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Sexual dysfunction: What you need to know

Key learning points

 - Sexual dysfunction and sexual problems are very common, but only about 20% seek help

 - Most sexual dysfunction is eminently curable

- Most medical and psychiatric conditions and most medications can cause sexual problems

Sexual dysfunction is one of the most common psychiatric disorders, but often remains ignored in clinical assessment and management. The reasons include both embarrassment and ignorance. Patients may not wish to talk about their problems or may be ignorant of the underlying causes. It is becoming less stigmatised and increasingly people are beginning to talk about their problems and seek help.
The classification of sexual dysfunction in both DSM-51 and ICD-102 follows desire, arousal and orgasm stage of the sexual act. Thus among men it would be decreased or increased desire, erectile dysfunction, premature or retarded ejaculation; and, in women, it would be increased or decreased desire, failure of genital response and anorgasmia or orgasmic dysfunction. Pain while having sexual intercourse both in men and women, and vaginismus in women, are other disorders. Sexual dysfunction can be primary or secondary. They may also be substance-induced or secondary to physical illness. These do not include gender identity disorders, and sexual dysfunction must be differentiated from paraphilias.
In psychiatric conditions, the common aetiological model is biopsychosocial. Biological causes of sexual dysfunction will include medical factors such as endocrinal abnormalities, diabetes, hypertension, cardiovascular, gynaecological and urological disorders. However, almost all medications, whether these are anti-diabetic, anti-hypertensive, antidepressants, anti-psychotics, or diuretics, can cause sexual problems. Social causation is related to interpersonal problems such as relationship difficulties, extra-marital relationships, matters related to fidelity, religious or sexual conflict. Psychological causes contributing to sexual dysfunction include past history of sexual abuse, trauma, stress related to work or poor relationship, clinical depression, substance abuse including alcohol, schizophrenia or low self-esteem. Sexual functioning is related to sexual fantasy, sexual orientation and actual act or behaviour. Thus an individual may have a heterosexual orientation and heterosexual fantasies, but may indulge in same sex acts due to lack of opportunities relating to the opposite sex.
There are also cultural factors that may be at play. Bullough3 divides cultures into sex positive (where sex is seen as a pleasurable and fun activity) or sex negative (where sex is used purely for procreative purposes). Cultures mould attitudes to sexual activity and sex education. Cultures can precipitate and perpetuate symptoms.
Prevalence rates vary according to questions asked and the sample collection. However, rates of sexual dysfunction vary from about a quarter to half of the population. Robins et al4 noted that 24% of the population in the USA experienced sexual dysfunction at some point in their lifetime. Laumann et al5 reported sexual dysfunction in 31% of men and 43% of women in their sample. Not surprisingly, they found that higher rates were due to ageing and poor physical health. The same group6 showed a prevalence rate of 28% of men reporting dysfunction and 38% of women doing so. From 27,500 participants in 29 countries, they found that half the participants had at least one sexual problem but only about 20% had sought help.
Shifren et al7 found that 43% of female participants in their 
study had at least one sexual problem. There are cultural differences.8
History taking
In primary care settings, the aim is to understand the type of dysfunction, assess whether it is organic or non-organic and to ascertain both the motivation and immediate cause and then point the individual or the couple to specialist teams if needed. Broad headings for history taking are illustrated in Box 1. The assessment may start with the individual in exploring the presence or absence of symptoms and then involve the couple in understanding the exact nature and extent of the problem.
Managing sexual dysfunctions
Patients with sexual dysfunction are likely to be highly motivated. In addition, the cure rate of sexual dysfunction disorders remains high, provided early interventions can be put in place. Physical examination may be needed if the patient has a co-morbid physical or psychiatric condition, they are over the age of 50, experience pain during sexual activity, has a history of abnormal puberty or the patient feels that they have something physically wrong.
Depending upon the causation, appropriate referral can be made to the specialist teams. Patients may often experience performance anxiety and their sexual knowledge may be poor. Often giving them adequate and accurate information and teaching them how to relax can help. Specific interventions depend upon the specific sexual disorder, and exercises can be recommended.
Depending upon the problem, the degree and motivation, interventions can be set in place; these would include both cognitive behaviour therapy or behaviour therapy. Physical treatments may include altering medication wherever appropriate.
In primary care settings, basic information and basic interventions can be provided. Assessment tools may be used to gather base line information and reach a diagnosis. These are further listed by Bhugra and Colombini.9 Working with gay, lesbian, bisexual or transgender individuals or people from diverse cultures can bring specific issues to the fore. Assessing, diagnosing and managing people with sexual dysfunction can be extremely satisfying, as the cure rates are quite high. Nurses in primary care settings are well placed to assess, but also need to be aware of their own limitations and specific intervention options. Health professionals may feel uncomfortable with asking intimate questions, in which case they may consider transferring the patient's care.
Sexual dysfunctions may exist in individuals without causing any distress, so therefore may not be an issue for the patient, which may reflect variation in prevalence rates. These may be caused by any number of physical, social or psychological factors. Their treatment is simple and success rates can be gratifying. Primary care nurses are ideally placed to assess and explore these issues so that appropriate interventions can be put in place.
1. APA. Diagnostic and Statistical Manual 5. Arlington, VA: American Psychiatric Association; 2013.
2. WHO. The ICD-10 Classifications of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO; 1992.
3. Bullough V. Sexual Variance in Society and History. Buffalo, NY; University of Buffalo Press; 1976.
4. Robins LN, Helzer JE, Weissman MM et al. Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry 1984;41:949-958.
5. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999;281:537-544.
6. Laumann EO, Nicolosi A, Glasser DB et al. Sexual problems among men and women aged 40-80 years. International Journal of Impotence Research 2005;17:39-57.
7. Shifren JL, Monz BU, Russo PA et al. Sexual problems and distress in US women: prevalence and correlates. Obstetrics and Gynaecology 2008;112:970-978.
8. Bhavsar V, Bhugra D. Cultural factors and sexual dysfunction in clinical practice. Advances in Psychiatric Treatment 2013;19:144-152.
9. Bhugra D, Colombini G. Sexual dysfunction: classification and assessment. Advances in Psychaitric Treatment 2013;19:48-55.