sexual disorders- hidden under the sheet , but written on the wall

From quite some time , I have been getting queries from my clients , regarding sexual disorders and the lack of information (authentic ones). It struck me only yesterday, that one of the easiest way to reach to as many people as possible , I could just start writing about it here (where else?).

what follows below , is a summarized account of everything and anything that one wanted to know about sexual disorders and shied away. Hope you enjoy reading it

P.S: forgive me for making it a little bland , but then nothing can match the actual fun, so I did not even try 😉

Sexual Disorders are quite common.  However there is lot of ignorance surrounding it. Surprisingly there is no quality platform to share and handle the concerns of people suffering from sexual disorders. I , in my humble being strive for complete mental health well-being of the society and that can’t be achieved without addressing sexual disorders.

To begin with, I would like to reemphasize the fact that Sexual problems are quite common. We may choose to think otherwise though. Statistically, these occur more frequently in:

  • Younger women and older men
  • People with less education

And perception of sexual problems is subjective

  • Not everyone experiencing a sexual problem is necessarily distressed or sexually dissatisfied

There are various types of specific sexual difficulties, however in reality, these overlap considerably

– Problems with desire and arousal often affect orgasm;

– Problems with orgasm easily affect desire and arousal

One way to classify is based on the phase

  • Desire-phase difficulties
  • Excitement/arousal-phase difficulties
  • Orgasm-phase difficulties

Now before we go further, we need to understand these different phases.

As a function of “normal” sexual responding:

  • Desire: Defined by an interest in being sexual and in having sexual relations by oneself or with an appropriate partner
  • Arousal: Refers to the physiological, cognitive & affective changes that serve to prepare an individual for sexual activity (e.g., penile tumescence(tightness) and erection, vaginal lubrication, expansion & swelling of vulva(female external genitalia)
  • Orgasm: Refers to climatic phase with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs:
    • Sense of ejaculatory inevitability in males followed by ejaculation
    • Contractions in the outer third of the vagina
  • Resolution: Refers to sense of muscular relaxation and general well-being; men are physiologically refractory(temporarily have no desire and arousal) while women may respond to further stimulation

Now let’s try to understand these sexual disorders with our basic understanding of the various phases of normal sexual response

  • Sexual desire disorders
    • Hypoactive Sexual Desire Disorder (HSDD); Male/Female
    • Sexual Aversion Disorder (SAD)
  • Sexual arousal disorders
    • Female Sexual Arousal Disorder (FSAD)
    • Male Erectile Disorder(E.D)
  • Orgasmic disorders
    • Female Orgasmic Disorder (Inhibited Female Orgasm)
    • Male Orgasmic Disorder (Inhibited Male Orgasm)
    • Premature Ejaculation
  • Sexual pain disorders
    • Dyspareunia (not due to General Medical condition)
    • Vaginismus- inability to relax female genitalia, leading to difficulty in penetration (not due to General Medical condition)
  • Sexual Dysfunction Due to General Medical Condition
  • Substance-Induced Sexual Dysfunction
    • With impaired desire
    • With impaired arousal
    • With impaired orgasm
    • With sexual pain
    • With onset during intoxication
  • Sexual Dysfunction Not Otherwise Specified (NOS)- broad category which leads to dysfunction and distress but does not fit into any of the specific categories.

Hypoactive Sexual Desire Disorder (HSDD)

  • Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity
  • Not better accounted for by any other psychological disorders (e.g., depression, anxiety) and not due to physiological effects of a substance (e.g., alcohol, prescription medications)

Sexual Aversion Disorder (SAD)

  • Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.

Clinical Presentation:

  • Negative/ indifferent affect (Mood and attitude)
    • Disparity in relationship member desire
    • Possess social expectations of “normal” sexual behavior
  • “Take it or leave it” attitude
  • Lack of attraction to partner
  • May be associated with trauma
  • Avoidance of sexual activity
    • When avoidance is accompanied by extreme aversion of genitals, SAD diagnoses may be more accurate

Arousal Disorders

Male Erectile Disorder

  • Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection

Female Sexual Arousal Disorder (FSAD)

  • Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate lubrication-swelling response of sexual excitement


Clinical Presentation:

  • Factors influencing Male Erectile Disorder
  • Physiological: partial or complete inability to attain, or maintain an erection sufficient for intromission and sexual activity
    • Some men report full erection potential during non-coital stimulation (e.g., masturbation, nocturnally during REM sleep)
  • Psychosocial:
    • Performance anxiety
    • Embarrassment
    • Depression
    • Negative affect in presence of erotic stimulation
    • Sensitive to feelings of demand
    • Underestimate erectile response
    • Result of chronic & acute stress

Clinical Presentation:

  • Factors influencing Female Sexual Arousal Disorder (FSAD)
  • Physiological:
    • lack of responsiveness to sexual stimulation (e.g., vaginal lubrication, swelling of vulva)
  • Psychosocial:
    • Anxiety, worry, fear
    • Depression
    • Low self esteem
    • Performance anxiety
    • Shame
    • Sexual abuse
    • Marital difficulties
    • Poor communication with partner
  • Negative affect toward sex during adolescence

Orgasmic Disorders in Men

Orgasmic Disorder (Inhibited Male Orgasm)

  • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration

Premature Ejaculation

  • Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors affecting duration of excitement phase, such as age, novelty of new partner and sexual situation and recent frequency of sexual activity
  • There is no minimum time limit varies from definition to definition with 1- 3 minutes of intra-vaginal ejaculatory latency time
  • Three core components:
    1. Short ejaculatory latency
    2. Lack of control over ejaculation
    3. Lack of sexual satisfaction
  • Perception of how long it takes for the “average” man to ejaculate varies between 7-14 minutes
    • Vary across countries, Germans, 7 mins; Americans, 14 mins



Female Orgasmic Disorder

  • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in type of stimulation that triggers orgasm.
  • Diagnosis based on clinician judgment that orgasmic capacity is less than reasonable given age, sexual experience, adequacy of sexual stimulation
  • Clients tend to compare themselves to unrealistic ideals, creating anxiety and perpetuating dysfunction
    • “Maybe I’m just dead down there”
  • Media influence of patient perceptions emphasizing importance of psychoeducation (e.g., myths of sexual encounter, male & female sexuality)

*Absence of orgasm during intercourse without direct clitoral stimulation is not uncommon in women

Clinical Presentation:

  • Factors Influencing Female Orgasmic Disorder
  • Physiological:
    • Inability to achieve orgasm
  • Psychosocial:
    • Sexual knowledge
    • Levels of sexual desire
    • Sexual fantasizing
    • Sexual attitude; confidence
    • Religious/cultural beliefs
    • Body image
    • Self-esteem


Arousal Disorders

  • Overall, prevalence range of ED is 10-20%
  • Presence of ED increases with age and poor medical status

Orgasmic Disorders

  • Prevalence of PE is approximately 30% across age groups (GSSAB)
    • Highest rates reported in Southeast Asia (30.5%) & lowest in Middle East (12.4%)
    • Found to be significantly correlated with Social Phobia


Other disorders

  • Prevalence of pain disorders 1%-21% in women
  • High rates of comorbidity with anxiety & depression
    • Loss of libido or decreased sexual desire has been reported in up to 72% of patients with unipolar depression; 77% with bipolar
  • General medical conditions associated with SD
    • Men: diabetes, cardiovascular disorder, hypertension, dyslipidemia, obesity, smoking, prostate disorders
    • Women: chronic illness, poor general health status, such as diabetes, breast cancer, lower urinary tract infection, surgical removal of ovaries, multiple sclerosis
  • Risk of SD is increased by smoking and excessive alcohol use
  • SD consistently reported in patients taking SSRIs
    • Estimates range from 10%-65%
  • Common factors of low sexual desire in men & women:
    • Boredom
    • Lack of physical attraction to partner
    • Negative or faulty attitudes
    • Dissatisfaction with partner sexual activity
    • History of sexual abuse
  • Common factors of arousal disorders in men & women:
    • Health status
    • Performance anxiety
    • Negative affect:
      • Suppression and expression of anger correlated with higher rates of ED
    • Organic theories of PE
      • Penile hypersensitivity – lower ejaculatory threshold, reached more rapidly
      • Hyperexcitability ejaculatory reflex – faster emission phase
      • Genetic predisposition
      • Risk factors
      • Age
        • Overall, SDs increase with age
        • PE decreases with age
        • Inverse relationship between age & distress brought on by SD
      • Health status
        • Genetic inheritance (Type 1 diabetes)
        • Hormone deficiency
        • Lifestyle (poor diet, low activity level)
      • Excessive substance use
      • Dyadic adjustment
      • Decreased sexual knowledge
      • CSA(Childhood sexual Abuse)

Predisposing factors (genetics) X Precipitating factors (coping with stressful life events) X Maintaining Factors (poor dyadic adjustment) = Diathesis Stress

                Myths of Sexuality

  • Myths of male sexuality
  1. A real man is not into sissy stuff like feelings and communicating.
  2. A real man performs in sex.
  3. Sex is centered on a hard penis and what is done with it.
  4. Real men do not have sexual problems
  5. Focusing more intensely on one’s erection is the best way to get an erection
  • Myths of female sexuality
  1. Sex is only for women under 30.
  2. All women have multiple orgasms.
  3. Pregnancy and delivery reduces women’s responsiveness.
  4. If a woman cannot have an orgasm quickly and easily, there is something wrong with her
  5. Feminine women do not initiate sex or become wild and unrestrained during sex.
  • Myths of Male & Female Sexuality(Common)
  1. We are liberated and comfortable with sex.
  2. All touching is sexual or should lead to sex.
  3. Sex is intercourse.
  4. Good sex requires orgasm.
  5. People in love should automatically know what their partners desire.
  6. Fantasizing about someone else means a person is not happy with what he/she has.

We are all susceptible to these false assumptions and seemingly silly generalizations about human sexuality. 

How to Enjoy and get the spark back (Take Home Tips)

  • Accepting this is as a problem and to seek help for is the first step.
  • You have to come over the shyness and stigmas associated with psycho-sexual issues and consider it just like any other medical or psychological problems you may be having.
  • Then plan to visit a professional (marriage therapist, sex therapist, behavior therapist or gynecologist) for proper guidance that would help you enjoy your sexual life.
  • Be aware and be wary of your own traits or external situations that may cause excessive stress and work on addressing it and also work on your coping skills if you anticipate a stressful situation to arise in the future.
  • Spend quality time with your partner which should be nonsexual intimate time to get to know your partner well and to develop a comfort level and confidence in each other which will help maintain the relationship. This will mostly lead to increase sexual interest in each other.
  • Talking about your sexual fantasies and where you would like to be touched would enhance your partners understanding about you and ask your partner about their preferences to make it a memorable experience. Talking sex is a part of foreplay so once you develop this comfort level it would lead to both adequate sexual arousal and increased sexual desires for each other
  • Have a lot of touch time with each other say holding hands or kissing or just giving each other massages to get comfortable with each other. This is very important for mutually satisfying sexual relationship.
  • Include a lot of humor around sexual acts and just have fun touching each other without having an intercourse till both of you become comfortable with each other.

Most importantly have a lot of respect and give each other time to open up and share any concerns regarding sex so as to work on them together rather than using these signs and symptoms against each other in an argument or to make fun of each other.

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