Although many mysteries of sexual pathophysiology await illumination, patients may expect mental health professionals to provide guidance about their persistent sexual disappointments. Insights here.
Table – DSM-5 sexual dysfunction diagnoses
Premiere Date: March 20, 2017
Expiration Date: September 20, 2018
This activity offers CE credits for:
1. Physicians (CME)
To understand the various sexual disorders that can present during a person’s lifespan and the psychiatrist’s role in helping relieve such problems.
At the end of this CE activity, participants should be able to:
• Discuss the 3 basic clinical concepts of sexual dysfunction
• Understand the reasons for limitations in prevalence data
• Describe the pathogenesis of the dysfunction
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit ™.
It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.
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Stephen B. Levine, MD, has no disclosures to report.
Katherine Hall, PhD, (peer/content reviewer) has no disclosures to report.
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The term sexual dysfunction became part of the vocabulary of clinical medicine in 1970 with the publication of Masters and Johnson’s Human Sexual Inadequacy.1 Before this book appeared, male sexual problems were conceived of as either premature ejaculation or impotence, and most female sexual function problems were categorized under frigidity. The terms for the specific sexual dysfunctions, which generally reference sexual behavior with partners, have been evolving ever since.
DSM-5 has separate vocabularies for men and women (Table). The current labels refer to complaints of low sexual desire, poor sexual arousal, difficult orgasmic attainment, and painful intercourse. DSM-5 categorizes these well-known symptom presentations but omits several problems.
The patterns that are not well characterized in DSM-5 include the so-called male sexual addictions or hypersexuality and 4 infrequently encountered patterns: persistent genital arousal syndrome, post-orgasmic illness syndrome, pleasureless orgasm, and highly restricted patterns of orgasmic attainment. The topic of sexual dysfunction, which is distinct from sexual identity issues, is too broad to be tersely summarized. To understand in detail the specific dysfunctions, readers can consult Binik and Hall2 and Levine and colleagues.3
The sources of dysfunctional patterns are scientifically not well established. Yet, for practical purposes, clinicians offer a variety of therapeutic interventions based on their history taking and their preferred understanding of pathogenesis. Although many mysteries of sexual pathophysiology await illumination, patients sometimes expect mental health professionals to provide guidance about their persistent sexual disappointments.
Three basic clinical concepts
When looking at the sexual dysfunctions as a group, it is useful to consider several basic ideas.
The first is to categorize the specific problem as seemingly always present (lifelong) or acquired after a period of normal sexual function (acquired) and as specific to a partner or a type of sexual activity (situational) or present with all partners and sexual circumstances (generalized). These distinctions help clinicians focus on the relevant history of the presenting problem-that is, to focus on the situation before the symptoms began or, if lifelong, to focus on past important developmental experiences.
The second is to keep in mind that all sexual behavior-solitary and partnered, normal and dysfunctional, morally acceptable or socially disapproved of-is constructed with biological, psychological, interpersonal, and cultural contributions. This concept helps clinicians to put generalizations about sexual dysfunction into perspective, to remain humble, and to bring an intelligent skepticism to pronouncements about causality and treatment claims. It is also why the need for clinical judgment in this arena is stressed so heavily within DSM-5. As psychiatry’s interest in the sexual dysfunctions has lessened over the past several decades, sexual medicine has become more prominent.
The latter is dominated by research and clinical interventions in urology and gynecology, and pharmaceutical research into prosexual agents. Nonetheless, a broad array of clinicians encounter patients’ sexual concerns. These include psychiatrists, psychologists, relationship therapists, sex therapists, counselors, infectious disease specialists, physical therapists, and primary care physicians. Each stakes out a narrow band of sexual concerns and dysfunctions. Each tends to have a biologic or psychological bias when it comes to explaining the problem and recommending treatment. A urologist, for instance, is more likely to prescribe a phosphodiesterase-5 inhibitor (PDE-5i) than to refer a man with erectile dysfunction to a mental health professional. A psychologist who confronts new lower desire and difficulty with ejaculation is less likely to consider a prolactinoma than would a primary care physician.
The sexual lives of patients, however, are rarely as simple as various professionals’ interventions suggest. Care is frequently optimized when medical and nonmedical professionals collaborate to bring their different skills and knowledge to patients.
The third basic concept is to keep in mind that sexual function, while very important to general well-being, is merely one aspect of a person’s life. While specialists tend to focus on the sexual problem, the process of determining the specific psychological, interpersonal, biological, and cultural determinants of a presenting problem often leads mental health professionals to realize that almost any sexual dysfunction can be a symptom of other DSM-5 diagnoses. MDD, for example, can lead to insufficient or excess sexual desire and impairment of arousal or orgasm. The clinician is called upon to separate:
• Sexual dysfunction that is the product of a psychiatric disorder from
• Reactive symptoms that stem from having the sexual dysfunction from
• Current life dilemmas beyond a DSM-5 diagnosis that impair sexual function or satisfaction from
• Remote adversities during childhood or adolescence that undermined the person’s ability to feel safe during the recurring intimate life experience
The skillful treatment of sexual dysfunction begins with a careful history to reveal the psychological, interpersonal, and biological health of the patient and his or her partner. An analogy may help. When learning histology, students are taught to look first at the tissue slice with the naked eye before they look under a microscope to correctly identify the organ they are examining. The following case illustrates the patient’s and the physician’s joint realization that focusing merely on the sexual problem can be usefully avoided.
A regimen of 60 mg of paroxetine and 5 mg of aripiprazole for several years has enabled a 37-year-old married father of 2 to stop watching pornography, to stop following women on the street who have shapely buttocks, and to quiet the strange noises in his head. At a follow-up visit, he complains that he ejaculates only about 50% of the time with his wife. He no longer masturbates and when he notices an attractive stranger, he turns away.
His ejaculatory difficulty began when the SSRI was prescribed. He and his wife were grateful for the drug because it enabled him to concentrate at work and to be more attentive at home. “Life is good now; before I thought I was losing my mind and my family!” After discussing his wife’s casual attitude toward his delayed ejaculation, he shares that the rear entry into the vagina position during intercourse is his preferred position for reaching orgasm.
When the risks and costs of the treatment options are reviewed, the patient and physician agree to keep his medicines as is. Periodic inability to ejaculate is viewed as the price he is paying for a much improved life.
Limitations of prevalence data
The prevalence of sexual dysfunction is greater among psychiatric and medical patients than in the general population. Results from a well-designed study of frequency in the latter group showed that the point prevalence of sexual dysfunction for those aged between 19 and 59 years was 35%.4 This fact has stirred prosexual medication research. The higher prevalence among psychiatric patients has been demonstrated for a variety of psychiatric disorders.5
Epidemiological data, however, cannot be translated into DSM-5 sexual dysfunction diagnoses because they do not measure distress. While men’s sexual life may be dysfunctional in terms of rapid ejaculation, unreliable erections, or undependable ejaculation during intercourse, and women’s sexual function impaired by painful intercourse, low interest in partner sexual expression, inefficient arousal, or low rates of orgasm with partner sex, prevalence estimates do not translate into help seeking.
Many people do not seek psychiatric attention for their sexual dysfunctions.6 They may know that the source of the problem is partner alienation and are distressed about their situation but not the dysfunction per se. Some are too embarrassed to discuss their situation, particularly their earlier childhood/adolescent experience with sexual molestation or intrafamilial abuse. Some are simply overwhelmed by all the demands on them, making their dysfunction low on their priority list. Some have already spoken to a medical doctor and have failed to improve with the recommendation made. Some realize that their partner has no interest in having sex after the discovery of infidelity. Some cannot afford the cost of treatment because many insurance plans do not pay for these diagnoses. Some do not think that their problem can be helped, and others do not know where to go for help. Finally, some simply do not value sexual expression.
When individuals or couples seek help for sexual dysfunction, it is often because their relationship is at a crisis point. This is why clinicians emphasize that residents try to determine why patients are seeking help at this juncture in their lives. A woman’s chief complaint may be lifelong anorgasmia, but she is seeking help now because she fears losing her husband to another woman via an affair or divorce because their sexual life is mutually unsatisfying.
After the publication of Human Sexual Inadequacy, many patients appeared at new sexual dysfunction clinics across the US and Europe because of the hope generated by the positive results of Masters and Johnson. A decade later, therapists were lamenting that the cases readily cured by sex therapy had disappeared; they were primarily seeing men, women, and couples with complaints of multidetermined complexity.
By 1980, the enigmatic problems with low sexual desire had been defined. When SSRIs were noted to delay ejaculation in the early 1990s, a wave of men requested treatment. When sildenafil was brought to market, a tsunami of patients sought this wondrous panacea, although as many as 50% of those who were given a prescription did not continue to use the drug.7
In stark contrast, in 2015 when flibanserin was approved by the FDA for sexual interest arousal disorder (SIAD) in women, there was only a trickle of interest in the drug.7 Given the purported high prevalence of SIAD, many are wondering about the reasons for the drug’s poor reception. Explanations include the contraindication of alcohol use, the lengthy time to a positive effect, controversy about its approval, the need for physician special education before prescribing, and marketing mismanagement.
What psychiatrists can do
Be sophisticated about drug-induced sexual dysfunction. Four phases of sexual function can be efficiently covered in taking a history of this complaint. These help to illuminate the pathogenesis of the dysfunction:
• What was sexual function like before the psychiatric problem (depression, psychosis, addiction) was established?
• What was the effect of the condition on sexual function? (Often it is impaired)
• What was the effect of improvement of the condition on the patient’s sexual function? (Sometimes no improvement in sexual function has occurred)
• What was the effect of the medication when the condition was treated initially and after several months? (A highly unusual new sexual symptom-penile or vaginal anesthesia, burning during or after orgasm, clitoral priapism-suggests a medication adverse effect)
By asking the first 2 questions before prescribing a psychotropic, not only does it prepare the patient to think clearly about medication effects, it can also strengthen the patient’s trust about the psychiatrist’s concern for his or her welfare.
Drug-induced sexual dysfunction depends on the degree of excitement and stimulation in a person’s life. Thus, one episode of sex with one’s partner may be quite arousing because of special circumstances, yet most of the time the level of arousal is low enough that the medication limits what is physiologically possible. Psychiatrists must recognize that not all sexual activity among the married occurs within marriage. Here is an example.
A 40-year-old chronically depressed mother of 3, who was living in an asexual marriage with a man without sexual interest in her, stopped her infrequent masturbation once an SNRI was prescribed. “What good is my sexual interest? I’m glad it is gone.” A year later, while taking 300 mg/d of the SNRI, she began an affair during which she was multiorgasmic with almost any sexual behavior the couple engaged in. “I guess it was not just the Effexor!” she remarked.
Provide a follow-up appointment when prescribing a drug for sexual dysfunction. An SSRI for premature ejaculation or a PDE-5i for erectile disorder may or may not be immediately effective. Not only might the dose need to be modified, but the patient may need to better understand what the medications can and cannot do. Despite the availability of flibanserin for women, many clinicians prescribe other medications, such as testosterone and bupropion. The follow-up appointment is also for the physician so that he or she can continue to learn about the patient’s life and the efficacy of the previous intervention. Many patients consider their gradual revelation of their lives to be therapeutic.
Appreciate the gynecological changes of menopause. Perimenopause is often associated with reduced vaginal lubrication, diminished sexual drive, and decreased vulvar and nipple sensitivity.8 As many women age beyond the menopause, a high percentage lose interest in sex because of pain during intercourse. This pain often signals the beginning of vulvar-vaginal atrophy.9 While early in its course the discomfort may be significantly relieved by moisturizers and lubricants, a surprising number of male partners and women do not understand these physiological changes. Instead, unfortunate couples needlessly consider the problem to be a manifestation of the loss of love.
A woman with a long history of regular satisfying sex with her husband developed “a spare tire” around her abdomen and voiced concern over not feeling attractive in her mid-50s. In addition, intercourse began to be painful, and she began to minimize their sexual encounters. Sex was something they did; it was not discussed. Her husband-a craftsman who fished, hunted, taught wrestling, and drank heavily in his spare time-never talked much about anything. To her, he seemed indifferent when she complained about the changes in her body. He suddenly decided to leave her, saying only that they never had sex anymore. By the time he returned apologetically 2 months later because he was unhappy apart from her, she had learned that he had a younger girlfriend. They sought help for their marriage when she could not get over her anger for being abandoned and being lied to about the younger woman.
While there is much more to these lives, it is startling how little they appreciated these physiological events. I casually educate patients and their partners about the expected sexual impact of menopause for the majority of women.
Be aware that any sexual dysfunction in any era of adult life can lead to the demise of a couple’s sexual life. There are 2 main sources of couples’ nurturance: psychological intimacy and sexual behavior.10 Without sex, individuals often feel disconnected, alone, and without the reassurance that comes from a pleasurable sexual intimacy.
The prevalence of rapid ejaculation and anorgasmia is highest among young adults, whether single or partnered. When paired together, such couples have a difficult time outgrowing their youthful problems. Sex tends to become devalued and may end because the partners lose interest in experiencing their individual and joint disappointments. As years go by and life gets complicated by work and children, many women begin to lose their desire for partner sex. Sometimes this is compounded by a subtle loss of respect for the partner as they more clearly realize the partner’s limitations. Middle-aged men do not complain of low desire as frequently as middle-aged women; they complain of erection problems. Long-standing couples, aged approximately 60 years and older, often share sexual arousal complaints. Each is no longer as spontaneously interested in sex; each may be less sexually arousable and may find regular orgasmic attainment more difficult.
These common age-related patterns are not inevitable! The sexual dysfunctions raise the vital question of what accounts for individuals who are able to sustain a vital, nurturing, pleasurable, nondysfunctional sexual life despite the expected physiological challenges of aging.
PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR A YEAR AFTER.
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Dr. Levine is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland, OH. He has written several books, including Sex Is Not Simple, Sexual Life: A Clinician’s Guide, Sexuality in Midlife, Demystifying Love: Plain Talk for the Mental Health Professional, and Barriers to Loving: A Clinician’s Perspective. He is co-director of the Center for Marital and Sexual Health in Beachwood, OH.
1. Masters W, Johnson V. Human Sexual Inadequacy. Boston: Little Brown; 1970.
2. Binik YM, Hall KSK. Principles and Practice of Sex Therapy. 5th ed. New York: Guilford Press; 2014.
3. Levine SB, Risen CB, Althof SE. Handbook of Clinical Sexuality for Mental Health Professionals. 3rd ed. New York: Routledge; 2015.
4. Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544.
5. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross-sectional population survey. J Epidemiol Commun Health. 1999;53:144-148.
6. Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav. 2003;32:193-208.
7. Brotto LA. Flibanserin. Arch Sex Behav. 2015;44:2103-2105.
8. Hayes R, Dennerstein L. The impact of aging on sexual function and sexual dysfunction in women: a review of population-based studies. J Sex Med. 2005;2:317-330.
9. Palma F, Volpe A, Villa P, et al. Vaginal atrophy of women in postmenopause: results from a multicentric observational study: the AGATA study. Maturitas. 2016;83:40-44.
10. Levine SB. Barriers to Loving: A Clinician’s Perspective. New York: Routledge; 2013.