Sexual Dysfunction, Part 1: Classific~tion, Etiology,
`And Pathogenesis
`
`john G. Halvorsen, M.D., M.S., and Michael E. Metz, Ph.D.
`
`Abstraet: Bllellgrountl: The sexual dysfunctions are extremely common but are rarely recognized by
`primary care physicians. They represent inhibitions in the appetitive or psychophysiologic: c:haoges that
`characterize the complete adult sexual response and are c:lassifted into four maJor categories: ( 1) sexual
`desire disorders (hypoactive sexual desire, sexual aversion disorder), {2) sexual arousal disorders (female
`sexual arousal disorder, male erectile dysfunc:tion), (3) orgasmic: disorders (inhibited male or female
`orgasm, premature ejaculation), and (4) sexual pain disorders (dyspareunia, -vaginismus).
`Metbotls: Artic:les about the sexual dysfunctions were obtained from a search of MEDUNE ftles from 1966
`to the present using the categories as key words, along with the general key word "sexual dysfunc:tion."
`Additional artic:les came from the reference lists of dysfunc:tion-speclflc: reviews.
`ReSfllts fiiUl CtmelfiSimu: Cause and pathogenesis span a continuum from organic: to psychogenic: and
`most often inc:lude a mosaic: of factors. Organic: factors inc:lude chronic: illness, pregnancy, pharmacologic:
`agents, endoc:rine alterations, and a host of other medic:al, surgic:al, and traumatic: factors. Psychogenic:
`factors inc:lude an array of individual factors (e.g., depression, anxiety, fear, frustradon, guilt, hypochondria,
`intrapsychic: c:ontlic:t), interpersonal and relationship factors (e.g., poor c:ommunic:ation, relationship
`c:ontlic:t, diminished trust, fear of intimacy, poor relationship models, family system c:ontlic:t), psychosexual
`factors (e.g., negative learning and attitudes, performance anxiety, prior sexual trauma, restric:tive religiosity,
`intellec:tual defenses), and sexual enactment factors (e.g., skill and knowledge deftclts, unrealistic:
`performance expectations).
`Understanding the cause and pathophysiology of sexual disorders will help primary care physicians
`diagnose these problems accurately and manage them eft'ec:tively. (J Am Board Fam Prac:t 1992; 5:51-61.)
`
`Sexual dysfunctions are exceptionally common
`but infrequendy recognized. The classic "Con(cid:173)
`tent of Family Practice" study from the Depart(cid:173)
`ment of Family Practice, Medical College ofVir(cid:173)
`ginia 1 recorded sexual dysfunctions rarely. Other
`investigators, however, have reported that sexual
`problems can occur in 50 percent of all marriages2
`and that they are present in 7 5 percent of couples
`who seek marital therapy. J,4 Moore and Gold(cid:173)
`stein5 found that 56 percent of patients in a family
`practice reported one or more sexual problems,
`but these problems were recorded in only 22
`percent of the cases. In one of the most cited
`prevalence studies, Frank and colleagues6 sur(cid:173)
`veyed well-adjusted couples with high marital
`
`satisfaction and found that 63 percent of the
`women and 40 percent of the men experi(cid:173)
`enced a specific sexual dysfunction, and an even
`higher percentage (77 percent of the women and
`50 percent of the men) reported general "sexual
`difficulties."
`Because many sexual problems are hidden, pri(cid:173)
`mary care physicians need to help discover them.
`Once discovered, to manage these disorders
`effectively, physicians must understand their
`cause and pathogenesis; evaluate them thor(cid:173)
`oughly by history, physical examination, and
`laboratory testing; initiate management; and
`refer to other appropriate professionals when
`necessary.
`
`Submitted, revised, 9 August 1991.
`From the Department of Family Practice and Community
`Health, University of Minnesota, Minneapolis. Address reprint
`requests to John G. Halvorsen, M.D., M.S., University of Min(cid:173)
`nesota, 3-100 Phillips-Wangensteen Bldg., 516 Delaware St.
`S.E., Box 381 UMHC, Minneapolis, MN 55455.
`
`Classification of Sexual Dysfunctions
`Inhibitions in the appetitive or psychophysiologic
`changes that characterize the complete adult sex(cid:173)
`ual response are at the heart of the sexual dysfunc(cid:173)
`tions. They are not usually diagnosed, however, if
`they occur exclusively during the course of an-
`
`Sexual Dysfunction 51
`
`MYLAN - EXHIBIT 1026
`
`

`
`other psychiauic disorder, such as a major depr c.S·
`sio:a or an obsessive compulsive disorder
`The complete sexual response cycle consists of
`four phase.;~ appetitive, excitement (arousal), or·
`gasmic, and resoluaon. The appetttive phase in
`volve5 sexual ta1l&asies and a destre for i>exual ac(cid:173)
`tivity. Dmmg the excitement phase, in addition
`w a subjecave .ie:use oi sexual pleasure, men ex(cid:173)
`pe~·ie.~lcc penile ru..u..::.;:,ccnc.:: and erection, md
`.;ec1·ettons appear from the bulbourethral glands.
`Women experience pelvic vasoco:age:>tion, vagi·
`nallubi.·tcarion, swelling of the external genitalia,
`narrowing of d1e outer third of the vagina
`by increased pubococcygeal muscle rension and
`labia
`vasocongesnon, vasocongesrion of the
`minora, breasr tumescence, and lengthening
`and widemng of the inner two-thirds of the
`vagma. Sexual pleasure peaks during the orgas~
`mic phase and Is accompamed by che release
`of sexual tension and rhythmic contraction of
`the perineal ana pelVIC reproductive organs. ln
`men, a sensation of ejaculacory inevitability pte·
`cedes the contraCtions m the prostate, serninal
`vesicles, and urethra that results in seminal ernis
`sion. In women, contractions occur in the outei
`thtrd of the vaginal walt During resolutton,
`both men and women feel relaxed and free
`from muscular rension. Men are temporarily It·
`fractory to further en::ction and mgasm, but
`women can respond almost immediately w ad&.
`tional stmmlation.
`Inhibitions m dte :>exual response cycle can
`occur at one or more of these phases, although
`only the first three are of primary clinical stgnifi
`cance. The maJor dysfuncnons are classified and
`defined as follows7:
`Sexual desire disorde1·s include (1) hypoactive
`sexual desire disorder, characterized by deficient
`or :1bsent sexual fantasies and desire fm sexual
`activity; and (2) sexual av~rsion disorder, defined
`as exaeme aversion to and avoidance of genital
`contact with a sexual parmer.
`Sexual arousal disorders include (1) female ;;ex-·
`uai arousal disorder, characterized by failure to
`attain or mamwn the lubncatlOil··swctling I'e"
`sponse of sexual exCitement unttl completion of
`the sexual activity or by lack of a subJc:Ctive sense
`of sexual excitement and pleasure during :;exual
`actiVIty; :md (2) male ereCtile disorder, marked by
`failure tc attain or maimain erection until com(cid:173)
`pietion of sexuai activity or by lack of a subjective
`
`52 JABFP Jan. Ft.b. 1992 Vol; l-Jo, 1
`
`Orgasm
`
`Sexual Dysfunctions
`J! r·· t:s~ Phase
`Q :wllihJ Oll"tlllat6
`Sexw: :, ·rx.t..'\B~
`C'lz..·.or~r,
`
`c. ~.IIIOittt.::
`F"enaJe Otg.iioJn
`
`~ hy~ .. ~b.-u
`.)~.~: c:' ~nirr
`,~ .... ,
`
`.81·C.I:-.iQ-
`
`Figun l 'Ibe sexualtesponse cycle, with several nonnal
`patktGS and the oommon dysfunctions classltled by the
`phaw: that they affect.
`
`sen.,c: of sexual exctttulent and pleasure during
`sexual activity.
`Orgasm disorde1s mclude (1) inhibited male
`and female mgasm, characterized by delayed or
`absent mgasm following a normal sexual excite(cid:173)
`ment pha,;e that is adequate in focus, intensity,
`and duration; and (2) premature ejaculation, de(cid:173)
`fined as ejaculation with mirumal sexual stimula(cid:173)
`tion or before, upon, or shortly after penetration
`and befure the man wishes it.
`Sexual pain disorders include (1) dysparew1ia,
`characterized by genital pain in either sex be(cid:173)
`fore, during, or after sexual intercourse that is
`not caused exclusively by lack of lubrication or
`vaginismus; and (2) vaginismus, defined as in(cid:173)
`voluntary spasm of the musculature of the
`outer third of the vagina that interferes with
`COitUS ..
`Figure 1 summarizes these sexual dysfunctions
`according to the phase of the sexual response
`cycle that they affect. It also depicts several nor(cid:173)
`mal response patterns.
`
`Cause and Pathophysiology
`lhe sexual dysfunctions have both organic and
`psychogenic causes A specific dysfunction can be
`mosdy psychogemc, mosdy organic, or mixed.
`Dysfunctions can be lifelong (primacy) or ac(cid:173)
`qwred (secondary), generalized (o<..curring in any
`situauon or with any parUler) or situational
`(lirmted to ct:rtain situations or partners), and
`co.cnplete or partial in severity.
`
`

`
`Geltertll CtlfiSIIHve FMtors
`Organic Factors
`Organic problems affect all phases of the sexual
`response cycle. According to current estimates,
`the cause of at least 50 percent of erectile dysfunc(cid:173)
`tion cases is primarily organic, 8 with some esti(cid:173)
`mates ranging as high as 75 to 85 percent.9Thirty
`percent of surgical procedures on the female
`genital tract result in temporary dyspareunia, and
`30 to 40 percent of the women seen in sex therapy
`clinics for dyspareunia have pathologic pelvic
`conditions.9,10 The common general organic fac(cid:173)
`tors that affect sexual function include chronic
`illness, pregnancy, pharmacologic agents, endo(cid:173)
`crine alterations, and chemical abuse. A variety of
`other medical, surgical, and traumatic factors can
`be implicated in specific dysfunctions.
`The degree to which chronic illness interferes
`with sexual function depends on the type of
`chronic illness, the age of onset with regard to
`sexual maturation, and whether the illness was
`recognized before the current relationship.ll
`Congenital illnesses and illnesses that begin be(cid:173)
`fore or during puberty have a greater impact on
`the course of sexual development. The more visi(cid:173)
`ble the problem, the more it will interfere with
`sexual development. Relationships that begin be(cid:173)
`fore the onset of a chronic illness are more af(cid:173)
`fected by the illness because they require a greater
`number of difficult adjustments.11
`Pregnancy affects sexual desire in different
`ways.l2,13 In the first trimester, nausea, fatigue,
`and the fear of miscarriage interfere with sexual
`desire. In the last trimester, increasing size and a
`perception of decreasing attractiveness, along
`with a focus on the well-being of the infant and on
`enduring labor and delivery, decrease sexual de(cid:173)
`sire. During the middle trimester, increasing pel(cid:173)
`vic vasocongestion and an overall feeling of well(cid:173)
`being facilitate sexual responsiveness.
`Pharmacologic agents interfere with sexual
`functioning through several mechanisms.14 Some
`cause adrenergic inhibition.l5,16 Drugs that alter
`the neurotransmitter norepinephrine by block(cid:173)
`ing a-adrenergic receptors, by depleting nor(cid:173)
`epinephrine stores, or by blocking norepineph(cid:173)
`rine release can cause sexual dysfunction by
`altering emission or ejaculation. Adrenergic an(cid:173)
`tagonists include such drugs as guanethidine, re(cid:173)
`serpine, methyldopa, clonidine, prazosin, and
`phenoxybenzamine.
`
`Drugs that sedate and depress the central nerv(cid:173)
`ous system adversely affect sexual functioning by
`decreasing libido and altering potency, perhaps by
`increasing brain serotonin and decreasing dopa(cid:173)
`mine levels.l5,l7-19 Depressants include alcohol,
`cannabis, barbiturates, and benzodiazepines, as
`well as antihypertensive and anticonvulsant medi(cid:173)
`cations that have sedating properties.
`Increased prolactin levels reduce the respon(cid:173)
`siveness of the male gonads to leutinizing hor(cid:173)
`mone, thereby inhibiting testosterone produc(cid:173)
`tion.IS,l9·23 Some drugs can cause increased
`prolactin release through dopaminergic antago(cid:173)
`nism (e.g., phenothiazines, thioxanthenes, buty(cid:173)
`rophenones). Other drugs, such as cimetidine
`and narcotics, increase prolactin levels through
`mechanisms that are incompletely defined. Some
`drugs have antiandrogen effects.1S.24-26 The aldo(cid:173)
`sterone antagonist spironolactone causes es(cid:173)
`trogenlike side effects with decreased libido, im(cid:173)
`potence, and gynecomastia in men and painful
`breast enlargement and menstrual irregularity in
`women. It likely causes these effects by inhibiting
`dihydrotestosterone binding to its cytosol protein
`receptor. Alcohol also decreases testosterone lev(cid:173)
`els, perhaps by peripheral suppression of testos(cid:173)
`terone production in the testes. Oral contracep(cid:173)
`tives can decrease libido in women by decreasing
`estrogen levels. Progesterone is thought to sup(cid:173)
`press sexual activity in some women because of an
`antiandrogen effect.
`agents, or drugs with
`Anticholinergic
`atropinelike actions, can cause sexual problems
`(chiefly arousal difficulties) secondary to their
`parasympatholytic activity.15.27-29 These agents
`include antiparkinsonian drugs, tricyclic anti(cid:173)
`depressants, many antipsychotic agents, antihista(cid:173)
`mines, antiemetics, antivertigo drugs, and the
`antiarrhythmic disopyramide.
`Various mechanisms are proposed to explain
`the sexual dysfunction associated with drugs that
`do not appear to fit the other categories.1S,l9,30-3B
`Examples include decreasing receptor sensitivity
`to dopamine or a decrease in its intraneuronal
`turnover (lithium) and peripheral vasoconstric(cid:173)
`tion or sympathetic blockade (propranolol).
`The specific drugs that are associated with sex(cid:173)
`ual dysfunction and the dysfunctions associated
`with each are listed in Table 1. The particular
`effect of any drug on a patient will vary depend(cid:173)
`ing on such factors as age, absorption, body
`
`Sexual Dysfunction 53
`
`

`
`'Dible 1. JlllaanaKolopc AF&11 Allodated witb Sexual Dylfaacdoa. *
`Phase of Sexual Response Cycle
`Affected(+) or Not Affected(-)
`Arousal
`Orgasm
`(erection) (ejaculation)
`
`Desire
`
`Drua:
`A11tilmxiety
`~razolam
`orazepate
`Chlordiazepoxide
`Diazepam
`A11ticbolinergic
`Atropine
`Benztropine
`Glycopyrrolate
`Mepenzolate
`Methantheline
`Propantheline
`Scopolamine
`lliliexyphenidyl
`A11tico1lvulstmt
`Carbamazipine
`Phenytoin
`Primidone
`A11tideprtssant
`Htterocycli&
`Amitriptyline
`Amoxapme
`Oomipramine
`Desmethylimipramine
`Doxepin
`Imipramine
`Maprotiline
`N orttiptyline
`Prottiptyline
`Trazodone
`M0110f1111me oxidase inhibitor
`Carboxazid
`Fluoxetine
`Pargyline
`Phenelzine
`Tranylcypromine
`A11tihistamme
`Cyproheptadine
`Diphenhydramine
`HydroxyZine
`A11tibypertmsive
`Diuretic
`Amiloride
`Furosemide
`Indapamide
`Spironolactone
`Thiazide
`Cmtra/Jy acting sympatholytic
`Alpha-methyldopa
`Oonidine
`Guanfacine
`Reserpine
`a-Atlrenergic bi«Jter
`Guanabenz
`Guanadrel
`Pheno~nzamine
`Phento amine
`13-Admlerr bi«Jter
`Labetalo
`Metoprolol
`Pindolol
`Propranolol
`Timolol
`~lilmic bi«Jter
`ecamylamine
`Trimethaphan
`~pathetic neurfKjfeaor agent
`uanethidine
`N~ vasodikltor
`Hydralazme
`Prazosin
`
`+
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`
`Coodnued
`
`54 JABFP jan.-Feb. 1992 Vol. 5 No.1
`
`'Dible 1. Continued.
`
`DruB:
`A11giotmsive comJertmg enzyme
`inhibitor
`Captopril
`Enalapril
`Lisino ril
`Cilkium cta111ltl bl«lcer
`Diltiazem
`Nifedipine
`Verapamil
`A11#microbial
`Ethionamide
`K.etoconazole
`A11~chotic
`orpromazine
`Chlorprothixene
`Fl~henazine
`H operidol
`Mesoridazine
`Perphenazine
`Pimozide
`Thioridazine
`Thiothixene
`Trifluoperazine
`Hz-rrceptor antagonist
`Cimetidine
`Famotidine
`Ranitidine
`Hllt7fi()M
`Danazol
`Hy~rogesterone
`Norethindrone
`Oral contraceptives
`Progesterone
`Narcotic
`Codeine
`Heroin
`Meperidine
`Methadone
`Morphine
`Propoxyphene
`Sttiative-rotic
`Alcoho
`Barbiturates
`Chloral hydrate
`Ethchlo~ol
`Methaq one
`Otberagmts
`Acetazolamide
`Aminocaproic acid
`Amiodarone
`Am~etamines
`Ba ofen
`Cannabis
`Cocaine
`Oofibrate
`Digitalis
`Dis~de
`Dis
`m
`Fenfluramine
`Interferon
`Levodopa
`Lithium
`Mazindol
`Methandrostenolone
`Methazolamide
`Metoclopramide
`Metyrosine
`Mexiletine
`Naltrexone
`N.Jl:roxen
`L- ryptophan
`
`Phase of Sexual Response Cycle
`Affected(+) or Not Affected(-)
`Arousal
`Orgasm
`(erection) (ejaculation)
`
`Desire
`
`+
`+
`+
`
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`

`
`weight, dosage, duration of use, rates of metabo(cid:173)
`lism and excretion, presence of other drugs,
`underlying disorders, patient compliance, and
`suggestibility.
`Based on current research, it is unlikely that
`hormonal fluctuations during the menstrual cycle
`play a significant role in sexual dysfunction.11,39
`The combination of somatic and emotional
`symptoms that some women experience during
`menses, however, can result in sexual disinterest
`and arousal difficulty. Furthermore, menstruation
`can affect sexual function because of religious
`teachings, taboos, sexual ignorance, fears of dis(cid:173)
`pleasing one's sexual partner, or simple esthetics
`rather than because of physiologic factors. II
`A number of commonly abused chemical
`agents also cause sexual dysfunction. Alcohol is
`associated with decreased libido and erectile diffi(cid:173)
`culty.14,15,40 Marijuana also can decrease libido and
`cause erectile difficulty.14·15 Phencyclidine hydro(cid:173)
`chloride (PCP) can cause erectile and ejaculatory
`failure_I4,41 Cocaine is associated with sexual in(cid:173)
`difference, dysphoria, aggressiveness, situational
`impotency, and anorgasmia.14·42 Heroin users also
`experience reduced sexual desire, erectile dys(cid:173)
`function, and anorgasmia.l4·43 Methadone and
`amphetamines reportedly decrease sexual per(cid:173)
`formance.14·44·45 Tobacco abuse results in sexual
`dysfunction primarily through its adverse effects
`on the vascular system.l4
`Androgens play an important role in the libido
`of both men and women. Androgen deficiency
`can result from panhypopituitarism,46 combined
`bilateral adrenalectomy and ovariectomy in
`women, or castration in men. Hyperprolactine(cid:173)
`mia caused by a prolactin-secreting pituitary
`tumor has been associated with sexual dysfunc(cid:173)
`tion.47 The mechanism responsible is not clearly
`defined but may relate· to hypogonadism second(cid:173)
`ary to prolactin-induced hypogonadotropism.
`Both hypothyroidism and hyperthyroidism can
`also cause sexual dysfunction. 8,48
`
`Psychosexual Factors
`Sexual dysfunctions are invariably multideter(cid:173)
`mined; a single cause is rare.49,50 Even when an
`organic factor is present, it is essential to treat the
`principal psychological factors that can compli(cid:173)
`cate the organic problem or that could have re(cid:173)
`sulted from it. Three areas of psychological focus
`are important: individual psychological deter-
`
`minants, relationship issues, and psychosexual
`factors.
`Empirical studies have linked many individual
`psychological factors with sexual dysfunction. 51
`Depression 52 and anxiety2·53·54 are most common.
`Diminished self-esteem,55 frustration, guilt, hy(cid:173)
`pochondria, sexual fear, hostility or anger, 54,56 un(cid:173)
`realistic expectations or perfectionism, 57 intrapsy(cid:173)
`chic conflicts (such as grief, unresolved sex
`orientation, concerns about paraphilic arousal
`patterns54), and serious psychopathologic disor(cid:173)
`ders also contribute. Depression and anxiety are
`considered generic causes of sexual dysfunction,
`but they also commonly occur as consequences of
`sexual dysfunction 58; therefore, determining cau(cid:173)
`sality can be challenging. As a general rule, severe
`depression or anxiety is more likely causative;
`mild forms more commonly represent the impact
`of sexual failure.
`Sexual and relationship factors can interact in
`several ways. 59 Relationship problems can cause
`sexual dysfunction, organic sexual dysfunction
`can precipitate relationship distress, or the two
`factors can exist independendy. Recognizing that
`sometimes there is no clear relation between sex
`and marital problems is important. Some couples
`with serious marital dysfunction appear to have a
`satisfactory sexual relationship. The reverse is
`also true. The most common relationship factor
`that causes sexual dysfunction, however, remains
`marital dissatisfaction60 involving relationship
`problems that generate stress, fatigue, or dyspho(cid:173)
`ria. Dissatisfaction can focus on poor communica(cid:173)
`tion,53,54 unrealistic marital expectations,61 failure
`to resolve relationship conflict,53·61·62 diminished
`trust, 54 fears of intimacy or romantic success, 54,63
`a history of poor relationship modeling that is
`transferred to the marriage, family system distress
`(such as caring for an elderly relative or preschool
`and school-age children), sex role conflicts, diver(cid:173)
`gent sexual preferences or sex values, career prob(cid:173)
`lems, and legal troubles.
`The most common psychosexual factors caus(cid:173)
`ing sexual dysfunction are prior sexual failure
`(often at first intercourse), chronic sexual per(cid:173)
`formance inconsistency, negative learning and
`attitudes about sex, 2·64 and prior sexual trauma. 2,54
`Other identified factors include sexual guilt and
`shame,65,66 unrealistic expectations about sexual
`performance,67 restrictive religiosity,2 sexual per(cid:173)
`formance anxiety generated by fears of failure or
`
`Sexual Dysfunction S S
`
`

`
`perceived performance demands from a partner, 2
`interpersonal insensitivity,58 intellectual defenses
`(such as denying sexual arousal and detachment
`from sensual pleasure),54 sexual identity conflict,68
`sexual orientation issues, and a parent-child rela(cid:173)
`tionship history filled with conflict.
`Other sexual disorders sometimes underlie sex(cid:173)
`ual dysfunctions, especially in men. For example,
`gender dysphoria or paraphilia (e.g., transvestism,
`voyeurism, pedophilia) in some cases manifests as
`erectile dysfunction or inhibited orgasm. Current
`evidence suggests that these factors are more
`common than previously thought. 69
`In some cases, sexual dysfunction is caused by
`deficient skill and knowledge about sexual physi(cid:173)
`ology and sexual stimulation or by unrealistic per(cid:173)
`formance expectations. For example, a potential
`cause of erectile dysfunction can be inadequate
`physical stimulation to the penis. Female dyspa(cid:173)
`reunia can be caused by insufficient foreplay to
`cause arousal, overly aggressive digital or penile
`penetration, or an unfavorable pelvic position for
`intercourse.
`
`Dysfulldlon-Speci.Jk Ft~eltm
`Sexual Desire Disorders
`Hypoactive sexual desire disorder is common (40
`percent) for both men and women, complicated
`in its origin, and difficult to treat.so,7o,n Common
`organic problems associated with loss of desire
`include chronic illness, thyroid disorders, disfig(cid:173)
`uring trauma, congenital disfigurement, and pitu(cid:173)
`itary disorders. Libido loss can be profound in
`hypopituitarism. In women, early pregnancy
`should also be considered.
`In severe forms, such as sexual aversion, the
`cause is commonly rooted in developmental fac(cid:173)
`tors (often sexual trauma), family-of-origin con(cid:173)
`flicts, or serious individual psychopathology. In
`less severe cases, lack of sexual desire can accom(cid:173)
`pany a major depression, relationship issues, or
`negative beliefs about sex. Some cases involve loss
`of desire in a specific situation only and are rela(cid:173)
`tively uncomplicated.
`Because loss of sexual interest is a symptom
`diagnostic of depression, the diagnosis of sexual
`desire disorder is complicated. 'When events are
`present that clearly make a reactive or anticipa(cid:173)
`tory depression diagnosis appropriate, the depres(cid:173)
`sion should be treated presuming that sexual de(cid:173)
`sire will return. Other individual factors include
`
`56 JABFP Jan.-Feb. 1992 Vol. 5 No. 1
`
`primary sexual identity dysphoria, sexual orienta(cid:173)
`tion. conflict, negative sexual learning, and sexual
`trauma.
`Learning conflicts about sex create an emo(cid:173)
`tional double bind for some patients with a
`hypoactive sex drive. Mixed messages about sex
`often originate with parents, religious instruction,
`and society in general. Young people are praised
`for appearing sexually attractive but chastised for
`behaving sexually. Negative sexual experiences
`can create feelings of disregard, avoidance, or
`even repugnance, and avoidance behavior can re(cid:173)
`sult from fears of sex related to problems of infec(cid:173)
`tious disease, exploitation, and control. "Anti(cid:173)
`fantasies, "54 a focus on negative aspects of sex, are
`common also.
`Loss of sexual interest commonly blunts rela(cid:173)
`tionship affect, often generalizes to other feelings,
`and can signal important marital distress. The
`most common relationship issues in sexual desire
`disorders are unresolved conflict and disappoint(cid:173)
`ment that lead to subsequent anger, hidden re(cid:173)
`sentment, and unconscious alienation. Covert re(cid:173)
`sentment in overly conventionalized, attractive,
`adaptive couples can manifest itself in lost "pas(cid:173)
`sion" or desire. In other couples, sex is withheld
`or used to exploit, control, or manage the partner
`to negotiate other desires. Anger, fear of intimacy,
`commitment, or sexual success (with resultant
`shame), and emotional fatigue are other relation(cid:173)
`ship factors that decrease desire.
`Research documents that men and women with
`a normal sex drive perceive their parents' attitudes
`toward sex and their parents' affectionate interac(cid:173)
`tion with each other as more positive than do
`those with hypoactive sexual desire.l 1 Parental
`attitudes and modeling can be latent predisposing
`factors that influence sexual interest in later life.
`Incestuously eroticized relationships with the
`parent of the opposite sex, exposure to parental
`conflict, and failure to introject the sex role of the
`same-sex parent are also adverse influences.
`
`Sexual Arousal Disorders
`Organic origins of male sexual impotence include
`more than 100 distinct entities. The major disor(cid:173)
`ders are listed in Table 2. Organic origins of fe(cid:173)
`male sexual arousal disorders have not been stud(cid:173)
`ied as extensively. Many of the same factors,
`however, might be important, e.g., chronic car(cid:173)
`diovascular and neurologic disorders; pituitary,
`
`

`
`'l'llble 2. Medical Problea Alloclated with Erectile Dllorden.
`
`Category
`Cardiovascular
`
`Endocrine
`
`Genetic
`
`Hematologic
`Hepatic
`Infectious
`Neurologic
`
`Nutritional
`Poisoning
`Pulmonary
`Renal and urologic
`Surgical
`
`'Ihlumatic
`Other problems
`
`Condition or Disease
`Atherosclerosis, arteritis, arterial thrombosis, arterial embolism, aortic aneurysm, the Leriche syndrome,
`cardiac failure
`Pituitary problems (e.g., acromegaly, chromophobe adenoma, craniopharyngioma, pituitary destruction,
`hyperprolactinemia), adrenal problems (Addison disease, the Cushing syndrome), thryroid problems
`(hyperthyroidism, hypothyroidism), gonadal dysfunction (castration, postinfl.ammatory fibrosis, exogenous
`estrogens, feminizing interstitial-cell tumor), diabetes mellitus, the Frohlich syndrome
`The Klinefelter syndrome, the male Turner syndrome, congenital vascular or structural abnormalities
`(extrophy, epispadias, hypospadias, spermatocele, varicocele)
`Anemia, leukemia, immunologic disorders, sickle cell disease
`Cirrhosis (usually alcoholic)
`Urethritis, prostatitis, seminal vesiculitis, cystitis, gonorrhea, tuberculosis, elephantiasis, mumps orchitis
`Multiple sclerosis, myasthenia gravis, Parkinson disease, amyotrophic lateral sclerosis, stroke, central nervous
`system (CNS) tumors, CNS infections (espec:ially of the temporal lobe), trauma (head, spinal cord), ~inal
`cord compression (disc, tumor, abscess, spinal stenosis), tabes dorsalis, temporal lobe epilepsy, spina bifida,
`syringomjrelia, subacute combined degeneration of the spinal cord, peripheral neuropathy, cerebral palsy,
`electroconvulsive therapy, transverse myelitis
`Malnutrition, vitamin deficiencies, morbio obesity
`Lead, herbicide
`Respiratory failure
`Peyronie disease, priapism, urethral stricture, chronic renal failure
`Perineal prostatectomy, perineal prostatic biopsy, suprapubic and transurethral prostatectomy, abdominal
`aortic aneurysmectomy, aortofemoral bypass, retro_peritoneallvmphadenectomy, sympathectomy (lumbar,
`dorsal, pelvic), cystecomy, abdominoperineal resection, external sphincterotomy
`Pelvic fraCture, urethral rupture, penectomy
`Radiation therapy, any severe or debilitating systemic problem
`
`adrenal, and thyroid disorders; hematologic, he(cid:173)
`patic, pulmonary, and renal disorders; and pelvic
`surgery, trawna, or infection.
`Diabetes mellitus deserves special mention as
`the most common medical disorder causing male
`sexual impotence. Between 30 and 60 percent of
`all diabetic men will develop erectile dysfunc(cid:173)
`tion.48,72 Impotence can occur as the presenting
`symptom of diabetes, as a complication of the
`disease, or as a transient phenomenon during pe(cid:173)
`riods of poor control.73 There is no apparent
`correlation between impotence and the severity
`of diabetes, the duration of the illness, or the type
`or amount of hypoglycemic medication. 73 Preva(cid:173)
`lence rates of25 to 30 percent are reported among
`diabetics in their 20s and 30s up to 50 to 70
`percent in diabetic men aged> 50 years.73 Most
`investigators believe that the erectile dysfunction
`in diabetes mellitus is caused principally by the
`autonomic neuropathy and the macrovascular
`and microvascular changes that result from the
`disease.74
`While most research exploring the psychologi(cid:173)
`cal causes of sexual dysfunction has examined in(cid:173)
`hibited excitement in men, many clinicians as(cid:173)
`swne that the findings apply to women as well.
`Further research on female arousal disorders is
`needed to establish whether this asswnption is
`warranted.
`Depression again is a common factor inhibiting
`the arousal phase of the sexual response cycle by
`
`psychologically "nwnbing" the body and sensual(cid:173)
`ity. 75 By inhibiting arousal, depression causes dif(cid:173)
`ficulty with erections for men and problems with
`lubrication and emotional
`involvement for
`women. Anxiety can also interfere with sexual
`arousal. It is most common as performance anxi(cid:173)
`ety, the pressure to perform, to please one's part(cid:173)
`ner, or to succeed sexually as a medium for prov(cid:173)
`ing sexual and personal adequacy. Personal
`deficits in knowledge and perception can contrib(cid:173)
`ute to arousal disorders by creating a set of im(cid:173)
`possible expectations, which create a failure men(cid:173)
`tality that predictably results in an inhibited
`performance. Self-prophesied sexual failures then
`invariably lead to cognitive interference (a series
`of identifiable negative thoughts and judgments)
`that creates anxiety and detaches people from the
`sensual experience of sexual arousal.
`Pressures from the partner can exacerbate the
`individual pressures just described. Some persons
`express ambivalence toward their partner, an am(cid:173)
`bivalence that might reflect marital dysfunction.
`Others choose partners in whom they are less
`interested as a defensive protection from personal
`rejection. Conjoint adherence to the expectations
`that sex should always "work," be "spontaneous,"
`and conform to other societal standards is invari(cid:173)
`ably involved in arousal dysfunctions. In some
`cases, conflict with one's social sex role, non(cid:173)
`acceptance of the other sex, and relationship fac(cid:173)
`tors such as anger, resentment, frustration, disap-
`
`Sexual Dysfunction 57
`
`

`
`pointment, and fear of intunacy, sexual succe~, or
`rejection are causarive. In a few cases, fears of
`hurting the partner, of pregnancy, and of sexually
`transmitted disease are important.
`Cultural guilt about st:x, prior failwe!>, and st:x·
`ual trauma inhibit arousal in some patients, as can
`neganve amtudes toward sexuality that are
`learned in the family of origm, Oedipal problems,
`and unresolved interpersonal conflicts with family
`members.
`A common cause of male erectile dysfuncrion is
`th