SEXUAL DISFUNCTIONS

INTRODUCTION
• Importance of sexuality in human life:

• Procreation
• Pleasure

▪ The diagnosis will determine whether the cause is physical or

psychological and lead to the appropriate treatment.

▪ They are clinical disorders that can be a bottleneck for an

individual to perform sexually or enjoy the act.

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Different sexual disorders
• Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder
• Female sexual interest/arousal disorder
• Genito-pelvic pain/penetration disorder
• Male hypoactive sexual desire disorder
• Premature (early) ejaculation
• Substance: medication-induced sexual dysfunction.

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 Delayed Ejaculation
• Also known as male orgasmic disorder. It is a sexual disorder characterized by a persistent delay or
inability to achieve orgasm and ejaculate during sexual activity, despite normal sexual stimulation
and desire.

• The delay in reaching orgasm and ejaculation can be take an extended period or require intense
stimulation. In some cases, ejaculation may not occur at all, resulting in a condition known as
anejaculation.

• Delayed ejaculation can occur in various contexts, including masturbation, partner sexual activity, or
both.

• The disorder can be lifelong, meaning it has been present since the onset of sexual activity, or
acquired, where it develops after a period of normal sexual functioning.

• It can also be situational, occurring in certain circumstances or with specific partners, or generalized,
where it is present in all sexual situations.
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Types of Delayed Ejaculation
• Acquired Delayed Ejaculation:
• Lifelong Delayed Ejaculation:
• It occurs when an individual
• A condition where an individual
develops the problem after a
has experienced the inability or
period of normal sexual
significant delay in ejaculation
since the beginning of their functioning.
sexual activity.
• It can be triggered by various
factors, such as psychological or
• It is a persistent and ongoing
relationship issues, medical
issue throughout their sexual life.
conditions, or medication use.
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cont.
• Situational Delayed • Generalized Delayed
Ejaculation: Ejaculation:

• Refers to a condition where an • Involves the inability to ejaculate

individual experiences delayed in all sexual situations, regardless
ejaculation only in specific of the partner or context.
situations or with certain partners.
For example, a person may be able
to ejaculate during masturbation but • It is not limited to specific
not during partnered sexual activity. circumstances and can be present
consistently across various sexual
activities.
• This type of delayed ejaculation is
often associated with psychological
or relational factors.
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Causes of Delayed Ejaculation
• There are multifactorial and can involve a combination of
psychological, biological, and interpersonal factors:
1. Substance Use
• Excessive alcohol consumption or substance abuse can have detrimental
effects on sexual functioning, including delayed ejaculation.

• Additionally, this can impair the central nervous system and disrupt the
normal physiological processes involved in sexual arousal and ejaculation

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Cont.
2. Psychological Factors
• Stress and Depression: High levels of stress and depressive
symptoms can impact sexual functioning and contribute to delayed
ejaculation.

• Stress can disrupt the body's natural response to sexual stimulation,

while depression can dampen overall sexual desire and pleasure.

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Cont.
• Performance Anxiety: this refers to the fear or worry about one's sexual performance, including
concerns about satisfying a partner or meeting certain expectations.

• In the context of delayed ejaculation, performance anxiety can create pressure and tension, leading to
difficulties in reaching orgasm and ejaculation.

• Excessive Self-Monitoring: Some individuals with delayed ejaculation may engage in excessive self-
monitoring during sexual activity. They may become overly focused on their own bodily sensations,
worrying about the timing of ejaculation or feeling pressured to perform. This hyper-awareness can
interfere with the natural progression of sexual arousal and inhibit ejaculation.

• Negative Beliefs about Sexuality:, often influenced by cultural or religious factors, can contribute to
delayed ejaculation. These beliefs may include viewing sexual pleasure as sinful, dirty, or shameful,
leading to guilt or anxiety that inhibits the ability to ejaculate.

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Cont.
3. Relationship Issues

• Lack of Emotional Intimacy: Emotional intimacy, including feelings of trust,

closeness, and vulnerability, is crucial for healthy sexual functioning. When this is
lacking in a relationship, it can affect sexual arousal and prevent the relaxation and
release necessary for ejaculation.

• Conflict and Unresolved Emotional Issues: Relationship conflicts, unresolved

emotional issues, or past traumatic experiences within a partnership can create
tension and inhibit sexual intimacy. Emotional distance or unresolved resentments
can contribute to delayed ejaculation by disrupting the necessary emotional and
relational connection required for sexual satisfaction.

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 Cont.
4. Medical Conditions and Medications

• Certain medical conditions, such as diabetes, neurological disorders, prostate problems, or

hormonal imbalances, can disrupt the normal functioning of the reproductive system and
interfere with ejaculation.

• Medication used to treat conditions such as depression (e.g., selective serotonin reuptake
inhibitors or SSRIs), antipsychotics, or blood pressure medications, may have side effects
that interfere with ejaculation.

• These medications can affect neurotransmitter levels or alter hormonal balance, leading to
delayed ejaculation as an unintended.

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Treatment
1. Therapy:
• Psychotherapy, sex therapy, or couples therapy, can be beneficial in
addressing psychological factors contributing to delayed ejaculation.
• This aims to identify and modify underlying beliefs, reduce performance
anxiety, improve communication, and enhance sexual intimacy.

2. Lifestyle Modifications:
• Managing stress levels, adopting healthy lifestyle habits, reducing
substance use, and improving overall well-being can positively impact
sexual functioning

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Cont.
3. Medication Evaluation:
• If delayed ejaculation is suspected to be a side effect of
medication, consulting with a healthcare professional to explore
alternative medications or adjust dosages may be beneficial.

4. Medical Interventions:
• In cases where an underlying medical condition is identified,
appropriate medical interventions, such as hormone replacement
therapy or surgical procedures, may be considered.

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 Erectile Disorder
• Commonly known as erectile dysfunction (ED)
• Refers to the persistent inability to attain or maintain an erection sufficient for satisfactory sexual
performance.

• Causes of Erectile Dysfunction

• Physical Factors: include cardiovascular diseases, diabetes, high blood pressure, obesity, hormonal
imbalances (e.g., low testosterone), and neurological disorders.

• Psychological Factors: can contribute to the development or worsening of erectile dysfunction.

Performance anxiety, stress, depression, relationship conflicts, and self-esteem issues can interfere with
sexual arousal and inhibit the ability to achieve or maintain an erection.

• Medications and Substance Use: Certain medications, such as antidepressants, antihypertensives, and
medications used to treat prostate conditions, can have side effects that contribute to erectile
dysfunction. Substance abuse, including excessive alcohol consumption and illicit drug use, can also
affect sexual functioning.
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 Treatment
• Lifestyle Changes: Adopting a healthy lifestyle can have a positive impact on erectile
function. Regular exercise, a balanced diet, weight management, and smoking cessation.

• Psychological Interventions: Therapy approaches, such as cognitive-behavioral therapy

(CBT), sex therapy, or couples therapy, can address psychological factors contributing to
erectile dysfunction.

• Medications: drugs such as phosphodiesterase type 5 (PDE5) inhibitors (e.g., Viagra, Cialis)
are commonly prescribed to enhance erectile function.

• These medications work by increasing blood flow to the penis, facilitating erections.
• However, they should be used under medical supervision.

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 Female Orgasmic Disorder
Definition: Difficulty of experiencing orgasm or pronounced reduced intensity of orgasmic
sensations.
Criteria
• Should persist for about 6 months minimum
• Should cause significant distress in the patient
• The following criteria should be present on almost or all occasions of sexual activities:

⚬ Severe delay, infrequency or absence of orgasm

⚬ Severe reduced intensity of orgasmic sensation

⚬ NOTE: The therapist should find out whether the situation is lifelong or
acquired; generalized or situational; never happened; severe, mild or moderate.

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 Prevalence and risk factors
• Women experiencing orgasmic disorder in premenopausal are 8 to 72%,
depending on factors such as age, cultural background and context, duration,
severity of symptoms.

• Risk and prognostic factors

• Temperamental: Anxiety and worries about pregnancy can cause the disorder.
• Environmental: It could be caused by relationship issues, physical health and mental
health. Sociocultural factors may also be the cause.

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 Risk and prognostic factors (cont.)
• Genetic and Physiological

• Medical conditions such as multiple sclerosis, pelvic nerve damage

from radical hysterectomy, and spinal cord injury, as well as
medication can influence orgasmic sensation. Women with
vulvovaginal atrophy are at risk of experiencing orgasmic problems. Note that
menopaused women are not consistently at risk.

• Sociocultural
• Depending on the culture and on the importance of orgasm for a woman, the issue
could be a taboo or discussed openly.
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 Female sexual interest/ Arousal disorder
• The disorder is characterized by a persistent or recurring lack of or reduction in sexual desire, fantasies,
and the inability to sustain or achieve sufficient sexual interest or arousal.

SYMPTOMS
• Reduction or absence of sexual interest or desire manifested as
• Reduced interest in sexual activity.
• Absence or reduced sexual thoughts or fantasies.
• Difficulty in maintaining sexual excitement during sexual activity in all or almost all sexual encounters.
• Decreased genital sensations or an absence of bodily reaction to sexual stimulation in all or almost all
sexual encounters
• The symptoms have to persist for a minimum period of six months in almost all or all sexual encounters.
• The symptoms cause the individual significant distress.
• The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a
severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to
the effects of a substance/ medication or another medical condition.
Sexual dysfunctions
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 RISK FACTORS
• PSYCHOLOGICAL • BIOLOGICAL

• Emotional or sexual abuse • Hormone changes such as those

• Childhood stressors that occur during menopause,
• Relationship dissatisfaction pregnancy
• Negative beliefs surrounding sex • Medical conditions like diabetes,
• Body image issues or body dysmorphia thyroid dysfunction and
• Low self-esteem cardiovascular disease.
• High levels of stress, anxiety and • May be genetic.
depression.
Sexual dysfunctions
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 Effects and Treatment
Effects
• Diminished sense of self-worth
• Sexual confidence
• Emotional distress
• Strain in intimate relationships
• Feelings of frustration and guilt.
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Treatment
• Psychological problems that contribute to
the disorder with the aid of therapy,
including sex therapy, individual or
couples counseling, cognitive-behavioral
therapy (CBT)
• Women can incorporate lifestyle changes
like practicing stress management and
healthy habits like eating a balanced diet,
exercising and getting sufficient sleep,
which can improve overall sexual health.
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 Genito- Pelvic pain/ Penetration Disorder
• It is characterized by severe discomfort during vaginal penetration, which makes it
difficult to engage in sexual activity and other pelvic functions.
• The disorder typically affects women, but it can also affect transgender and non-
binary people.

Major symptoms include:

• Recurrent and persistent difficulties with one or more of the following:
• Vaginal penetration during intercourse.
• Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts
(vaginismus and dyspareunia).
• Marked anxiety or fear connected to sexual activity

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 Cont.
• Marked tensing or tightening of the pelvic floor muscles during attempted
vaginal penetration.
• Minimum duration of approximately 6 months.
• Significant distress in the individual.
• The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of a severe relationship distress (e.g., partner
violence) or other significant stressors and is not attributable to the effects
of a substance/ medication or another medical condition

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 Risk factors
Biological Psychological

• Conditions linked to GPPPD • Anxiety

include:
• Uterine fibroids
• Endometriosis
• Pelvic Inflammatory Disease
• Interstitial Cystitis.
• Marital problems
• Past traumatic events; sexual
abuse

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 Effects of genito-pelvic pain/penetration disorder

• Difficult for the women to participate in sexual relationships

• Low self-esteem
• Anxiety
• Frustration
• Breakdown in communication between partners and a sense of
loneliness as a result

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 Treatment options
• Fortunately, genito-pelvic/penetration disorder is a treatable condition, and a
number of methods can assist people in regaining control over their sexual
health and general wellbeing.

• The treatment approach could combine behavioral interventions,

psychotherapy, and physical therapies.

• Physical treatments for pain can include vaginal dilators, topical drugs, and
pelvic floor muscle relaxing methods.

• Cognitive-behavioral therapy (CBT), in particular, can assist in addressing

underlying psychological problems and helping patients establish coping
mechanisms

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 Male Hypoactive Sexual Desire Disorder

• Defined as persistent or recurrent deficient or absent sexual fantasies and desire for
sexual activity. Symptoms must have persisted for a minimum duration of
approximately 6 months.

• This disorder is sometimes associated with erectile and/or ejaculatory concerns. For
example, difficulties obtaining an erection may lead a man to lose interest in sexual
activity.

• Men with MSHDD often report that they no longer initiate sexual activity and that they
are minimally receptive to a partner’s attempt to initiate. Sexual activities such as
masturbation may sometimes occur even in the presence of low sexual desire.

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 Its causes
• Age
• Drugs side effects
• Conflicts with one’s partner.
• Sexual performance insecurities
• stress for instance due to loss of a job
• Religious/cultural beliefs that discourage sexual activities.

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Its assessment…
• Factors to considered during assessment and diagnosis of male hypoactive
sexual desire disorder include:

• partner factors for instance partner’s sexual problems, partner’s health status,
relationship factors (poor communication, discrepancies in desire for sexual activity),
individual vulnerability factors (poor body image, history of sexual or emotional
abuse), psychiatric comorbidity (depression, anxiety), or stressors ( job loss,
bereavement), cultural/religious factors ( inhibitions related to prohibitions against
sexual activity; attitudes toward sexuality) and medical factors relevant to prognosis,
course, or treatment.
• Each of these factors may contribute differently to the presenting symptoms of different
men with this disorder.

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 Risk Factors according to the DSM-5

• Temperamental. Mood and anxiety symptoms appear to be strong predictors of low

desire in men. Men with a history of psychiatric symptoms may have loss of desire,
compared to those without such a history. A man’s feelings about himself, his perception
of his partner’s sexual desire toward him, feelings of being emotionally connected to
one’s partner may negatively or positively affect sexual desire. Beliefs about sexuality
for example restrictive sexual attitudes and conservative beliefs can be associated with
low sexual desire in men.

• Environmental: This may include alcohol, living in a long-term relationship, sexual

boredom use may increase the occurrence of low desire

• Genetics: Endocrine disorders such as hyperprolactinemia and hypogonadism

significantly affect sexual desire in men

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 Treatment
• Psychological interventions, lifestyle changes, and medical approaches.
• Counseling/therapy by working with a sex therapist or psychologist can help identify
underlying issues, improve communication, and address any psychological factors
contributing to the lack of desire.
• Relationship counseling: Involving a partner in therapy sessions can be beneficial to
address any relationship issues or conflicts that may be affecting sexual desire.
• Lifestyle changes: Adopting a healthy lifestyle, managing stress, improving sleep,
and addressing any underlying medical conditions can contribute to overall well-
being and potentially improve sexual desire.
• Medications: In some cases, medications such as testosterone therapy or off-label use
of certain medications (e.g., bupropion, buspirone) may be prescribed to address
hormonal imbalances or increase sexual desire. However, these medications should
be prescribed and monitored by a healthcare professional
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 PREMATURE EJACULATION
- Premature ejaculation (PE) is a common sexual dysfunction that
affects many men worldwide.

- It is characterized by the recurrent ejaculation occurring shortly

after sexual penetration, causing distress or interpersonal
difficulties.

- This condition can have significant psychological and emotional

consequences, impacting both the individual and their partner

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 Causes
• One of the key factors contributing to premature ejaculation is the interplay
between biological and psychological factors.
• Biological factors such as abnormal hormone levels, neurotransmitter imbalances,
and genetic predisposition.
• For example, low levels of serotonin, a neurotransmitter involved in mood
regulation, have been associated with premature ejaculation (Serefoglu et al.,
2014). Additionally, certain medical conditions like prostate problems or thyroid
disorders may increase the chances.
• Performance anxiety, relationship problems, and stress are common psychological
factors that can affect sexual functioning.
• The fear of not being able to satisfy one's partner or the pressure to perform well
sexually can lead to heightened arousal and rapid ejaculation.
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 Its Impact
• Men with PE often experience feelings of inadequacy, frustration, and decreased
self-esteem.
• These negative emotions can lead to anxiety and depression, further exacerbating
the problem. Relationship difficulties may arise, as partners may feel dissatisfied
or resentful due to the lack of sexual fulfillment.

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 Treatment
• Behavioral techniques can help individuals gain better control over their
ejaculation.

• The start-stop technique involves pausing sexual stimulation when

approaching climax and then resuming after the sensation subsides .

• The squeeze technique involves applying pressure to the base of the penis to
decrease arousal and delay ejaculation .

• Counseling and therapy can also play a significant role in managing

premature ejaculation.

Sexual dysfunctions
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 Substance/ medicine induced sexual dysfunction

CRITERIA
• This condition involves experiencing difficulties with sexual arousal, desire, or performance due to
substances and medications.
• A. A clinically significant disturbance in sexual function is predominant in the clinical picture.

• B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication or

withdrawal or after exposure to or withdrawal from a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

• C. The disturbance is not better explained by a sexual dysfunction that is not substance/medication-
induced. Such evidence of an independent sexual dysfunction could include the following:

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 Cont.
• The symptoms precede the onset of the substance/medication use;
• the symptoms persist for a substantial period of time (e.g., about 1
month) after the cessation of acute withdrawal or severe intoxication;
• or there is other evidence suggesting the existence of an independent
non-substance/medication-induced sexual dysfunction (e.g., a history of
recurrent non-substance/medication-related episodes).

• D. The disturbance does not occur exclusively during the course of a

delirium.

• E. The disturbance causes clinically significant distress in the individual.

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 Associated Features
• Sexual dysfunctions can occur in Medicines
association with intoxication with the • Antidepressants (e.g., escitalopram,
following classes of substances and sertraline, fluoxetine, venlafaxine)
medicines. • Antipsychotics (e.g., aripiprazole,
Substances risperidone, paliperidone, haloperidol)
• alcohol • Benzodiazepines (e.g., lorazepam,
clonazepam, diazepam)
• opioids • Statins and fibrates, or medications used for
• sedatives, hypnotics, or anxiolytics high cholesterol (e.g., fenofibrate,
atorvastatin, simvastatin)
• stimulants (including cocaine)
• Blood pressure medications (e.g., metoprolol,
• Other (or unknown) substances propranolol, chlorthalidone, clonidine)
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 Prevalence
• The prevalence and the incidence of substance/medication-induced sexual dysfunction
are unclear, likely because of underreporting of treatment-emergent sexual side effects.
• Approximately 25%–80% of individuals taking monoamine oxidase inhibitors,
tricyclic antidepressants, serotonergic antidepressants, and combined serotonergic
adrenergic antidepressants report sexual side effects.
• Approximately 50% of individuals taking antipsychotic medications will experience
adverse sexual side effects, including problems with sexual desire, erection,
lubrication, ejaculation, or orgasm. The incidence of these side effects among different
antipsychotic agents is unclear.
• The prevalence of sexual problems appears related to chronic drug abuse and appears
higher in individuals who abuse heroin (approximately 60%–70%) than in individuals
who abuse amphetamine-type substances or 3,4-
methylenedioxymethamphetamine(i.e., MDMA, ecstasy)
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 Development and Course
• The onset of antidepressant-induced sexual dysfunction may be as early as 8 days after the
agent is first taken.
• Approximately 30% of individuals with mild to moderate orgasm delay will experience
spontaneous remission of the dysfunction within 6 months.
• In some cases, serotonin reuptake inhibitor–induced sexual dysfunction may persist after the
agent is discontinued.
• The time to onset of sexual dysfunction after initiation of antipsychotic drugs or drugs of
abuse is unknown.
• It is probable that the adverse effects of nicotine and alcohol may not appear until after years
of use.
• Premature (early) ejaculation can sometimes occur after cessation of opioid use.
• There is some evidence that disturbances in sexual function related to substance/medication
use increase with age.
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 Cont.
• Culture-Related Diagnostic Issues
There may be an interaction among cultural factors, the influence of medications on sexual functioning,
and the response of the individual to those changes.

• Sex- and Gender-Related Diagnostic Issues

Some gender differences in sexual side effects from substances and medications may exist, such that men
may more often report impairments with desire and orgasm following antidepressant use, and women
may more often report difficulties with sexual arousal.

• Functional Consequences of Substance/Medication-Induced Sexual Dysfunction

Medication-induced sexual dysfunction may result in medication noncompliance, such as stopping
medications or using them irregularly, which could contribute to the lack of efficacy for antidepressants.

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 Treatment

Lifestyle changes
• Lose weight if you are overweight
• Cut back on drinking alcohol
• Stop using tobacco, marijuana, and/or other illicit substances
• Increase exercise
• Reduce stress or anxiety (e.g., deep breathing, meditating, yoga)

Psychotherapy: CBT or Couples therapy can provide support and solutions

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 Cont.
Medication
• Medication-induced sexual side effects are not permanent. There are many different
options for treating this, however, DO NOT STOP your medication without working
with your primary care provider. Some possible treatment options that your provider
may consider are:

• Giving your body time to adjust to the new medication or dose

• Lowering the medication dose
• Switching medications to one that has less risks of causing sexual side effects
• Starting a new medication to help fix the sexual side effects
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THANK
YOU!