• Disturbance in one or more aspects of the sexual response cycle.
  
• Cause is often multifactorial, associated with medical conditions, therapies, and lifestyle.

General Considerations

Sexual dysfunction is a disturbance in one or more of the aspects of the sexual response cycle. It is a common problem that can result from communication difficulties, misunderstandings, and side effects of medical or surgical treatment, as well as underlying health problems. Because sexual difficulties often occur as a response to stress, fatigue, or interpersonal difficulties, addressing sexual health requires an expanded view of sexuality that emphasizes the importance of understanding individuals within the context of their lives and defining sexual health across physical, intellectual, emotional, interpersonal, environmental, cultural, and spiritual aspects of their lives and their sexual orientation. Family physicians are ideally situated to address the sexual health needs of both men and women, and it is likely that the therapeutic options for addressing these needs will continue to expand over the next decade.

Sexual dysfunction is extremely common. A survey of young to middle-aged adults found that 31% of men and 43% of women in the general population reported some type and degree of sexual dysfunction. The prevalence of sexual concerns and difficulties is even higher in clinical populations.

Recognition of sexual dysfunction is important whether specific treatment is available or desired. Sexual dysfunction may be the initial manifestation of significant underlying disease or provide a marker for disease progression and severity. It should be a consideration when managing a number of chronic medical conditions.

Sexual dysfunction is positively correlated with low physical and emotional relationship satisfaction, as well as low general happiness. Despite this, only 10% of men and 20% of women with sexual dysfunction seek medical care for their sexual difficulties. The key to the identification of sexual function disorders is for the provider to inquire about their presence. A discussion of sexual health can be initiated in a variety of ways. Educational material or self-administered screening forms, placed in the waiting area or the examination rooms, send the message that sexual health is an important topic that is discussed in the clinician’s office. Table 18-1 lists several questionnaires that can be incorporated into self-administered patient surveys for office practices.

Sexual history can be included as part of the social history, as part of the review of systems under genitourinary systems, or in whatever manner seems most appropriate to the clinician. There are many other opportunities to bring a discussion of sexual health into the clinical encounter, as outlined in Table 18-2. Clinician anxiety may be reduced by asking the patient for permission prior to taking the sexual history.

Once the history confirms the existence of sexual difficulties, obtain as clear a description as possible of the following elements: the aspect of the sexual response cycle most involved, the onset, the progression, and any associated medical problems. Asking the patient what he or she believes to be the cause can help the clinician identify possible relationship, health, and iatrogenic etiologies. Asking the patient what he or she has tried to do to resolve the problems and clarifying the patient’s expectations for resolution can help facilitate an appropriate therapeutic approach. Involving the partner in both identification and subsequent management can be very valuable.

Sexual dysfunction is associated with many factors, including medical conditions and therapies and lifestyle choices (Table 18-3). In some instances the underlying medical condition may be the cause of the sexual dysfunction (eg, arterial vascular disease causing erectile dysfunction). In other instances the sexual dysfunction contributes to the associated condition (eg, erectile dysfunction leads to loss of self-esteem and depression). Sexual difficulties can begin with one aspect of the sexual response cycle and subsequently affect other aspects; for example, arousal difficulties can lead to depression, which can then negatively affect sexual interest.

General Considerations

Difficulties with sexual desire are the most common sexual concern. Over 33% of women and 16% of men in the general population report experiencing an extended period of lack of sexual interest. Other investigators have reported prevalence rates as high as 87% in specific populations. Women who were younger, separated, black, less educated, and of lower socioeconomic status reported the highest rates. Among men, the same demographics as well as increasing age were associated with the highest rates.

Classification

Decrease in sexual desire can be related to decrease or loss of interest in or an aversion to sexual interaction with self or others, or both. It can be lifelong (primary) or acquired (secondary), generalized or situational in occurrence. Sexual aversion is characterized by persistent or extreme aversion to, and avoidance of, sexual activity. Separating these difficulties can be difficult or impossible. For example, a patient who has experienced sexual trauma may have difficulties with subsequent partners and ultimately develop an aversion to sexual activity.

A common situation in clinical practice is discrepancy in sexual desire within a partnership, in which partners differ in their level of sexual desire. Although most couples negotiate a workable solution, in some instances it may be significant enough to cause relationship dissatisfaction. It can also be a marker for extrarelationship affairs or domestic violence.

Pathogenesis

Changes in or a loss of sexual desire can be the result of biological, psychological, or social and interpersonal factors. Numerous medical conditions directly or indirectly affect sexual desire (Table 18-4). Illnesses and medications that decrease relative androgen levels, increase the level of sex hormone–binding globulin, or interfere with endocrine and neurotransmitter functioning can negatively affect desire. Examples include exogenous hormones (eg, estrogens and progesterones), diabetes, and depression, as well as erectile difficulties due to arterial vascular disease or dyspareunia due to estrogen deficiency–induced atrophic vaginitis. In both men and women, sexual desire is linked to levels of androgens, testosterone, and dehydroepiandrosterone (DHEA). In men, testosterone levels begin to decline in the fifth decade and continue to do so steadily throughout later life. For both genders, DHEA levels begin to decline in the thirties, decrease steadily thereafter, and are quite low by age 60.

Decreased sexual desire is a common manifestation of some psychiatric conditions, particularly affective disorders. Several medications can negatively affect desire and the sexual response cycle (Table 18-5). The agents most commonly associated with these changes are psychoactive drugs, particularly antidepressants, and medications with antiandrogen effects. Many psychosocial issues affect sexual desire. Factors as widely varied as religious beliefs, primary sexual interest in individuals outside of the main relationship, specific sexual phobias or aversions, fear of pregnancy, lack of attraction to partner, and poor sexual skills in the partner can all diminish sexual desire.

Clinical Findings

Symptoms and Signs