Normal sexuality is difficult to define. But it is easier to define abnormal sexuality. Sexual behavior is diverse and determined by a complex interaction of factors. It is affected by relationships with others, by life circumstances, and by the culture in which a person lives. Humans, like other animals, have always been interested in sexuality and have depicted almost every form of sexual behavior.
Sexual dysfunctions are cognitive, affective, and / or behavioral problems that prevent an individual or couple from engaging in and / or enjoying satisfactory intercourse and orgasm. Sexual dysfunctions are also seen as disturbances in one more of the sexual response cycle's phases, or pain associated with arousal or intercourse. Sexual dysfunction refers to a person's inability to participate in a sexual relationship as he or she would wish.
Classification: (DSM IV TR)
1) sexual desire disorder
- hypoactive sexual desire disorder
- sexual aversion disorder
2) sexual arousal disorder
- female sexual arousal disorder
- male erectile disorder
3) Orgasmic disorder
- Female orgasmic disorder
- Male orgasmic disorderPremature ejaculation
4) Sexual pain disorder
5) sexual dysfunction due to a general medical condition
ICD 10 Classification:
- Lack or loss of sexual desire
- Sexual aversion and lack of sexual enjoyment
- Failure of genital response
- Orgasmic dysfunction
- Premature ejaculation
- Non orgaanic vaginismus
- Non organic dyspareunia
- Excessive sexual drive
- Other sexual dysfunction
- Unspecified sexual dysfunction
I. sexual desire disorders :
a)Hypoactive sexual desire disorder
It is characterized by a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. The complaint is more common in women than in men.
b) Sexual aversion disorder :
This disorder is characterized by a persistent or recurrent extreme aversion to, and avoidance of, all genital sexual contact with a sexual partner. Individuals displaying hypoactive desire are often neutral or indifferent toward sexual interaction, but sexual aversion implies anxiety, fear or disgust in sexual situations.
II. Sexual arousal disorder
a) Female sexual arousal disorder:
It is characterized by the persistent or recurrent partial or complete failure to attain or maintain the lubrication swelling response of sexual excitement until the completion of the sexual act.
b) Male erectile disorder :
It is characterized by the recurrent and persistent, partial or complete failure to attain or maintain an erection to perform the sex act. Primary erectile dysfunction refers to cases in which the man has never been able to have intercourse. Secondary erectile dysfunction refers to cases in which the man has difficulty getting or maintaining an erection but has been able to have vaginal or anal intercourse at least once.
III. Orgasmic disorders:
a) Female orgasmic disorder:
It is characterized by persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase In short, a women's inability to achieve organism by masturbation or coitus
Primary orgasmic dysfunction: Never experienced orgasm by any kind of stimulation. Secondary orgasmic dysfunction: Experienced at least one orgasm, regardless of the means of stimulation, but no longer does so. Sometimes referred to as an anorgasmia.
b) Male orgasmic disorder :
It is characterized by persistent or recurrent delay in, or absence of orgasm following a normal sexual excitement phase.Sometimes called retarded ejaculation A man with lifelong orgasmic disorder was never been able to ejaculate during coitus.
Primary disorder: History of never having experienced an orgasm.
Secondary disorder: Occasional problems in ejaculation.
c) Premature ejaculation :
It is described as persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
35-40% of men treated for sexual disorders have premature ejaculation as the chief complaints.
IV. Sexual pain disorders
a) Dyspareunia: It is recurrent or persistent genital pain occurring in either men or women before, during, or after intercourse. More common in women It is related to, and often coincides with, vaginismus. In women, the pain may be felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis. In men, the pain is felt in the penis
b) vaginismus: it is an involuntary constriction of the outer one third of the vagina that prevents penile insertion and intercourse.
V. Sexual dysfunction due to a general medical condition and substance induced sexual dysfunction
Types of medical conditions that are associated with sexual dysfunction include; Neurological (multiple sclerosis, neuropathy) Endocrine (diabetes mellitus, thyroid dysfunctions) Vascular (atherosclerosis) Genitourinary (testicular disease, urethral or vaginal infections). Substances (alcohol, amphetamines, cocaine, opioids, sedatives, hypnotics, anxiolytics, antidepressants, antipsychotics and antihypertensive).
ETIOLOGY: (Hgam, 1978).
1) Psychological causes:
Stress or anxiety from work or family responsibilities Concern about sexual performance Conflicts in the relationship with partner. Depression / anxiety Unresolved sexual orientation issues. Previous traumatic sexual or physical experience Body image and self esteem problems.
2) Physical causes :
Diabetes, hearts disease, liver disease, kidney disease, pelvic surgery, pelvic injury or trauma, neurological disorders, medication side effects, hormonal changes, alcohol or drug abuse, fatigue.
3) Interpersonal relationship :
Partner performance and technique Lack of partner Relationship quality and conflict. Lack of privacy
4) Socio cultural :
- Inadequate education
- Conflict with religious, personal or family values.
- Societal taboos.
Basic principles of direct treatment of sexual dysfunction (Lopiccolo, 1978)
mutual responsibility information and education attitude change
eliminating performance anxiety increasing communication and effectiveness of sexual technique
changing destructive life styles and sex roles
- prescribing changes in behavior
1) Biological treatment
Sildenafil, oral phentolamine, alprostadil transurethral alprostadil (erectile disorder) Intravenous methohexital sodium has been used in desensitization therapy. Antianxiety agents. Bromocriptive, a dopamine agonist, may improve sexual function impaired by hyperprolocatinemia. Dopaminergic agents have been reported to increase libido and improve sex function.
b) Hormone therapy
androgens increase the sex drive. Antiandrogens have been used to treat compulsive sexual behavior in men. Antiestrogens increases libido
c) Mechanical treatment approaches
These are mechanical devices that patients without vascular diseases can use to obtain erections. The blood drawn in to the penis following the creation of the vacuum is kept there by a ring placed around the base of the penis.
EROS: A device developed to create clitoral erections in women. It is a small suction cup that fits over the clitoral region and drawn blood in to the clitoris.
d) Surgical treatment:
Male prostheses Vascular surgery Hymenectomy for dyspareunia Vaginoplasty and release of vaginal adhesions
2) Dual sex therapy: (William masters & Virginia Johnson)
Treatment is based on a concept that the couple must be treated when a dysfunctional person is in a relationship Both are involved in a sexually distressing situation, both must participate in the therapy program. The keystone of the program is the round table session in which a male and female therapy team clarifies, discusses, and works through problems with the couple. Treatment is short term and behaviorally oriented Therapist suggests specific sexual activities. Initially, intercourse is inter directed and the couple learn to give and receive bodily pleasure without the pressure of performance or penetration. The aim of the therapy is to establish an effective communication within the marital unit. Psychotherapy sessions follow each new exercise period, and problems and satisfactions are discussed.
Specific techniques of exercises:
Vaginismus: Woman is advised to dilate her vaginal opening with her fingers or with dilators Premature ejaculation :
a) sequeeze technique is used to raise the threshold of penile excitability. In this exercise the man or the woman stimulates the erect penis until the earliest sensations of impending ejaculation are felt. At this point, the woman forcefully sequeezes the coronal ridge of the gland, the erection is diminished, and ejaculation is inhibited.
b) stop start technique in which the woman stops all stimulation of the penis when the man first senses an impending ejaculation
Erectile disorder: sometimes told to masturbate to prove that full erection and ejaculation are possible. ·
Lifelong female orgasmic disorder: women is directed to masturbate, sometimes using a vibrator.
Focus specifically on the anxiety producing situation - that is, the sexual interaction that results in dysfunction.
4) Behavior therapy
Behavior therapists assume that sexual dysfunction is learned maladaptive behavior, which causes patients to be fearful of sexual interaction. Hierarchy of anxiety provoking situations Ranging from least threatening to most threatening Systematic desensitization Assertiveness training.
5) Group therapy
Used to examine both intra psychic and interpersonal problems in patients with sexual disorders. Groups can be organized in several ways.
6) Analytically oriented sex therapy
The sex therapy is conducted over a longer period than usual, which allows learning or relearning of sexual satisfaction under the realities of patient's day-to-day lives.
1) Sexual dysfunction
Assess client's sexual history and previous level of satisfaction in sexual relationship. Assess client's perception of the problem Assess client's level of energy Review medication regimen, observe for side effects Provide information regarding sexuality and sexual functioning Refer for additional counseling or sex therapy if required.
2) Ineffective sexuality patterns.
- Take sexual history, noting client's expression of areas of dissatisfaction with sexual pattern.
- Assess areas of stress in client's life and examine relationship with sexual partner. Note cultural, social, ethnic, racial, and religious factors that may contribute to conflict regarding variant sexual practices.
- Be accepting and non judgmental Assist therapist in plan of behaviour modification to help client decrease variant behaviours.
- Teach client that sexuality is a normal human response and is not synonymous with any sexual act. Client must understand that sexual feelings are human feelings.
Nurse may become involved in the primary prevention process. The focus of primary prevention is to intervene in home life or other facets of childhood in an effort to prevent problems from developing. An additional concern of primary prevention is to assist in the development of adaptive coping strategies to deal with stressful life situation.
- Benjamin J S, Sadock VA. Synopsis of psychiatry. Lippincott Williams &wilkins ; Philadelphia : 2007.
- Benjamin JS, Sadock UA. Comprehensive text book of psychiatry. Lippincott Williams & wilkins; Philadelphia: 2005.
- Niraj Ahuja. A short text book of Psychiatry Jaypee brothers medical publishers; New Delhi: 2006.
- Katherine MF, Worret PAH. Psychiatric mental health nursing. Mosby, St. louis : 2008.
- Louise Rebance shives. Psychiatric mental health nursing. Lippincott Williams & wilkins; Philadelphia : 2008.
- Leonardo F F et al. Sexual dysfunction in patients with OCD and Social anxiety disorder. The J of Nervous and Mental Disease. 195(3): 2007
- Anita HC et al. Symptoms of sexual dysfunction in patients treated for major depressive disorder. J Clin Psychiatry, 2007: 68: 1860-1866
- Rakesh G et al . A variant o Dhat syndrome. Indian journal of psychiatry, 49: 2007
- Arackal BS et al. prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian journal of Psychiatry. 49(2):2007.