 75% of sexual encounters. It replaces “male orgasmic of men ages 18–70 in an international cohort. However,
disorder,” which was similar but substituted “ejaculation” for less than 3% of men meet DSM-5 criteria, which specify
“orgasm.” Delayed ejaculation is rare; fewer than 1% of men that symptoms must cause clinically significant distress and
meet DSM-5 criteria. Risk factors include sexual inexperience occur for 6 months or more in at least 75% of sexual
and young age (under 35). Delayed ejaculation is usually encounters. Prolonged periods without sexual activity
restricted to failure to reach orgasm during intercourse. increase the risk of premature ejaculation. If the problem
Orgasm can usually occur with masturbation and/or from is chronic and untreated, secondary erectile dysfunction
a partner’s manual or oral stimulation. The condition must may occur.38

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284 Chapter 25     Sexual Disorders or Sexual Dysfunction

Male Hypoactive Sexual Desire Disorder Sexual Dysfunction Disorders Affecting

This disorder, new to DSM-5, is characterized by persistent Both Genders
or recurrent absence of sexual thoughts or fantasies and
desire for sexual activity. Symptoms must be present for 6 Substance/Medication Induced-Sexual Dysfunction
months or more. Unlike its DSM-IV predecessor, “hypoac- This disorder is characterized by clinically significant sexual
tive sexual desire disorder,” the new DSM-5 diagnosis is impairment that is immediately temporally related to the
specific to men; there is no “female” version. In men, sexual ingestion of a specific substance or medication. The disorder
desire declines with increasing age. In fact, more than 2 in should not be diagnosed during a state of delirium.25
5 men aged 66–74 report decreased sexual desire, compared
with 6% of men aged 18–44. Yet, low sexual desire is usually Other Specified and Unspecified Sexual Dysfunction
not associated with clinically significant distress; less than These DSM-5 disorders replace the “sexual dysfunction
2% of men aged 16–44 meet DSM-5 criteria for male not otherwise specified” designation in previous DSM
hypoactive sexual desire disorder.39 editions and serve the same purpose. The “specified’ modifier
should be used if the clinician chooses to state the reason
Female Disorders of Sexual Function that criteria for another disorder are not met. Of note,
DSM-5 has eliminated “sexual aversion disorder,” which
Female Sexual Interest/Arousal Disorder was characterized by marked disinclination towards partnered
This disorder (FSIAD) is new to DSM-5, and replaces the genital sexual contact; however, it can still be acknowledged
prior “female sexual arousal disorder” (FSAD). It is defined as an “other specified” disorder.25
by reduced or absent sexual interest, thoughts, arousal,
excitement, genital sensation and/or activity (with reluctant
participation in and initiation of sex). Three or more of
Paraphilic Disorders
these components must be present for at least 6 months Paraphilias refer to any persistent, intense sexually arousing
and cause significant personal distress to meet the criteria. fantasies, urges, or behaviors other than genital stimulation
The exact prevalence of FSIAD is not known; FSAD had or fondling with a mature, consenting human partner. They
an estimated lifetime incidence of 60%.40–43 may involve non-human objects or the suffering or humili-
ation of one’s partner, children, or other non-consenting
Female Orgasmic Disorder persons. Paraphilias may involve a conditioned response in
This disorder is defined as a recurrent delay in, or absence which non-sexual objects become sexually arousing when
of, orgasm following a normal sexual excitement phase, in paired with a pleasurable activity (masturbation). Some
at least 75% of sexual encounters. Some women who can individuals always require paraphilic fantasies, while others
have orgasm with direct clitoral stimulation find it impossible rely on them during times of stress. Paraphilias run the
to reach orgasm during intercourse; however, this is a normal gamut from exhibitionism (exposure of genitals to an
variant. While as much as 35% of women experience dif- unsuspecting stranger) to masochism (pleasure from abuse)
ficulties with orgasm at some point in their lifetime, few to pedophilia (sex with a prepubescent child).25
report significant associated distress. The ability to reach Under DSM-5, paraphilias are considered disorders when
orgasm increases with sexual experience. Claims that stimula- they have been present at least 6 months; the individual has
tion of the Grafenberg spot, or G-spot, in a region in the acted on the underlying urges; and the associated behaviors
anterior wall of the vagina will cause orgasm and female cause marked personal distress or harm to self or others.
ejaculation have never been substantiated, despite ongoing Most paraphilic disorders are thought to have a psychological
research. Premature ejaculation in the male may contribute basis. Individuals with these conditions often have difficulty
to female orgasmic dysfunction.41,44,45 forming more socialized sexual relationships. An interest
in non-consenting partners may have legal and societal
Genito–pelvic Pain/Penetration Disorder implications. Co-existent attention deficit hyperactivity
This disorder, new to DSM-5, is defined as recurrent disorder (ADHD), substance abuse, major depression or
and persistent vulvovaginal pain or fear of pain during dysthymia, and phobic disorder are common.25
penetration or intercourse. It combines the DSM-IV enti-
ties vaginismus (involuntary vaginal spasm) and dyspareunia
(painful intercourse), which clinically were difficult to
Gender Dysphoria
distinguish, into a single diagnosis. Of note, genito–pelvic This group of disorders is characterized by discordance
pain/penetration disorder can be diagnosed only in women, between one’s assigned and one’s preferred gender associa-
whereas dyspareunia was gender-neutral (albeit uncommon in tion, causing marked personal distress or impaired function
men). Approximately 15% of North American women report for at least 6 months. It is subclassified into childhood and
recurrent pain with sexual intercourse, although the actual adult/adolescent forms, depending on the age of onset. The
prevalence of the new disorder is not known. Contraction childhood form is typified by gender-atypical play and
of the vaginal outlet as an examining finger or speculum is behavior. In contrast, adolescents and adults usually express
introduced during routine gynecologic examination may be a a strong desire to rid oneself of assigned secondary sexual
clue to the diagnosis. Sexual trauma and co-existing medical/ characteristics. By late adolescence or adulthood, 75%
pelvic conditions are important associations and potential of boys with a history of gender dysphoria as a child will
precipitants. Lack of vaginal lubrication and other physiologic have a homosexual or bisexual orientation. Children with
contributors to sexual pain should be first excluded.46 gender dysphoria may have co-existing separation anxiety,

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 Chapter 25     Sexual Disorders or Sexual Dysfunction 285

generalized anxiety, and depression. Adolescents and adults improvement in diet; and addition of medications for
have a propensity for suicidal thoughts and actions as well psychiatric conditions (e.g., depression). Although many
as anxiety, depression, and paraphilic behaviors. Associated medications for the treatment of hypertension inhibit sexual
personality disorders are also common in male patients. function, the angiotensin II-receptor blockers (e.g., losartan),
One in 30,000 males and 1 in 100,000 females have gender- are not associated with sexual side effects and may actually
confirming (sex-reassignment) surgery.16,25 help prevent or correct sexual problems (such as sexual
dissatisfaction, low frequency of sex, or ED).47 Any hormone
deficiency should be corrected (e.g., addition of testosterone
DIFFERENTIAL DIAGNOSIS OF for hypogonadism, thyroid hormone for hypothyroidism,
estrogen/testosterone for postmenopausal females, or
SEXUAL DISORDERS
bromocriptine for elevated prolactin after neuroimaging of
The differential diagnosis of sexual disorders includes medical the pituitary). Many medical illnesses are associated with
and surgical conditions (Table 25-3),21 adverse effects of physiologic and psychological impairments that when treated
medications (Table 25-4),26–30 and other psychiatric disorders improve sexual function; selected examples are shown in
(Table 25-2).25 Before a primary sexual disorder is diagnosed, Table 25-8.5
it is important to identify potentially treatable conditions
Psychotropic Medication-induced Sexual Dysfunction
(both organic and psychiatric) that manifest as problems
with sexual function. For example, treatment of depression Antidepressants
may improve erectile function. Although paraphilic disorders Sexual dysfunction is a commonly reported side effect of
often have a psychological basis, an organic cause should selective serotonin re-uptake inhibitors (SSRIs). According
be considered if the behavior begins in middle age or later; to some estimates, as many as 30% to 40% of SSRI users
there is regression from previously normal sexuality; there experience anorgasmia, 10% to 20% of patients experience
is excessive aggression; there are reports of auras or seizure-
like symptoms before or during the sexual behavior; there
is an abnormal body habitus; or there is an abnormal TABLE 25-7  Psychiatric Differential Diagnosis
neurologic examination. See Table 25-7 for the psychiatric of Paraphilias
differential diagnosis of paraphilias.25 Patients who present Intellectual disability
with gender dysphoria generally have normal physical Dementia
findings and normal laboratory studies. The differential Substance intoxication
diagnosis includes non-conformity to stereotypical sex role Manic episode (bipolar disorder)
behaviors, transvestic fetishism (cross-dressing), and schizo- Schizophrenia
phrenia (e.g., with the delusion that one belongs to the Obsessive–compulsive disorder
other sex). Gender dysphoria
Personality disorder
Sexual dysfunction
TREATMENT Non-paraphiliac compulsive sexual behaviors
Compulsive use of erotic videos, magazines, or
Organically Based Treatment cybersex
Uncontrolled masturbation
The essence of treatment for sexual disorders involves Unrestrained use of prostitutes
the treatment of pre-existing illnesses (e.g., diabetes); dis- Numerous brief, superficial sexual affairs
continuation or substitution of offending medications; Hypersexuality/sexual addiction
reduction of alcohol, smoking, or both; increase in exercise;

TABLE 25-8  Specific Treatments for Sexual Dysfunction Attributable to Medical Illness
ASSOCIATED IMPAIRMENT
DISEASE CAUSING SEXUAL DYSFUNCTION TREATMENT
Coronary artery disease Fear of recurrent MI Reassure, encourage exercise
Fear of nitrate–PDE-5 interaction Switch from nitrate to trimetazidine (not FDA-approved)
Concurrent depression Treat depression
Renal failure Low testosterone (men) Consider testosterone
Hyperprolactinemia Try bromocriptine, 25(OH)D
Low zinc levels Consider zinc replacement
Anemia Erythropoietin
Uremic menorrhagia Consider cyclic or daily progesterone
Concurrent depression Treat depression
Estrogen deficiency Local estrogen therapy
Urinary incontinence Urinary leakage during sex Consider surgery
Diabetes Hyperglycemia Improve glycemic control
Elevated prolactin Hyperprolactinemia Treat underlying cause
Adrenal disease Diminished adrenal hormones Consider DHEA

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286 Chapter 25     Sexual Disorders or Sexual Dysfunction

TABLE 25-9  Treatment Strategies for SSRI-Induced Sexual Dysfunction

STRATEGY COMMENTS
Decrease the dose May diminish antidepressant effect
Consider in patients on high doses
Switch SSRIs Paroxetine linked to highest rates of sexual dysfunction
Fluvoxamine may have fewer sexual side effects
No clear evidence to support this strategy
Switch to a non-SSRI agent Data support bupropion, mirtazapine, duloxetine (±), vilazodone, nefazodone (brand name
Serzone withdrawn in the United States)
Consider transdermal selegiline
Not FDA-approved: tianeptine, reboxetine, moclobemide, agomelatine, gepirone
Venlafaxine and desvenlafaxine not superior to SSRIs
Add “antidote” drug Best evidence to support PDE-5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil), next
bupropion, then buspirone (high dose)
PDE-5 inhibitors not only improve erectile dysfunction but also arousal and orgasm even
in some women on SSRIs
Small studies support maca root (herbal agent)
Consider amantadine, dextroamphetamine, methylphenidate, ginkgo biloba, granisetron,
cyproheptadine, yohimbine, atomoxetine (data mixed)
Take a drug holiday Limited studies show no clear benefit to this approach
May precipitate withdrawal and encourage noncompliance
Await spontaneous remission Rarely occurs

decreased libido or ED, and 30% to 50% experience low leads to erectile problems. The most popular of these agents
desire.5,48 Strategies to treat SSRI-induced sexual dysfunction is EMLA cream, a combination of lidocaine and prilocaine.66
are presented in Table 25-9.48–58 Monoamine oxidase inhibi- When the premature ejaculation is secondary to ED, PDE-5
tors (MAOIs) and tricyclic antidepressants (TCAs) also cause inhibitors should be used to treat ED first.
sexual problems. Because of their sexual side effects, the
SSRIs have been used with success to treat premature Erectile Dysfunction
ejaculation and reduce compulsive sexual acts associated The mainstay of treatment for ED is the use of oral PDE-5
with Alzheimer’s disease,59 paraphilic behavior,60 and sexual inhibitors (e.g., sildenafil, vardenafil, tadalafil, and most
obsessions in obsessive–compulsive disorder (OCD) spectrum recently avanafil), which can help men with a wide range
patients.61 of conditions; they are easy to use, and have few adverse
effects (Table 25-10).19,57,67,68 An important absolute contra-
Antipsychotics indication is the recent concurrent use of nitrates, which
Typical antipsychotics (e.g., haloperidol, thioridazine) as can lead to profound hypotension. Other potential risks
well as atypical agents (e.g., risperidone, clozapine) are all include: hypotension with concurrent use of an α-blocker
associated with sexual dysfunction. Hyperprolactinemia may (e.g., for benign prostate hypertrophy or hypertension) and
play a causal role. Most second-generation antipsychotics possibly hearing loss and development of non-arteritic
(e.g., olanzapine, quetiapine, aripiprazole, ziprasidone) are anterior ischemic optic neuropathy (NAION). The PDE-5
associated with fewer sexual side effects.62 Antipsychotics inhibitors are effective in the treatment of antidepressant-
have also been used to dampen sexually inappropriate induced ED and delayed ejaculation. Of note, the PDE-5
behaviors and paraphilic behaviors.63 inhibitors are metabolized by P450 3A4 and 2C9 isoenzyme
systems. Patients who take potent inhibitors (including
Premature Ejaculation grapefruit juice, cimetidine, ketoconazole, erythromycin,
There is no Food and Drug Administration (FDA)-approved and ritonavir) of these P450 isoenzyme systems, should
treatment for premature ejaculation. However, the SSRIs have a lower starting dose of a PDE-5 inhibitor. Statins
(e.g., fluoxetine, sertraline, paroxetine) used continuously may also help improve the efficacy of PDE-5 inhibitors.
or intermittently (2 to 12 hours before sex), can cause delayed Other oral agents are used to treat ED. Yohimbine
or retarded ejaculation, which can treat premature ejacula- (Yocon), an α2-adrenergic inhibitor, has been available for
tion. Low doses may be effective. Clomipramine (a TCA) many years and it may be useful in the treatment of psy-
may be more effective in delaying ejaculation than the chogenic ED; however, its efficacy is uncertain. Phentolamine
SSRIs.64 Dapoxetine, an SSRI in phase III clinical trials (Vasomax) is an α-blocker (not yet FDA-approved) that
with a rapid onset and short half-life, is being studied as an may produce erections by dilation of blood vessels. Apo-
on-demand treatment for premature ejaculation.65 Topical morphine (Uprima) is a centrally acting D1/D2 dopamine
anesthetic creams (such as lidocaine derivatives) appear to receptor agonist administered sublingually (not yet FDA-
be successful in slowing ejaculation without inducing the approved). Although efficacious in the stimulation of
systemic side effects of antidepressants; however, they can erections, the drug is limited by its side effects, especially
cause local skin irritation and penile numbing that sometimes nausea and vomiting.69 Centrally acting melanocortin

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TABLE 25-10  First-Line Treatment for Erectile Dysfunction: Comparison of PDE-5 Inhibitors
FOOD
MEDICATION DOSE ONSET DURATION INTERACTION ADVANTAGES SIDE EFFECTS CONTRAINDICATIONS
Sildenafil 25–100 mg 30–60 min 4 h (up to Delayed 50–85% efficacy Headache, low BP, flushing, Active CAD, hypotension
(Viagra) Max—one dose per day 12 h) absorption with Longest track record dyspepsia, vasodilation, No nitrates for 24 h after dose
high-fat foods diarrhea, visual changes Caution with α-blockers
(blue tinge to vision),
hearing loss (rare)
Non-arteritic anterior
ischemic optic neuropathy
(NAION)—not proven
Vardenafil 2.5–20 mg 15–30 min 4 h (up to Delayed 75% efficacy Headache, low BP, flushing, Active CAD, hypotension
(Levitra) Max—one dose per day 12 h) absorption with No visual side effects dyspepsia, vasodilation, May prolong QTc
high-fat foods Available as ODT diarrhea, visual changes, May increase LFTs
preparation (Staxyn) hearing loss (rare) Avoid nitrates for 24 h after
Non-arteritic anterior dose
ischemic optic neuropathy Avoid α-blockers (Hytrin and
(NAION)—not proven Cardura). Use cautiously with
Flomax or Uroxatral
Tadalafil 5–20 mg 15–45 min 24–36 h None 75% efficacy Headache, low BP, flushing, Active CAD, hypotension
(Cialis) No visual side effects dyspepsia, vasodilation, Avoid nitrates for 48 h after
Can be taken with food diarrhea, back pain, dose
More PDE5 selective myalgias, hearing loss (rare) Avoid α-blockers (Hytrin and
Non-arteritic anterior Cardura). Use cautiously use
ischemic optic neuropathy with Flomax or Uroxatral
(NAION)—not proven
Avanafil 50–200 mg 15 min Up to 6 h Delayed Shortest onset of action Headache, low BP, flushing, Active CAD, hypotension
(Stendra) Max—one dose per day absorption with Shortest duration nasal congestion, dizziness, No nitrates for 12 h after dose
high-fat foods Fewer drug interactions hearing loss (rare) (weaker and briefer effect
More PDE-5 selective Non-arteritic anterior compared with other PDE-5s)
ischemic optic neuropathy Start at lower dose (50 mg) if
(NAION)—not proven on (stable) α-blocker

CAD, coronary artery disease; QTc, corrected QT interval; LFTs, liver function tests.

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Chapter 25     Sexual Disorders or Sexual Dysfunction 287
288 Chapter 25     Sexual Disorders or Sexual Dysfunction

receptor agonists (in development as an intranasal prepara- ospemifene (Osphena), an oral selective estrogen receptor
tion) appear to be effective, but side effects (flushing, nausea) modulator indicated for postmenopausal dyspareunia
may limit their utility.70 The amino acid L-arginine (an NO (encompassed under “genito-pelvic pain” in DSM-5).74 An
precursor) appears promising in men. Other agents under alternative non-medication but approved intervention is
study include: naltrexone, an opioid antagonist, clavulanic EROS-CTD, a clitoral suction device, which is used to
acid (Zoraxel), a serotonin/dopamine modulator, and tra- increase vasocongestion and engorge the clitoris for better
zodone, a 5-HT2C serotonin receptor. Herbal agents and sexual arousal and orgasm.75
supplements have shown limited benefit, with P. ginseng, B. Numerous drug trials are being done using medications
superba, and L. meyenii (maca root) showing the most promise. approved for male sexual dysfunction (such as PDE-5
Some “natural agents” in fact contain traces of PDE-5 inhibitors), hormone-based therapies, and novel agents. In
inhibitors. general, PDE-5 inhibitors are not effective in improving
Non-approved topical agents include: alprostadil cream female sexual function, but they may benefit some women
(Topiglan), minoxidil solution, and nitroglycerine ointment. who exhibit greatly diminished genital vasocongestion.76
In hypogonadal men, transdermal testosterone or clomiphene PDE-5 inhibitors also appear to be effective for women
citrate may be considered. In fact, a recent large-scale set with SSRI-induced sexual dysfunction. Bupropion (a
of randomized controlled trials showed improvement in dopamine and noradrenergic agonist) may increase arous-
erectile function, sexual desire, and sexual activity among ability and sexual response in women. As in men, trials
elderly men with initially low testosterone who took tes- of yohimbine, apomorphine, and melanocortin agonists
tosterone therapy.71 Second-line treatment for ED includes are ongoing. L-arginine may also enhance female sexual
use of intra-penile injection therapy, intraurethral suppository function.41
therapy, and vacuum-assisted devices (Table 25-11). The Testosterone (in a variety of forms), in combination with
third-line treatment for ED is surgical implantation of an estrogen (Estratest), has been shown to improve libido,
inflatable or malleable rod or penile prosthesis. Endarter- sexual arousal, and the frequency of sexual fantasies in
ectomy or drug-eluting stents may correct ED in certain surgically and naturally postmenopausal women.77 However,
patients with underlying vascular disease.72 Injectable gene it requires a relatively high dose, and because long-term
therapies are in early investigational stages. estrogen use (including combination with progestin) is
associated with risks, it is not routinely recommended.
Female Sexual Dysfunction Recently, transdermal testosterone was shown to improve
The first medication for female sexual dysfunction, flibanserin sexual function in postmenopausal women not taking
(Addyi) was approved by the FDA in August 2015 after estrogen, but long-term safety data are not available.78 One
twice being rejected. It is indicated for premenopausal women agent in this category, Intrinsa, has been rejected by the
with a DSM-IV diagnosis of hypoactive sexual desire disorder FDA, while another, LibiGel, is in investigational stages.
(HSDD); HSDD is not in DSM-5 but most closely resembles Tibolone, a steroid hormone with estrogenic, androgenic,
FSIAD. The drug remains controversial, given its only and progestogenic metabolites, has been shown to increase
modest benefit with a potential for serious side effects, such vaginal lubrication, arousability, and sexual desire. However,
as marked hypotension when combined with alcohol.73 it is also associated with an increased risk of stroke in women
Besides flibanserin, the only other FDA-approved medication with osteoporosis over age 60 and has been rejected by the
relevant to the treatment of female sexual dysfunction is FDA.79 In general, once fervent interest in hormonal

TABLE 25-11  Second-Line Treatments for Erectile Dysfunction

TREATMENT EFFECTS ADVANTAGES DISADVANTAGES
Intraurethral suppository: MUSE Prostaglandin E1 gel delivered by 60% efficacy Not recommended with
(alprostadil) applicator into meatus of penis Less penile fibrosis and pregnant partners
Induces vasodilation to cause priapism than with Mild penile/urethral
erection penile injections pain
Can be used twice daily
Penile self-injection: alprostadil Prostaglandin E1 injected into 50–87% efficacy Can cause penile pain,
(Caverject and Edex) base of penis Few systemic side priapism, fibrosis
Induces vasodilation to cause effects Not recommended for
erection daily use
Intracavernosal injection: VIP causes veno-occlusion while Associated with less Less effective than
vasoactive intestinal polypeptide phentolamine increases arterial pain than alprostadil alprostadil
(VIP) + phentolamine: aviptadil flow and therefore
(Senatek) preferred by patients
Vacuum constriction device Creates vacuum to draw blood 67% efficacy May not be acceptable
(pump) into penile cavernosa No systemic side effects to partner
Elastic band holds blood in penis Safe if erection not Erection hinged at base;
maintained more does not allow for
than 1 h external ejaculation

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 Chapter 25     Sexual Disorders or Sexual Dysfunction 289

therapies has been tempered by associated risks of cardio- therapy. Permission-giving involves reassuring the patient
vascular disease and breast cancer highlighted by landmark about sexual activity, alleviating guilt about activities the
Women’s Health Initiative (WHI) studies. patient feels are “bad” or “dirty,” and reinforcing the normal
Additional novel therapies for female sexual dysfunction range of sexual activities. Limited information includes
include intranasal oxytocin for improving sexual satisfaction. providing basic knowledge about anatomy and physiology
Onabotulinum toxin A (Botox) injections may help ameliorate and correcting myths and misconceptions. Specific sugges-
vaginismus. Vaginal diazepam may also decrease sexual pain. tions include techniques of behavioral sex therapy (Table
In addition, sacral neuromodulation (Interstim), currently 25-12). Intensive therapy may be useful for patients with
indicated for overactive bladder, has been shown in small chronic sexual problems, complex psychologic issues, or
pilot studies to increase sexual desire, lubrication, orgasm, both. Whereas the first three stages (P, LI, SS) may be
and satisfaction.80 implemented by any health care provider, the last stage
(IT) usually requires an expert with special training in sex
Paraphilic Disorders therapy.21,83
Pharmacologic therapy for paraphilias is aimed at suppression
of compulsive sexual behavior. The antiandrogen drugs, Paraphilic Disorders
cyproterone (CPA) and medroxyprogesterone acetate (MPA, Paraphilic disorders are often refractory to treatment, and
Depo-Provera), which act by competitive inhibition of recidivism is high, but several non-pharmacologic modalities
androgen receptors, are used to reduce aberrant sexual have been used with varying success. Insight-oriented or
tendencies by decreasing androgen levels (not yet FDA- supportive psychotherapy is relatively ineffective. Cognitive-
approved). Treatment with a synthetic gonadotropin-releasing behavioral therapy (CBT) can be used to help patients
hormone analog (approved for prostate cancer but not identify aberrant sexual tendencies, alter their behavior, and
paraphilia), including leuprorelin, triptorelin, and goserelin, avoid sexual triggers to prevent relapse. Aversive therapy,
decreases testosterone to chemically castrating levels (after via conditioning with ammonia, is used to reduce paraphiliac
an initial transient increase), and may completely abolish behavior. Orgasmic re-conditioning is used to teach the
deviant sexual tendencies. The SSRIs and clomipramine paraphilic how to become aroused by more acceptable mental
may lower aberrant sexual urges by decreasing the images. Social skills training (individual or group) is used
compulsivity/impulsivity of the act and by decreasing to help the paraphilic form better interpersonal relationships.
aggressive behaviors. Psychostimulants, such as methylphe- Surveillance systems (using family members to help monitor
nidate sustained-release, SR (Ritalin-SR), may be helpful patient behavior) may be helpful. Lifelong maintenance is
when co-existing ADHD is present. Antipsychotics have required.84
also been used to treat paraphilias.81,82
Gender Dysphoria
Gender Dysphoria Individual psychotherapy is useful both in helping patients
The definitive treatment for gender dysphoria is gender- understand their gender dysphoria and in addressing other
confirming surgery (formerly known as sex reassignment psychiatric issues. A thorough psychologic evaluation is
surgery), in combination with hormonal therapies to suppress generally required before gender confirming surgery can be
secondary characteristics. Such hormonal agents include performed. Marital and family therapy can help with adjust-
luteinizing-hormone releasing hormone (LHRH) agonists, ment to a new gender, including the possibility of intense
gonadotropin-releasing hormone agents (GnRH), spirono- and under-anticipated stigmatization and discrimination.16,85
lactone, CPA, estrogens, and testosterone, with associated
risks of cardiovascular and thromboembolic disease and
osteoporosis. Of note, hormonal therapy alone is in general
CONCLUSION
associated with significantly improved psychological symp- Sexual problems are common in the general population,
toms and quality of life. In contrast, gender-confirming and in medically ill, hospitalized patients, the prevalence is
surgery is not uncommonly associated with significant regret even greater. Even when a sexual problem is not the primary
and may actually not affect objective measures of psychologi- reason for consultation, the consulting psychiatrist should
cal functioning.16 feel comfortable and well-equipped to take a sexual history
as a routine part of the evaluation. Although time and privacy
Psychologically Based Treatments are important limitations in the inpatient setting, the sexual
history may reveal an unrecognized sexual concern; uncover
Sexual Dysfunction an underlying medical or psychiatric illness; or at the very
General principles of treatment include improving com- least help better understand the patient in a functional context,
munication (verbally and physically) between partners, and in turn, improve the patient–doctor relationship.
encouraging experimentation, decreasing the pressure of With our population growing older, the potential for
performance by changing the goal of sexual activity away sexual problems is on the rise. Patients both in and out of
from erection or orgasm to feeling good about oneself, and the hospital are living with complex medical problems and
relieving the pressure of the moment (by suggesting there taking multiple medications. At the same time, with the
is always another day to try). The PLISSIT model provides shifting focus of medicine from improving not only the
a useful framework for approaching treatment of sexual length of life but also the quality of life, physician responsibil-
problems and can be tailored to the desired level of interven- ity to recognize and treat sexual problems is ever greater.
tion. The stages are: (1) P, permission; (2) LI, limited Consulting psychiatrists can be helpful in discerning the
information; (3) SS, specific suggestions; and (4) IT, intensive biological, psychological, and social factors that contribute

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290 Chapter 25     Sexual Disorders or Sexual Dysfunction

TABLE 25-12  Specific Behavioral Techniques of Sex Therapy

SEXUAL DISORDER SUGGESTIONS
Male hypoactive sexual desire disorder Sensate focus exercises (non-demand pleasuring techniques) to enhance
enjoyment without pressure
Erotic material, masturbation training
Female sexual interest/arousal disorder Sensate focus exercises
Lubrication: saliva, KY jelly for vaginal dryness
Other specified sexual dysfunction: sexual Sensate focus exercises
aversion For phobic/panic symptoms, use anti-anxiety/antidepressant meds
Erectile disorder Sensate focus exercises (non-demand pleasuring techniques)
Use female superior position (heterosexual couple) for non-demanding
intercourse
Female manually stimulates penis, and if erection is obtained, she inserts the
penis into the vagina and begins movement
Learn ways to satisfy partner without penile/vaginal intercourse
Female orgasmic disorder Self-stimulation
Use of fantasy materials
Kegel vaginal exercises (contraction of pubococcygeus muscles)
Use of controlled intercourse in female superior position
“Bridge technique”—male stimulates female’s clitoris manually after insertion
of the penis into the vagina
Delayed ejaculation (during intercourse) Female stimulates male manually until orgasm becomes inevitable
Insert penis into vagina and begin thrusting
Premature ejaculation Increased frequency of sex
“Squeeze technique”—female manually stimulates penis until ejaculation is
approaching, then the female squeezes the penis with her thumb on the
frenulum. The pressure is applied until the male no longer feels the urge to
ejaculate (15–60 seconds). Use the female superior position with gradual
thrusting and the “squeeze” technique as excitement intensifies
“Stop–start technique”—female stimulates the male to the point of
ejaculation then stops the stimulation. She resumes the stimulation for
several stop–start procedures, until ejaculation is allowed to occur
Genito-pelvic pain/penetration disorder Treat any underlying GYN problem first
Treat insufficient lubrication using, e.g., KY jelly
Female is encouraged to accept larger and larger objects into her vagina (e.g.,
her fingers, her partner’s fingers, Hegar graduated vaginal dilators, syringe
containers of different sizes)
Recommend the use of the female superior position allowing the female to
gradually insert the erect penis into the vagina
Practice Kegel vaginal exercises to develop a sense of control

to a sexual problem. Recognizing the sexual side effects of offer creative solutions to facilitate a sexual life. The inpatient
psychotropics and other medications is a key part of the setting also provides a unique opportunity to get multiple
evaluation. Fortunately, many effective treatment strategies specialists involved as necessary (e.g., urologist, gynecologist,
now exist (e.g., use of PDE-5 inhibitors for SSRI-induced and endocrinologist) to provide comprehensive care.
sexual dysfunction). With increasing understanding of the Ultimately, the consultant psychiatrist may play a pivotal
biological basis for sexual dysfunction, the opportunity to role in triaging the patient to an outpatient provider for
treat sexual problems should only continue to expand. longer-term management.
Some sexual problems may be the result of an acute
illness or require only short-term treatment or medication
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290.e2 Chapter 25     Sexual Disorders or Sexual Dysfunction

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