Sexual Dysfunction

Psychosexual disorders were listed for the first time in 1980 in the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), a handbook used by almost all mental health professionals. This listing has led to an increasing medicalization of sexual problems that can allow individuals to avoid examining their own attitudes and experiences that could have contributed to their dysfunction. If the source of the problem is "medical," the individuals may not see the need to take responsibility for their problems. If the problem is a lack of desire, the medical diagnosis can be used as a rationale to continue to avoid sexual activity.

The DSM-IV (the fourth edition of the DSM, published in 1994) classifies sexual dysfunctions as primary or secondary. A primary dysfunction occurs when an individual has never experienced one of the phases of the sexual response cycle. A secondary dysfunction refers to a situation in which a person has been able to respond in the past to one of the phases but is not responsive at the current time, or can experience one of the phases only in certain circumstances.

It is important to remember that many people do not neatly fit into any of the diagnostic categories described. In many cases, problems with desire, excitement, and orgasm overlap. (Everaerd and Laan 2000)

There has been very little systematic survey information on the prevalence of sexual dysfunction. Robert Francouer (1977) edited three volumes that covered 170 countries and cultures. Almost all of the accounts were anecdotal or based on data collected in various types of clinics. In those countries that did have information based on representative samples of their population (Czech Republic, Slovakia, Denmark, Finland, France, Iceland, and Sweden), it is difficult to make comparisons because of methodological differences in how these studies were carried out.

An overview of the National Health and Social Life Survey (NHSLS), which was the first to question a nationally representative sample of U.S. adults about their sexual attitudes and behaviors, reveals that sexual problems are most common among young women and older men (Laumann, Park, and Rosen 1999). Low sexual interest and problems with erection tend to become more common as men age probably due to the physiological changes that occur over time. Young women "are more likely to be single, their sexual activities involve higher rates of partner turnover as well as periodic spells of sexual inactivity. This instability, coupled with inexperience, generates stressful sexual encounters, providing the basis for sexual pain and anxiety"(p. 9).

The effects of race and ethnicity on the prevalences of sexual dysfunction are fairly modest. Hispanic women report lower prevalence of sexual dysfunction than do African-American or white women. White women are more likely to experience sexual pain then are African-American women, whereas African-American women report experiencing less pleasure with sexual experience and sexual desire more frequently than white women. Differences between men roughly follow those among women but the differences are not as large. Generally, Hispanics are less likely to report sexual problems whereas African Americans report more sexual problems across the spectrum of sexual dysfunction (Laumann, Park, and Rosen 1999).

Sexual Desire Disorders

The DSM-IV divides desire disorders into two categories: hypoactive sexual desire disorders and sexual aversion disorders. The first of these, hypoactive sexual desire disorder, is defined as deficient or absent sexual fantasies and desire for sexual activity with anyone. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning such as age, sex, and the context of the person's life. The deficiency may be selective: a person may experience erection or lubrication and orgasm but derive little pleasure from the physical feelings and thus have little interest in sexual activity. In other cases, the individual's desire is at such a low ebb that he or she has no interest in self-stimulation or in participation in sexual interaction that might even lead to arousal. Some people can be described as asexual; in other words, they do not experience desire for any kind of sexual activity. This is not considered a dysfunction if the individual is satisfied with not engaging in sexual activity.

The sources of sexual desire disorder have not been well clarified. Most current knowledge of the causes of low sexual desire is based on clients who are seen in therapy and thus must be viewed with caution until more objective research has been conducted using nonclinical samples. With that caveat in mind, low sexual desire has been associated with such factors as anxiety, religious orthodoxy, depression, habituation to a sexual partner, fear of loss of control over sexual urges, sexual assault, side effects of medication, marital conflict, and fear of closeness. (Allgeier and Allgeier 2000).

In the general population, 16 percent of men and 33 percent of women aged eighteen to fifty-nine reported that they lacked interest in sex for a period of several months or more in the year before they were interviewed (Laumann et al. 1994). The suppression of sexual desire is, of course, not dysfunctional in and of itself. Most of us learn scripts to suppress sexual desire for inappropriate partners, such as parents, close relatives, and children, and in inappropriate situations.

Sexual aversion disorder is a persistent aversion to almost all genital sexual contact with a partner. Whereas individuals displaying hypoactive sexual desires are often indifferent about sexual interaction, sexual aversion reflects fear, disgust, or anxiety about sexual contact with a partner. An individual with sexual aversion disorder may still engage in autosexual behaviors such as masturbation and fantasy, while avoiding interpersonal sexual behavior.

Excessive sexual desire is often associated with paraphilias. Preliminary evidence indicates that men with paraphilic disorders are two to three times more sexually active than men in the general population (Kafka 1997).

Sexual Arousal Disorders

Some people feel deep sexual desire and want to make love with their partners but experience little or no physical response (erection or vaginal lubrication and swelling) to sexual stimulation. Sexual arousal disorders are diagnosed when there is recurrent or persistent failure by a woman to attain or maintain the lubrication and swelling response or failure by a man to attain erection during sexual activity. Such a diagnosis is made only when the clinician is sure that the difficulty does not stem from physical disorders or medication and when the amount of sexual stimulation provided should be adequate to produce vasocongestion. Sometimes failure to respond results from insufficient stimulation rather than from inhibition of excitement.

Women's reactions to an inability to respond to erotic stimulation show much greater variation than do men's responses. Most men react to erectile dysfunction as if it were a disaster, whereas women's responses range from anxiety or distress to casual acceptance of the difficulty. To some extent, cultural expectations are responsible for these differences. In most cultures, men are expected to be sexually active and to perform satisfactorily. Women are not generally subjected to the same performance pressures and, in some cultures, are not expected to be sexually responsive. The restrictiveness of a culture is linked to the incidence of difficulties in a man's getting or maintaining an erection. In an examination of thirty preindustrial and industrializing countries, Michael Welch and Pamela Kartub (1978) found that the more restrictive a society was regarding such behaviors as premarital, marital, and extramarital sex, the greater was the number of reported problems with erectile functioning.

Erectile dysfunction is generally the most common complaint among men seeking sex therapy. In a more representative sample, however, about 10 percent of men report experiencing erectile dysfunction (Laumann et al. 1994). Some men with erectile dysfunction never have more than a partial erection during sexual activity. Others become erect, only to lose firmness when they attempt to have intercourse. Some men have erection problems with one partner but not with another.

Most men who experience problems with erection after a period of normal responsiveness respond well to treatment. The prognosis is not so good for men who have never been able to attain or maintain an erection with a partner.

About 20 percent of women and 10 percent of men aged eighteen to fifty-four in the general population reported arousal problems in 1992. Often the problem stems from the combination of widespread ignorance in our culture regarding women's sexual anatomy and the socialization of women to attend more to others' needs then to their own.

Orgasm Disorders

Some people have orgasms within minutes of sexual interaction. Others engage in sexual stimulation for an hour or more before having orgasm. Some people never have orgasms. Nowhere else is the problem of defining sexual dysfunction more evident. In fact, except in extreme cases involving orgasm within seconds or no orgasm at all, the main difficulty is a difference in the speed of the partners' responsiveness rather than any dysfunction.

The fact that one person responds quickly and his or her partner responds more slowly does not necessarily imply that either is dysfunctional. Although orgasmic and ejaculatory dysfunctions do exist in some people, simple differences between partners in the timing of orgasmic release are not necessarily problematic or indicative of sexual dysfunction.

Perhaps the most useful definition of premature ejaculation is ejaculation before the man wants it to occur. Speed of ejaculation is related to age (older men have fewer problems with ejaculatory control than do younger men, particularly adolescents), sexual inexperience, and novelty of the sexual partner.

The diagnosis of premature ejaculation is not appropriate unless the speed of a man's ejaculation becomes a regular, unwanted aspect of a couple's sexual activity. Ejaculation is a reflex that is difficult to control once it has been activated. The key to learning control is to recognize the signals that occur just before ejaculation, an awareness that can be difficult for young, inexperienced men. Roughly 30 percent of men report that they ejaculate more rapidly than they would like. Some men who continue to have problems with premature ejaculation after they have become sexually experienced may be hypersensitive to penile arousal and predisposed to early ejaculation (Slob, Van Berkel, and van der Werff ten Bosch 2000).

In clinical studies, inhibited male orgasm (also known as retarded ejaculation or ejaculatory incompetence) accounts for about 3 to 8 percent of men seeking treatment, and this rarer form of sexual dysfunction has been found to occur in about 3 to 10 percent of men in nonclinical samples (Simons and Carey 2001). The inhibition of orgasm may include delayed ejaculation or a total inability to ejaculate despite adequate periods of sexual excitement. As with the other dysfunctions, a diagnosis of inhibited male orgasms is not made when the problem stems from side effects of medication or some physical disorder.

In a physical condition known as retrograde ejaculation, the usual expulsion of ejaculate through the urethra is reversed. The neck of the bladder does not contract, so the semen is expelled into the bladder rather than out through the urethral opening in the penis. The condition usually results from surgery involving the genitourinary system or can be a side effect of some medications.

Some women suffer from inhibited orgasm, a condition that prevents them from having orgasm despite adequate sexual stimulation. Difficulty with orgasm is one of the most common sexual concerns among women

Women with this dysfunction may look forward to sex, and many experience high levels of sexual excitement with vaginal swelling and lubrication, but they are usually unable to have orgasm. Sexual arousal causes congestion of the pelvic blood vessels, and without orgasm, the congested blood remains for a while (analogous to the congestion in the testes associated with the absence of orgasmic release in highly aroused men). Consistent arousal in women without orgasmic release can result in cramps, backache, and irritation. Prevalence rates have ranged between 4 and 24 percent in European and U.S. studies (Simons and Carey 2001)

It is debatable whether a dysfunction exists when a woman does not have orgasm during coitus but does climax during other kinds of stimulation—oral or manual stimulation, for example. Calling this pattern a sexual dysfunction and assuming that it requires sex therapy would dictate treatment for a large number of women, given that fewer than 50 percent of women consistently have orgasm during coitus.

Sexual Pain Disorders

Sexual pain disorders include dyspareunia, which males and females can experience, vaginismus and vulvodinia, which are exclusively female complaints.

Dyspareunia is the technical term for recurrent and persistent genital pain in a man or woman before, during, or after sexual intercourse. They may experience the pain as repeated, intense discomfort; momentary sharp sensations of varying intensity; or intermittent twinges and/or aching sensations. Dyspareunia in men, who may experience the pain in the testes and/or the glans after ejaculation, appears to be much less common than painful intercourse in women

In a study by Edward O. Laumann and colleagues (1994), U.S. women reported prevalence rates of almost 15 percent. A large study in France found that 5 percent of the sexually active female respondents indicated that they had often experienced pain during sexual relations (Spira, Bajos, and LeGroupe 1993). The discrepancy between these prevalence rates may result, in part, from different methodologies and/or cultural differences.

A wide variety of disease and disorders of the external and internal sex organs and their surrounding structures can make intercourse painful for men and women. When physical disorders have been ruled out, psychological factors are assumed to be the cause.

Vaginismus refers to the involuntary spasm of the pelvic muscles surrounding the outer third of the vagina. Women who experience these spasms of the pubococcygeus (PC) and related muscles may be quite capable of becoming sexually aroused, lubricating, and experiencing orgasm but cannot have intercourse. The partner of a woman with this dysfunction who tries to have intercourse with her may have the sensation that his penis is hitting a rigid wall about an inch inside her vagina. Vaginismus rates have ranged from 0.5 to 30 percent of the women treated at clinics (Simons and Carey 1990).

Treatment ranges from the medical correction of physical problems to the use of psychotherapy, although it is sometimes difficult to determine the precise source(s) of the vaginismus. Relaxation training and gradual insertion of successively bigger dilators into the vagina appear to be highly effective in curing vaginismus. It is very important, however, that the woman (rather than a therapist or her partner) control the pace of treatment and the size of dilator (Heiman and Metson 1997)

Vulvodinia is characterized by a painful burning sensation in the vulvar and vaginal area. Also called burning vulva syndrome, the presenting complaint of women with this problem is burning and painful intercourse. The syndrome is associated with a history of vulvo/vaginal infection, microorganisms that cause dermatosis, and early contraceptive use (Binik et al. 1999). Current treatments include laser surgery, topical preparations, dietary restrictions, physical therapy, and pain reduction techniques such as self-hypnosis.

From this review of sexual dysfunctions, it should be clear that whatever the original source (biological, psychosocial, or both) of a person's inability to respond as he or she wishes, the problem may be aggravated by the development of fear of failure in future sexual contacts. Such fear can produce self-fulfilling prophecies; in other words, an intense focus on whether a person will respond adequately can reduce the likelihood that healthy sexual feelings and responses will unfold. No matter what particular treatment procedures sex therapists use, they should also identify and attempt to eliminate both clients' fears of sexual inadequacy and their tendency to engage in distracting and maladaptive thoughts during sexual intimacy.

Sex Therapy

Although sexual dysfunctions have been treated by a wide array of different therapies, this entry concentrates on the most commonly used techniques in sex therapy. Until the 1960s, the predominant approach to the treatment of sexual dysfunction was psychoanalysis. Sexual problems were viewed as symptoms of emotional conflict originating in childhood.

Cognitive-behavioral psychologists have long taken issue with the psychoanalytic approach. They believe that a person can be emotionally healthy and still have sexual difficulties. Maladaptive sexual functioning is learned, they believe, and it can be unlearned without extensive probing into a client's past.

Masters and Johnson's approach. The treatment program that William Masters and Virginia Johnson developed is a two-week process, conducted by a man and a woman. Both partners in the couple seeking treatment are given a thorough medical examination and interviewed by the therapist of the same sex, followed by an interview with the other therapist. All four people (the couple and the two therapists) then discuss treatment goals.

Masters and Johnson recommended the use of both a male and a female therapist to provide a "friend-in-court" for the client of the same sex. They stressed the treatment of specific symptoms rather than extensive psychotherapy aimed at determining potential underlying, unconscious sources of difficulty.

Kaplan's approach. Helen Singer Kaplan (1974) developed an approach to sex therapy that combined some of the insights and techniques of psychoanalysis with behavioral methods. Her approach begins at the surface or behavioral level, and probes more deeply into emotional conflicts only if necessary.

Many sexual difficulties stem from superficial causes. If a sexual difficulty is rooted in a lack of knowledge, for example, information and instruction may be all that are needed to treat it. If the trouble is of recent origin, a series of guided sexual tasks may be enough to change patterns of response. If deep-seated emotional problems exist, the therapist may use more analytic approaches to help clients obtain insight into the less-conscious aspects of their personality. This last approach has been designated as psychosexual therapy to distinguish it from sex therapy.

Nondemand pleasuring and sensate focus. In exercises involving nondemand sensate focus, the clients initially avoid sexual intercourse. In fact, couples are forbidden to engage in any sexual activity until the therapist instructs them to do so. Over the course of treatment, they receive homework assignments that gradually increase their range of sexual behaviors. Initially, only kissing, hugging, and body massage may be allowed.

The partners are instructed to take turns in the roles of giver and receiver as they touch and caress each other's body. When playing the role of giver, the person explores, touches, and caresses the receiver's body. In applying this technique, called nondemand pleasuring, the giver does not attempt to arouse the receiver sexually. In an exercise called sensate focus, the receiver concentrates on the sensations evoked by the giver's touch on various parts of the body. In these exercises, the giver's responsibility is to provide pleasure and to be aware of his or her own pleasure in touching. The receiver's role is to prevent or end any stimulation that he or she finds uncomfortable or irritating by either telling or showing the partner his or her feelings.

The next step is to engage in nondemand breast and genital caressing while avoiding orgasm-oriented stimulation. If the partner or the person who is experiencing sexual difficulty becomes highly aroused during this exercise, that partner may be brought to orgasm orally or manually after completion of the exercise.

Other sexual behaviors are gradually added to the clients' homework. Successive assignments may include nongenital body massage, breast and genital touching, simultaneous masturbation, penile insertion with no movement, mutual genital manipulation to orgasm, and, finally, intercourse.

Masturbation training. Most treatment programs for orgasmically inhibited women include training in masturbation, particularly if the woman has never had an orgasm. This approach is used mainly in cases of primary orgasmic dysfunction and female hypoactive sexual desire. In this approach women are encouraged to learn about their bodies and relax to the point where they can experience orgasm.

The approach most commonly employed for premature ejaculation is the squeeze technique (Masters and Johnson 1970). The partner circles the tip of the penis with the hand. The thumb is placed against the frenulum on the underside of the penis, while the fingers are placed on either side of the corona ridge on the upper side of the penis. When the man signals that he is approaching ejaculation, his partner applies fairly strong pressure for three to five seconds and then stops with a sudden release. The partner stimulates his penis again after the sensations of impending ejaculation diminish, usually within twenty to thirty seconds. Typically, the man is told that he should not try to control his ejaculation but should rely instead on the squeeze technique. The entire process is usually repeated twice per session before ejaculation is allowed.

Some couples prefer to apply the squeeze technique as close as possible to the base of the penis rather than the tip. This variation has the advantage of being easier to do during intercourse, but for some couples it does not work.

Numerous other therapy formats and techniques are sometimes used in conjunction with the foregoing approaches to the treatment of sexual dysfunctions. For example, for women who have primary or secondary orgasmic dysfunction, group therapy is effective and less expensive than individual therapy (LoPiccolo and Stock 1986; McCabe and Delaney 1992).

Various approaches involving surgery and mechanical approaches, hormones, and drugs have been used in the attempt to treat sexual dysfunctions. The fact that most of these treatments have been developed for male sexual difficulties probably reflects the cultural emphasis on male sexual performance. In general, before permitting these kinds of treatment, the client should make sure no other type of treatment is effective for him and obtain a second opinion.

Surgical procedures, including implants, have been used in the treatment of erectile dysfunction. There are two basic types of plastic or silicone implants. One is a semirigid rod that keeps the penis in a constant state of erection but can be bent for concealment under clothing. The other type of silicone or plastic (polyurethane) implant an inflatable device surgically implanted under the skin of the penis; to achieve erection, the man presses a pump implanted in the scrotum. The pump forces fluid from a reservoir put under the abdominal muscles into cylinders implanted in the penis. Complications of this method include infection and mechanical failure. Follow-up studies of prosthesis recipients and their partners have indicated that they were generally satisfied with the choice to have the surgery.

The vacuum pump has been used as a nonsurgical method to treat erectile difficulties. The penis is inserted into an acrylic tube while a hand-held vacuum pump draws blood into erectile tissue. A rubber band holds the blood in place for up to thirty minutes.

Hormone administration, principally testosterone, has been used for years to treat erectile dysfunctions. If the problem is not due to hormone deficiency, however, hormones can increase sexual arousability without improving performance, which can result in further deterioration of the client's condition. Testosterone treatment also increases the risk of coronary thrombosis, atherosclerosis, and cancer of the prostate.

The use of testosterone-estrogen pills, creams, and gels have been used to try to increase women's sexual desire. It is unlikely that these medications are helpful except, perhaps, for women with abnormally low levels of testosterone and without other complicating factors (e.g., anxiety, stress, guilt, or anger at partner) that are inhibiting their sexual response. Research is badly needed on the effectiveness of this approach as well as possible side effects. For example, the dosage level is presumably important; high levels of testosterone might increase sexual desire in some women, but they also would tend to masculinize women, producing unwanted body hair and the like.

A number of drugs can create pharmacological erections through injection into the penis by relaxing the smooth muscle of the corpora cavernosa. They appear to be most useful for men with irreversible biological erectile dysfunction. The client can be taught to inject the drug himself. Erection usually occurs within ten minutes and lasts about two hours. There is some risk with this treatment, which has a number of side effects such as penile scarring, priapism, cardiac irregularities, and changes in the liver with long-term use.

A recent drug, sildenafil citrate, approved by the Food and Drug Administration in 1998, is taken orally as a pill. Sildenafil is marketed as Viagra. Used by men who have erectile difficulties, it is taken one hour before the man wants to have an erection and the erection can last for up to four hours following administration. Unlike other treatments, Viagra does not work unless the person is experiencing sexual arousal. It works by blocking an enzyme that allows blood to flow out of the penis.

Irwin Goldstein and his colleagues (1998) reported in a study of 532 men that 70 percent of all attempts at sexual intercourse with an erect penis were successful for men taking Viagra, whereas only 22 percent of attempts were successful when men were administered a placebo. Other studies have shown the effectiveness of Viagra for men with erectile dysfunction. Viagra's effectiveness for women with sexual arousal difficulties has been more mixed but there has been less research conducted with women.

Effectiveness of Sex Therapy

One of the most impressive aspects of Masters and Johnson's (1970) therapeutic approach with almost 800 people with sexual problems was that they reported success in treating more than 80 percent of their clients who experienced various types of sexual dysfunction. Of the successful clients who could be found five years later (313 couples), only 5 percent reported recurrence of the dysfunctions for which they had obtained treatment. The therapeutic community was quite impressed with the success of Masters and Johnson's approach, and for years other therapists used modified versions of many of their methods.

Gradually, however, outcome statistics reported from clinical practice revealed overall improvement in only about two-thirds of cases. The improvements obtained from controlled treatment studies have all been more modest than the proportions Masters and Johnson reported. Do these finding indicate that the only reliable source of sex therapy is Masters and Johnson? Probably not. Instead, differences between the failure rates that Masters and Johnson reported and those that other sex therapists and researchers reported probably stem from a combination of factors other than Masters and Johnson's skills as therapists.

In addition, many of the problems that Masters and Johnson's clients experienced stemmed from misinformation and ignorance. People in the 1950s and 1960s did not have the easy access to information about sexuality that exists today. Clients today whose problems stem from a lack of information may be "curing" themselves instead of seeking professional treatment. The caseloads of sex therapists today may include a greater proportion of clients with sexual difficulties resulting from deeply rooted emotional problems or from conflicts within their relationships—sexual problems that are often difficult to treat. This factor would, of course, result in lower success rates and higher relapse rates.

Another question that must be addressed in the evaluation of any sex therapy is whether the treatment yields sustained change over the years. There is very little available research on this subject. Summarizing what is known, Keith Hawton (1992) reported that the successful short-term results of sex therapy for erectile dysfunction was maintained in the long-term (one to six years), whereas those for premature ejaculation were less permanent. Men with low sexual desire had a fairly poor response to treatment in the short- and long-terms. Sex therapy for vaginismus was highly effective in the short- and long-terms, whereas the long-term results of treatment for low sexual desire in women were fairly poor. Interestingly, there was improvement in the way a number of clients felt about their sexuality, despite the fact that some had returned to pretreatment dysfunctions in sexual behavior. If these clients had received occasion clinical "booster" sessions over the years, their post-treatment improvement would perhaps have been maintained through preventive measures.

See also:Conflict: Couple Relationships; Intimacy; Marital Sex; Sexual Communication: Couple Relationships; Sexuality; Therapy: Couple Relationships

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a. r. allgeier

Sexual dysfunction

Definition

Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse. Specifically, sexual dysfunction is a group of disorders that interfere with a full sexual responsiveness. These disorders make it difficult for a person to enjoy or to have sexual intercourse. While sexual dysfunction rarely threatens physical health, it can take a heavy psychological toll, bringing on depression, anxiety , and debilitating feelings of inadequacy.

Description

Sexual dysfunction takes different forms in men and women. A dysfunction can be lifelong and always present, or it can be temporary and sporadic. It can be situational or generalized. In either gender, symptoms of a sexual problem include the lack or loss of sexual desire, anxiety during intercourse, pain during intercourse, or the inability to achieve orgasm. In addition, a man may have a sexual problem if he:

• Ejaculates before he or his partner desires.
• Does not ejaculate, or experiences delayed ejaculation.
• Is unable to have or maintain an erection sufficient for pleasurable intercourse.

Also, a woman may have a sexual problem if she:

• Feels vaginal or other muscles contract involuntarily before or during sex.
• Has inadequate vaginal lubrication.

The most common sexual dysfunctions in men include:

• Erectile dysfunction: an impairment of a man's ability to have or maintain an erection that is firm enough for coitus or intercourse.
• Premature ejaculation, or rapid ejaculation, with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
• Ejaculatory incompetence: the inability to ejaculate within the vagina despite a firm erection and relatively high levels of sexual arousal.
• Retarded ejaculation: a condition in which the bladder neck does not close off properly during orgasm so that the semen spurts backward into the bladder.

Female sexual dysfunctions include:

• Sexual arousal disorder: the general arousal aspect of sexual response is inhibited. A woman with this disorder does not lubricate, her vagina does not swell, and the muscle that surrounds the outer third of the vagina does not tighten—a series of changes that normally prepare the body for orgasm ("the orgasmic platform"). Also, in this disorder, the woman typically does not feel erotic sensations.
• Orgasmic disorder: the orgasmic component of the female sexual response is impaired. The woman may be sexually aroused but never reach orgasm.
• Vaginismus: a condition in which the muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration.
• Painful intercourse also known as dyspareunia.

Causes & symptoms

Many factors of both physical and psychological origin can affect sexual response and performance. Injuries, such ailments as infections , and drugs of abuse are among the physical influences. Certain prescription medications, such as drugs to regulate blood cholesterol levels, may also affect sexual functioning. In addition, there is increasing evidence that chemicals and other environmental pollutants depress sexual function. As for psychological factors, sexual dysfunction may have roots in traumatic events such as rape or incest, guilt feelings, a poor self-image, depression, chronic fatigue , certain religious beliefs, or marital problems. Dysfunction is often associated with anxiety. If a man operates under the misconception that all sexual activity must lead to intercourse and to orgasm by his partner, he may consider the act a failure if his expectations are not met.

In Chinese medicine, sexual dysfunction is considered an imbalance of yin and yang. Yin and yang are the two dependent and constantly interacting forces of energy in the world, according to ancient Chinese thought. Yin energy is receptive, dark, feminine, and cool. It is associated with the heavy, the cold, and the moist. Yang energy is masculine, active, bright, and warm. It is associated with the dry, the light, and the hot. People with sexual dysfunction who have yin deficiency are too dry and tired, causing premature ejaculation or dry and spastic conditions. Symptoms of a yang deficiency may include erectile dysfunction as well as lack of sexual appetite or excitement. There are other imbalances that can cause sexual dysfunction.

Other types of alternative medicine, such as herbalism, regard sexual dysfunction as stemming from the same causes as those recognized by Western medicine. In such alternative approaches as homeopathy , sexual dysfunction is seen as an energy deficiency in the sexual organs or the glands that regulate these organs.

Diagnosis

In deciding whether sexual dysfunction is present, it is necessary to remember that each person has a different level of sexual interest. While some people may be interested in sex at almost any time, others have low or seemingly nonexistent levels of sexual interest. A sexual condition is classified as sexual dysfunction only when it is a source of personal or interpersonal distress instead of a voluntary choice.

The first step in diagnosing a sexual dysfunction is usually discussing the problem with a doctor or an alternative practitioner, who will need to ask further questions so he or she can differentiate among the types of sexual dysfunction. The physician may also perform a physical exam of the genitals, and may order further medical tests, including measurement of hormone levels in the blood.

An expert in Chinese medicine will take the pulses at the wrist to assess the patient's overall health. According to Chinese thought, there are 12 pulses at the wrist, six on each wrist. The practitioner will ask questions that relate to yin and yang energy, such as whether the patient's hands and feet are cold or warm most of the time. An alternative practitioner is also likely to query the patient about his diet and any issues in his life that may be contributing to stress .

In allopathic medicine, men may be referred to a urologist, a specialist in diseases of the urinary and genital organs, and women may be referred to a gynecologist.

Treatment

A variety of alternative therapies can be useful in the treatment of sexual dysfunction. Counseling or psychotherapy is highly recommended to address any emotional or mental components of the disorder. Nutritional supplementation, as well as Western, Chinese, or ayurvedic botanical medicine , can help resolve biochemical causes of sexual dysfunction.

Beneficial supplements and herbs include gingko biloba, which improves circulation to the genitals and has been shown to be effective in a number of studies. If the cause is a psychological, emotional, or energy disorder, such adrenal tonics as licorice, epimedium , eucommia, and cuscuta can restore the patient's mood and increase sexual interest. These herbs increase the ability to adapt to physical and mental stress because they increase the power of the adrenal system, which secretes the brain chemical epinephrine. If the patient's reproductive organs are not producing enough of the hormones that regulate sex drive and function, vitex is also a good solution. When a patient lacks sexual drive, such tonics as deer antler can increase interest in sex.

One drug derived from herbal sources that is used in mainstream medicine to treat impotence in men is yohimbine, an alkaloid derived from the bark of the yohimbe or rauwolfia tree. Yohimbine is used to treat inadequate circulation in the arms and legs and to dilate the pupil of the eye as well as to treat impotence. It is available as a prescription medication under such brand names as Yocon and Yohimex. Yohimbine does not work for all men affected by impotence, but appears to have fewer side effects than sildenafil (Viagra).

Homeopathic treatment can be helpful by focusing on the energetic aspects of the disorder. A Chinese medicine practitioner might address sexual dysfunction by using acupuncture , in which hair-thin needles are used to stimulate the body's energy (or qi). According to ancient Chinese theory, the body has 12 meridians that correspond to various organs, their functions, and the patient's emotions. Acupuncture needles might be applied at points on these meridians that regulate the kidney, which forms the foundation for the reproductive system in traditional Chinese medicine , or to other meridians that have roles in sexual function.

Yoga and meditation provide needed mental and physical relaxation for conditions such as vaginismus. A yoga teacher may advise forward bends to calm the patient and yoga twists to help the body produce hormones that increase sexual drive and a feeling of well-being.

Relaxation therapy eases and relieves anxiety about dysfunction. Massage is extremely effective at reducing stress, especially if performed by the partner.

A massage therapist or aromatherapist can also provide sandalwood or jasmine oils to boost sexual drive. An aromatherapist usually prescribes singular scents or a mixture created with the person's preferences and his or her symptoms in mind.

Allopathic treatment

Allopathic treatments break down into two main categories: behavioral psychotherapy and physical treatment. Sex therapy, ideally provided by a member of the American Association of Sexual Educators, Counselors, and Therapists (AASECT), emphasizes correction of sexual misinformation, the importance of improved partner communication and honesty, anxiety reduction, sensual experience and pleasure, and interpersonal tolerance and acceptance. Sex therapists believe that many sexual disorders are rooted in learned patterns and values. These disorders or symptoms are termed psychogenic. An underlying assumption of sex therapy is that relatively short-term outpatient therapy can alleviate learned patterns, restrict symptoms, and allow a greater satisfaction with sexual experiences.

In some cases, a specific technique may be used during intercourse to correct a dysfunction. One of the most common is the "squeeze technique" to prevent premature ejaculation. When a man feels that an orgasm is imminent, he withdraws from his partner. Then, the man or his partner gently squeezes the head of the penis to halt the orgasm. After 20-30 seconds, the couple may resume intercourse. The couple may repeat this technique several times before the man proceeds to ejaculation.

In cases in which significant sexual dysfunction is linked to a broader emotional problem such as depression or substance abuse, intensive psychotherapy and/or medications may be appropriate. People who are taking such medications as fluoxetine (Prozac), paroxetine (Paxil), or reboxetine (Edronax) for depression, however, should be advised that sexual dysfunction in adults of either sex is a fairly common side effect of these medications.

In many cases, doctors prescribe medications to treat an underlying physical cause of sexual dysfunction. Possible medical treatments include:

• Clomipramine and fluoxetine for premature ejaculation.
• Papaverine and prostaglandin for erectile difficulties.
• Hormone replacement therapy or androgen therapy for female dysfunctions.
• Sildenafil (Viagra), a drug approved in 1998 as a treatment for impotence. As of 2002, however, sildenafil has been shown to have potentially serious side effects, including headaches, nausea , sudden changes in blood pressure, and eye disorders.

Expected results

There is no single cure for sexual dysfunction, but almost all of the individual conditions can be controlled. Most people who have a sexual dysfunction fare well once they get into a treatment program. Most alternative therapies, however, take at least several weeks to take effect. If the patient doesn't see improvement in that time, he or she should consider trying another practitioner.

Prevention

It often helps to continue such treatments, such as acupuncture and massage after the initial problem is resolved. Doing so keeps sexual energy high and the genital organs and sex glands healthy. By continuing to use alternative therapies, the patient can help maintain sexual interest even when normal sexual doldrums occur. Continuing to take alternative medicines or treatment also ensures the problem won't return.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000.

Masters, William H., Virginia E. Johnson, and Robert C. Kolodny. Human Sexuality. New York: HarperCollins, 1992.

Molony, David. The American Association of Oriental Medicine's Complete Guide to Herbal Medicine. New York: Berkley Books, 1998.

PERIODICALS

Guay, A. T., R. F. Spark, J. Jacobson, et al. "Yohimbine Treatment of Organic Erectile Dysfunction in a Dose-Escalation Trial." International Journal of Impotence Research 14 (February 2002): 25-31.

Haberfellner, E. M. "Sexual Dysfunction Caused by Reboxetine." Pharmacopsychiatry 35 (March 2002): 77-78.

Hensley, P. L., and H. G. Nurnberg. "SSRI Sexual Dysfunction: A Female Perspective." Journal of Sex and Marital Therapy 28 (2002, Suppl. 1): 143-153.

Pomerantz, H. D., K. H. Smith, W. M. Hart, Jr., and R. A. Egan. "Sildenafil-Associated Nonarteritic Anterior Ischemic Optic Neuropathy." Ophthalmology 109 (March 2002): 584-587.

Traish, A. M., N. Kim, K. Min, et al. "Androgens in Female Genital Sexual Arousal Function: A Biochemical Perspective." Journal of Sex and Marital Therapy 28 (2002, Suppl. 1): 233-244.

Wagstaff, A. J., S. M. Cheer, A. J. Matheson, et al. "Spotlight on Paroxetine in Psychiatric Disorders in Adults." CNS Drugs 16 (2002): 425-434.

ORGANIZATIONS

American Academy of Clinical Sexologists. 1929 18th Street NW, Suite 1166, Washington, DC 20009. (202) 462-2122.

American Association for Marriage and Family Therapy. 1100 17th Street NW, 10th Floor, Washington, DC 20036-4601. (202) 452-0109.

American Association of Oriental Medicine. 909 22nd St. Sacramento, CA 95816. (916) 451-6950. <http://www.aaom.org>.

American Association of Sex Educators, Counselors & Therapists. P.O. Box 238, Mt. Vernon, IA 52314. <http://www.aasect.org>.

Yoga Research and Education Center. P.O. Box 1386, Lower Lake, CA 95457. (707) 928-9898. <http://www.yrec.com.>.

Barbara Boughton

Rebecca J. Frey, PhD

Sexual Dysfunction

Definition

Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse. Specifically, sexual dysfunctions are disorders that interfere with a full sexual response cycle. These disorders make it difficult for a person to enjoy or to have sexual intercourse. While sexual dysfunction rarely threatens physical health, it can take a heavy psychological toll, bringing on depression, anxiety, and debilitating feelings of inadequacy.

Description

Sexual dysfunction takes different forms in men and women. A dysfunction can be life-long and always present, acquired, situational, or generalized, occurring despite the situation. A man may have a sexual problem if he:

• ejaculates before he or his partner desires
• does not ejaculate, or experiences delayed ejaculation

• is unable to have an erection sufficient for pleasurable intercourse
• feels pain during intercourse
• lacks or loses sexual desire

A woman may have a sexual problem if she:

• lacks or loses sexual desire
• has difficulty achieving orgasm
• feels anxiety during intercourse
• feels pain during intercourse
• feels vaginal or other muscles contract involuntarily before or during sex
• has inadequate lubrication

The most common sexual dysfunctions in men include:

• Erectile dysfunction: an impairment of the erectile reflex. The man is unable to have or maintain an erection that is firm enough for coitus or intercourse.
• Premature ejaculation: rapid ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
• Ejaculatory incompetence: the inability to ejaculate within the vagina despite a firm erection and relatively high levels of sexual arousal.
• Retarded ejaculation: a condition in which the bladder neck does not close off properly during orgasm so that the semen spurts backward into the bladder.

Until recently, it was presumed that women were less sexual than men. In the past two decades, traditional views of female sexuality were all but demolished, and women's sexual needs became accepted as legitimate in their own right.

Female sexual dysfunctions include:

• Sexual arousal disorder: the inhibition of the general arousal aspect of sexual response. A woman with this disorder does not lubricate, her vagina does not swell, and the muscle that surrounds the outer third of the vagina does not tighten—a series of changes that normally prepare the body for orgasm ("the orgasmic platform"). Also, in this disorder, the woman typically does not feel erotic sensations.
• Orgasmic disorder: the impairment of the orgasmic component of the female sexual response. The woman may be sexually aroused but never reach orgasm. Orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
• Vaginismus: a condition in which the muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration.
• Painful intercourse: a condition that can occur at any age. Pain can appear at the start of intercourse, midway through coital activities, at the time of orgasm, or after intercourse is completed. The pain can be felt as burning, sharp searing, or cramping; it can be external, within the vagina, or deep in the pelvic region or abdomen.

Causes and symptoms

Many factors, of both physical and psychological natures, can affect sexual response and performance. Injuries, ailments, and drugs are among the physical influences; in addition, there is increasing evidence that chemicals and other environmental pollutants depress sexual function. As for psychological factors, sexual dysfunction may have roots in traumatic events such as rape or incest, guilt feelings, a poor self-image, depression, chronic fatigue, certain religious beliefs, or marital problems. Dysfunction is often associated with anxiety. If a man operates under the misconception that all sexual activity must lead to intercourse and to orgasm by his partner, and if the expectation is not met, he may consider the act a failure.

Men

With premature ejaculation, physical causes are rare, although the problem is sometimes linked to a neurological disorder, prostate infection, or urethritis. Possible psychological causes include anxiety (mainly performance anxiety), guilt feelings about sex, and ambivalence toward women. However, research has failed to show a direct link between premature ejaculation and anxiety. Rather, premature ejaculation seems more related to sexual inexperience in learning to modulate arousal.

When men experience painful intercourse, the cause is usually physical; an infection of the prostate, urethra, or testes, or an allergic reaction to spermicide or condoms. Painful erections may be caused by Peyronie's disease, fibrous plaques on the upper side of the penis that often produce a bend during erection. Cancer of the penis or testes and arthritis of the lower back can also cause pain.

Retrograde ejaculation occurs in men who have had prostate or urethral surgery, take medication that keeps the bladder open, or suffer from diabetes, a disease that can injure the nerves that normally close the bladder during ejaculation.

Erectile dysfunction is more likely than other dysfunctions to have a physical cause. Drugs, diabetes (the most common physical cause), Parkinson's disease, multiple sclerosis, and spinal cord lesions can all be causes of erectile dysfunction. When physical causes are ruled out, anxiety is the most likely psychological cause of erectile dysfunction.

Women

Dysfunctions of arousal and orgasm in women also may be physical or psychological in origin. Among the most common causes are day-to-day discord with one's partner and inadequate stimulation by the partner. Finally, sexual desire can wane as one ages, although this varies greatly from person to person.

Pain during intercourse can occur for any number of reasons, and location is sometimes a clue to the cause. Pain in the vaginal area may be due to infection, such as urethritis; also, vaginal tissues may become thinner and more sensitive during breast-feeding and after menopause. Deeper pain may have a pelvic source, such as endometriosis, pelvic adhesions, or uterine abnormalities. Pain can also have a psychological cause, such as fear of injury, guilt feelings about sex, fear of pregnancy or injury to the fetus during pregnancy, or recollection of a previous painful experience.

Vaginismus may be provoked by these psychological causes as well, or it may begin as a response to pain, and continue after the pain is gone. Both partners should understand that the vaginal contraction is an involuntary response, outside the woman's control.

Similarly, insufficient lubrication is involuntary, and may be part of a complex cycle. Low sexual response may lead to inadequate lubrication, which may lead to discomfort, and so on.

Diagnosis

In deciding when a sexual dysfunction is present, it is necessary to remember that while some people may be interested in sex at almost any time, others have low or seemingly nonexistent levels of sexual interest. Only when it is a source of personal or relationship distress, instead of voluntary choice, is it classified as a sexual dysfunction.

The first step in diagnosing a sexual dysfunction is usually discussing the problem with a doctor, who will need to ask further questions in an attempt to differentiate among the types of sexual dysfunction. The physician may also perform a physical exam of the genitals, and may order further medical tests, including measurement of hormone levels in the blood. Men may be referred to a specialist in diseases of the urinary and genital organs (urologist), and primary care physicians may refer women to a gynecologist.

Treatment

Treatments break down into two main kinds: behavioral psychotherapy and physical. Sex therapy, which is ideally provided by a member of the American Association of Sexual Educators, Counselors, and Therapists (AASECT), universally emphasizes correcting sexual misinformation, the importance of improved partner communication and honesty, anxiety reduction, sensual experience and pleasure, and interpersonal tolerance and acceptance. Sex therapists believe that many sexual disorders are rooted in learned patterns and values. These are termed psychogenic. An underlying assumption of sex therapy is that relatively short-term outpatient therapy can alleviate learned patterns, restrict symptoms, and allow a greater satisfaction with sexual experiences.

In some cases, a specific technique may be used during intercourse to correct a dysfunction. One of the most common is the "squeeze technique" to prevent premature ejaculation. When a man feels that an orgasm is imminent, he withdraws from his partner. Then, the man or his partner gently squeezes the head of the penis to halt the orgasm. After 20-30 seconds, the couple may resume intercourse. The couple may do this several times before the man proceeds to ejaculation.

In cases where significant sexual dysfunction is linked to a broader emotional problem, such as depression or substance abuse, intensive psychotherapy and/or pharmaceutical intervention may be appropriate.

In many cases, doctors may prescribe medications to treat an underlying physical cause or sexual dysfunction. Possible medical treatments include:

• clomipramine and fluoxetine for premature ejaculation
• papaverine and prostaglandin for erectile difficulties
• hormone replacement therapy for female dysfunctions
• Viagra, a pill approved in 1998 as a treatment for impotence

Alternative treatment

A variety of alternative therapies can be useful in the treatment of sexual dysfunction. Counseling or psychotherapy is highly recommended to address any emotional or mental components of the disorder. Botanical medicine, either western, Chinese, or ayurvedic, as well as nutritional supplementation, can help resolve biochemical causes of sexual dysfunction. Acupuncture and homeopathic treatment can be helpful by focusing on the energetic aspects of the disorder.

Some problems with sexual function are normal. For example, women starting a new or first relationship may feel sore or bruised after intercourse and find that an over-the-counter lubricant makes sex more pleasurable. Simple techniques, such as soaking in a warm bath, may relax a person before intercourse and improve the experience. Yoga and meditation provide needed mental and physical relaxation for several conditions, such as vaginismus. Relaxation therapy eases and relieves anxiety about dysfunction. Massage is extremely effective at reducing stress, especially if performed by the partner.

Prognosis

There is no single cure for sexual dysfunctions, but almost all can be controlled. Most people who have a sexual dysfunction fare well once they get into a treatment program. For example, a high percentage of men with premature ejaculation can be successfully treated in two to three months. Furthermore, the gains made in sex therapy tend to be long-lasting rather than short-lived.

Resources

ORGANIZATIONS

American Academy of Clinical Sexologists. 1929 18th St. NW, Suite 1166, Washington, DC 20009. (202) 462-2122.

American Association for Marriage and Family Therapy. 1133 15th St., NW Suite 300, Washington, DC 20005-2710. (202) 452-0109. 〈http://www.aamft.org〉.

KEY TERMS

Ejaculatory incompetence— The inability to ejaculate within the vagina.

Erectile dysfunction— Difficulty achieving or maintaining an erect penis.

Orgasmic disorder— The impairment of the ability to reach sexual climax.

Painful intercourse (dyspareunia)— Generally thought of as a female dysfunction but also affects males. Pain can occur anywhere.

Premature ejaculation— Rapid ejaculation before the person wishes it, usually in less than one to two minutes after beginning intercourse.

Retrograde ejaculation— A condition in which the semen spurts backward into the bladder.

Sexual arousal disorder— The inhibition of the general arousal aspect of sexual response.

Vaginismus— Muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration, not allowing for penetration.

Sexual dysfunction

The persistent or recurrent inability or lack of desire to perform sexually or engage in sexual activity.

Sexual dysfunction involves both somatic and psychic phenomena which contribute to an overall inability or lack of interest in performing sexually. In males, the condition is most associated with erectile dysfunction (ED), formerly referred to as male "impotence." Studies estimate that 10-20 million American males have some degree of ED, which clinically presents as a persistent inability to attain or maintain penile erection sufficient for sexual intercourse.

Female sexual dysfunction falls into four main categories: (1) a low libido or aversion to sex; (2) difficulty in attaining sexual arousal; (3) inability to experience or attain orgasm; and (4) pain during sexual intercourse. Research in this area indicates that as many as 4 in 10 American women experience some form of sexual dysfunction.

Assessment

As recently as the mid-twentieth century, sexual dysfunction was considered a psychological condition or disorder. The Kinsey Reports and Masters and Johnson's studies tended to isolate "performance anxiety" as the root of most sexual disorders. Later, in the 1970s, Helen Singer Kaplan impressed many colleagues and practitioners with her focus on enhancing sexual desire rather than sexual performance. Her biological approach to sexuality , i.e., equating sexual desire with physical appetite, was indeed helpful in sex therapy. Her approach was further justified by the fact that epidemiological studies during the 1980s showed a disproportionate incidence of treatment-resistant desire disorders in the sex-therapy clinical populations of the United States and Northern Europe. It is clear that the proliferation of erotic material available to the general public (pornographic publications, movies, videos, sex toys, Internet sites, etc.) from the 1970s to the 1990s paralleled the therapeutic effort to enhance sexual desire rather than treat sexual performance.

However, by the 1990s, human sexuality was emerging as a complex bio-psychosocial phenomenon. Contemporary studies view the great majority of sexual dysfunction cases as having somatic or organic rather than psychologic etiologies, or at least as being "comorbid" in origin. This is particularly true in male disorders, where up to 80 percent of ED is the result of physical conditions which interfere with nerves and blood vessels. Most commonly, vascular disease is blamed for decreased blood flow to the penis. Once a physical condition affects the ability to maintain penile erection, psychological distress and performance anxiety sets in, complicating the problem. This leads to avoidance of sexual activity and the male may become socially withdrawn or depressed.

It is generally believed that for women, more so than for men, sexual drives and satisfactions are more complex and organized around the entire sexual relationship or sexual partner. Moreover, collateral factors such as birth control, abortion , fear of sexually-transmitted diseases, and feminism have greatly affected womens' general approach to sexual activity and sexual behavior. Key psychological causes associated with sexual dysfunction range from past sexual abuse , to unsatisfactory emotional relationships with sexual partners, to poor self-assessment regarding body image or appearance. Another factor to be considered is that half of all women over the age of 60 are without a partner (even though they have forestalled menopause with hormone replacement therapy), and the "use it or lose it" thinking about sexual activity has proven to have some medical basis. (Research suggests that long periods of sexual inactivity may result in loss of elasticity to the vagina in females, and muscle atrophy in the penis of males.) All of these factors may put pressure on both sexes to "perform" or engage in sexual activity more often, even if sexual intercourse results in physical pain. Thus, "remedicalization" of dysfunction from the psychological to the medical arena may not always address the coexisting psychosocial aspects of the condition. Adjunct psychological therapy may be warranted.

Treatment

The recent emphasis on physical rather than psychological etiology in addressing sexual dysfunction correlates with the widespread success of prescription and non-prescription drug therapy for ED, such as that found in Viagra (sildenafil citrate), which effectively increases blood flow to the genitals. By 2000, doctors increasingly considered therapeutic doses of testosterone to both male and female patients, as testosterone is known to enhance sexual libido in both sexes.

For women, treatment of sexual dysfunction has been more varied because of the varying causes and presenting symptoms. During 1999, studies were commenced to test the efficacy of Viagra on females who complained of low sexual desire or inability to become sexually aroused. However, initial results published in May 2000 indicated that Viagra proved no more effective than a placebo in the female group. This finding may further support the belief that a synergy between the mind and body provides the best relief for female sexual dysfunction.

Notwithstanding, for both genders, several physical conditions greatly affect sexual functioning. These include diabetes, obesity , vascular disease, stress , fatigue, and untoward affects of medication. Menopausal and post-menopausal women may experience pain with sexual intercourse caused by decreased lubrication of mucous membranes and tissues. In all of the above, treatment of the underlying medical condition may render the sexual dysfunction as nonexistent or effectively relieved.

Some studies have shown that a decrease in dietary minerals, particularly zinc, may adversely affect libido. Such dietary deficits are related to pituitary hormone production of prolactin, which, at high levels, contributes to sexual dysfunction. It is therefore believed that some persons may be helped by increasing their dietary intake of red meats, dark meat poultry, seafood, leafy greens, and whole grains (all rich in zinc).

Finally, in treating sexual dysfunction, clients and couples are encouraged to refrain from thinking of sexual intercourse as the only or the ultimate goal of sexual activity. Therapists advise couples to frequently engage in non-coital sexual activity, including oral and manual stimulation, and to continue to provide such sexual pleasure even if the male loses his erection. Further, couples are encouraged to make sexual activity a priority and not an incidental happening when they retire at night. This is because testosterone levels are in fact lower in the evening hours, and both persons may be tired. Added to this is the fact that with age, it takes both sexes longer to become sexually stimulated. Partners should also try to incorporate sensual and affectional feelings into their activities, for obvious benefit.

Lauri R. Harding

Further Reading

"FDA Approves First Device to Aid Female Version of Impotence." Jet, (May 22, 2000): 33.

"It Takes Two: Coping With Erectile Dysfunction." Harvard Womens Health Watch, (March 2000): 2.

Dosa, Laszlo. "Careful History Essential in All Patients With ED." Urology Times, (May 2000): 19.

Kring, Brunhild. "Psychotherapy of Sexual Dysfunction." American Journal of Psychotherapy, (Winter 2000): 97.

Leland, John, Kalb, Claudia, and Nadine Joseph. "The Science of Women and Sex." Newsweek, (May 29, 2000): 48.

Miller, TA. "Diagnostic Evaluation of Erectile Dysfunction." American Family Physician, (January 2000): 95.

Henderson, C.W. "Lahey Clinic to Study Effects of Viagra on Women." Women's Health Weekly, (April 1, 2000): 27.