Sexuality and sexual dysfunction have an expansive history, dating back to ancient times. In Egyptian mythology, sexuality was swirled throughout the tales. The gods and goddesses of that ancient culture were considered to be naturalistic, meaning identifiable with nature. As with the mythology of Greek and Roman culture, there were goddesses of fertility and gods of virility. Sexuality was wholesomely embraced and encouraged during this time frame; those suffering from dysfunction were considered weak or ineffectual (Roychowidhury, 2019). King Louis XVI of France was rumored to have erectile dysfunction from a young age (Gurtner, Salzman, Hebert, & Laborde, 2017). Flash forward to the 1900s, where psychoanalysis is brought forth by Sigmund Freud (1856-1939), with strong connections between human sexuality and the psyche (McLeod, 2019). Marching onward through the history of sex, we see waxing and waning in the display of sexuality. In the early 1950s, a person could be arrested for making insinuations regarding sexuality. Then in the 1960s and ‘70s, there was a “sexual revolution” after the introduction of birth control and an increase in the ease of communication through television and advertising (Allyn, 2016). With these cultural appropriations (and misappropriations) throughout history, sexual dysfunction has been a significant issue, from biblical times to modern-day society (Gurtner et al., 2017). Addressing sexual health is classically an uncomfortable, awkward experience, both for providers and patients. The information below describes a handful of causes of sexual dysfunction, along with recommendations for the care of patients and their partners (if applicable). It is of note that these are a sampling of common causes of sexual dysfunction and is not all-inclusive of the many sources of sexual dysfunction.
Sexual dysfunction is an umbrella term used to describe “the inability to fully enjoy sexual intercourse. Specifically, sexual dysfunctions are disorders that interfere with a full sexual response cycle” (Kaczkowski, 2018, para. 1). Sexual dysfunction can occur in both men and women and may be acute or chronic. The dysfunction may be situational or acquired. In men, sexual dysfunction may be considered if the man ejaculates before he or his partner desires, experiences delayed or no ejaculation, is unable to obtain an erection, feels pain during intercourse, or lacks or loses sexual desire. In women, sexual dysfunction may be comprised of a lack or loss of sexual desire, difficulty achieving orgasm, anxiety, or pain (dyspareunia) during intercourse, or involuntary vaginal muscle contractions before or during sexual intercourse. Sexual intercourse may be impaired due to congenital abnormalities, surgical, or traumatic changes to the reproductive anatomy. Inadequate lubrication may also be considered a form of sexual dysfunction in women. Risk factors for sexual dysfunction include age, obesity, diabetes, metabolic syndrome, smoking, and many others (Kaczkowski, 2018)
The male reproductive system consists of several different organs that have the following roles: production, transport, and deposition of sperm in the female reproductive tract, and hormone production. The primary male reproductive organs are the testes, which are responsible for spermatogenesis (the production of sperm), and the production of testosterone, the male sex hormone. Secondary male sex organs include ducts such as the epididymis, ductus deferens, ejaculatory duct, and urethra; glands such as the prostate gland, Cowper’s glands, and seminal vesicles; and the external genitalia (scrotum and penis) (Harding, Kwong, Roberts, Hagler, & Reinisch, 2020).
In contrast, the female reproductive organs have roles in producing ova (eggs), secrete hormones, and protect and grow a fetus in a pregnant female. The primary reproductive organs are the ovaries, which are responsible for the production of oocytes and the release of estrogen and progesterone, the female sex hormones. Secondary reproductive organs include the fallopian tubes, uterus, vagina, Bartholin’s glands, breasts, and external genitalia (the vulva) (Harding et al., 2020).
The male sexual response consists of an excitement phase, plateau phase, orgasmic phase, and the resolution phase. The excitement phase occurs when blood fills the tissue of the penis, allowing for erection. Note that the penis contains many cavern-like sinuses that fill with blood secondary to neurological feedback and several other factors. With erection, the penis is then ready for insertion into the vagina. Upon reaching the plateau phase, the erection is maintained, testicle size increases, and the glans penis may become red-purple in color due to vasocongestion. During the orgasmic phase, sperm and ejaculate fluid are propelled through the urethra and are ejaculated through the meatus. The male orgasm is characterized by “the rapid release of vasocongestion and muscular tension through rhythmic contractions…primarily in the penis, prostate gland, and seminal vesicles” (Harding et al., 2020, p. 1177). After orgasm, males begin the resolution phase, where the penis returns to its flaccid state (Harding et al., 2020).
Harding et al. (2020) insinuate a similarity in female arousal stages to male arousal stages, citing the initiation of sexual arousal as the congestion of blood in the clitoris. Vaginal lubrication increases during this, the excitation phase. During the plateau phase, the uterus is elevated, and the vagina expands. During orgasm, the cervical os opens slightly to allow for the passage of sperm. As with male orgasm, female orgasm allows rhythmic contractions and release of muscular tension; however, with females, this occurs in the clitoris, vagina, and uterus. Females then proceed to the resolution phase, where the abovementioned organs return to their normal state. It is noted that females do not have to return to the resolution phase in order to experience another orgasm; females may have multiple orgasms in the orgasmic phase without resolution, as opposed to males who must visit the resolution phase (Harding et al., 2020).
These organs, along with neuroendocrine influence from the hypothalamus and pituitary glands, contribute to the reproductive process. In order to complete this process, a sexual response must occur. The sexual response is a complex and in-depth process, with many variables that may result in dysfunction. Many different anatomical and/or structural deficits may cause sexual dysfunction, including (but not limited to) hypospadias/epispadias, micropenis, or Peyronie’s disease. Hypospadias and epispadias include placement of the male urethra other than the accepted position. Micropenis is a penis that is too small to function appropriately for sexual purposes. Peyronie’s disease is abnormal scar tissue inside of the penis, resulting in painful or dysfunctional erections (Roushias & Ossei-Gerning, 2019).
Causes of Sexual Dysfunction
Both males and females experience reproductive changes as they age, thereby potentially contributing to sexual dysfunction. Males may have increased breast size, a decrease in penile subcutaneous fat, easily retractable foreskin (if uncircumcised), or a decrease in size and frequency of erections. Benign prostatic hyperplasia occurs with aging, potentially causing urinary obstruction and incontinence. The testes produce less testosterone, a causative factor in erectile dysfunction. It is noted that erectile dysfunction is quite prevalent, affecting more than half of men aged 40-70 years (Cho & Duffy, 2018). Females experience decreased subcutaneous tissue in the breast. Menopause results in decreased or absent ovarian function. This absence of ovarian function affects sexual function greatly and will be discussed in a subsequent section. Both males and females may experience a decrease in libido or interest in sex as aging occurs (Harding et al., 2020). Nocturia, or the need to wake up one or more times during the night to urinate, is a common occurrence among aging individuals. Approximately half of adults over age 60 report nocturia, and the prevalence increases with age. This correlates with a loss of sleep, thereby resulting in decreased testosterone, which can cause sexual dysfunction (see below for more discussion on sleep and associated sexual dysfunction) (Cho & Duffy, 2018).
With the abovementioned decline in sexuality that occurs in aging, it is of vital importance to note the changes that occur with menopause. Menopause, or the cessation of menarche in women, causes a halt to the production of estrogen and progesterone. With this abrupt stoppage of the sex hormones, females experience many side effects, including decreased vaginal elasticity, vaginal dryness, and dyspareunia. Aside from the physical changes associated with menopause, life changes common to this age (40s-50s, age 51 being the average age of menopause) such as divorce, job change, or the lack of a partner can affect the desire for sexual intercourse (Thornton, Chervenak, & Neal-Perry, 2018).
With the changes that occur in menopausal women, two main disorders may occur: 1) hypoactive sexual desire disorder (HSDD) and 2) symptomatic vulvovaginal atrophy. HSDD, as the name insinuates, is an inherent lack of sexual desire and response to stimulation, thoughts, or activity. The greatest risk for this disorder is in women who have undergone surgical menopause. HSDD results in emotional side effects too, correlating with low satisfaction, poor self-image, and unhappiness. It is also important to note that men can suffer from HSDD as well, although typically from different mechanisms of action than women (Thornton et al., 2018).
Symptomatic vulvovaginal atrophy is highly prevalent in menopausal women. Signs and symptoms of this disorder include thin, pale, and dry vaginal and vulvar surfaces. It is often accompanied by dry mucous membranes in the area due to decreased secretions from the sebaceous glands. It is also noted that the decline of estrogen contributes to a decreased level of lactobacilli, thereby lowering the vaginal pH. causing a decrease in the natural flora of the vagina. With these changes, vaginal dryness and associated discomfort or pain during sexual intercourse may be present. In the Real Women’s Views on Treatment Options for Menopausal Vaginal Changes (REVIVE), 63% of women with symptomatic vulvovaginal atrophy reported that their symptoms interfered with the enjoyment of sexual intercourse, and 47% of partnered women indicated it interfered with their relationship. Additionally, 12% of women without a partner stated that they were not seeking a sexual partner due to the symptoms of this disorder (Nappi, Palacios, Particco, & Panay, 2016).
Surgery and Procedures
Some surgeries may lead to sexual dysfunction, either physically or psychologically. One example of this is patients who must undergo a radical cystectomy. Radical cystectomies are indicated in bladder cancer, metastases from other cancers to the bladder, or severe bladder dysfunction that cannot be treated via other means. In men, a cystectomy includes the removal of the bladder, prostate, and seminal vesicles. In women, it typically includes the removal of the uterus, fallopian tubes, cervix, and anterior vagina. Removal of additional structures may be indicated, particularly in patients with metastatic cancers. With the removal of these organs, erectile dysfunction (men) or sexual dysfunction (women) is common and can result in negative patient outcomes. Modh, Mulhall, and Gilbert (2015) note that cystectomy patients have a decreased interest in sex and a decreased ability to maintain an erection as opposed to patients treated with options other than cystectomy. Female patients commonly experience dyspareunia and sexual dysfunction after cystectomy due to surgical changes to the vagina. Additionally, colorectal, prostatic, and urological surgeries also put patients at risk of postoperative sexual complications. Surgical patients are not only at risk for sexual dysfunction due to anatomical changes related to the procedure, but psychological changes due to a change in body image can contribute to dysfunction as well (Modh et al., 2015).
Sexual dysfunction is a common side effect of many medications. For example, many antidepressants may cause sexual dysfunction, both in men and women. Because anxiety and depression can cause sexual dysfunction, at times, it is hard to tell if the medication has alleviated or increased the dysfunction. Commonly reported adverse sexual effects in women are problems with sexual desire (72%), and sexual arousal (83%) (Lorenz, Rullo & Faubion, 2016). Antidepressants that affect serotonin levels are noted to be associated with higher rates of sexual dysfunction that noradrenergic, dopaminergic, or nonmonoaminergic effects. Antidepressants that affect serotonin levels include sertraline (Zoloft), citalopram (Celexa), and venlafaxine (Effexor), while mirtazapine (Remeron) and bupropion (Wellbutrin) have minimal or no effects on serotonin levels. Providers may consider changing patients to other appropriate antidepressants if substantial sexual dysfunction is noted. It is also important to note the onset of the medication in relation to the symptoms. The onset of adverse sexual effects usually occurs one to three weeks after beginning medication, whereas the positive effects of the antidepressant medication do not usually occur until two to four weeks after starting the medication. Therefore, it may be of value for the provider to support and educate the patient prior to changing medication in that time period, as symptoms may improve after the medication level stabilizes. Other drugs that may affect sexual function include antihypertensives (thiazide diuretics), antipsychotics (neuroleptics), and antiandrogens (gonadotropin-releasing hormone analogs and antagonists) (Modh et al., 2015).
Another medication commonly used that may have detrimental sexual side effects are opioids. Long-term opioid use affects the hypothalamic-pituitary-gonadal axis, which can negatively affect sexual dysfunction, both in men and women. One descriptive, cross-sectional study identified that 33% of 1,750 patients with chronic, non-cancer pain that used opioids reported sexual dysfunction. Men reported sexual dysfunction more often than women in this study; however, these results may be due to an increased incidence of men having a regular partner and an active sex life. The morphine dose was positively correlated with the intensity of the sexual dysfunction in this particular study, meaning that higher doses of morphine led to more severe sexual dysfunction. It is noted that more evidence-based interventions are needed to support sexual health in chronic, non-cancer pain patients (Ajo et al., 2016).
As discussed above, opioids can cause sexual dysfunction when used for non-cancer pain. Other substances commonly abused that can cause sexual dysfunction include alcohol, tobacco, cannabis, heroin, and crack/cocaine. A study conducted in Brazil examined male users of alcohol, tobacco, and cocaine (smoked and intranasal ingestion (“snorted”). The study noted that 189 of 508 respondents (37.2%) reported sexual dysfunction. Chronic users of cocaine noted in this study that they experienced impaired sexual performance and increased difficulty in achieving orgasm. Nicotine dependence is detrimental to normal sexual activity due to the impact on the cardiovascular system. Nicotine is also thought to impact levels of testosterone and estrogen negatively. Chronic alcohol abuse can negatively affect cardiac vasculature and neurologic systems, which may explain the impact that alcohol has on sexual function; however, more research is needed in that area. It is also important to note that substance abuse increases the risk of engaging in unsafe sexual behaviors and having/contracting sexually transmitted infections (Diehl, Pillon & Santos, 2016).
It is also important to note the sexual side effects that those recovering from substance abuse may experience. Methadone (Dolophine) is commonly used as medication-assisted therapy for those recovering from opioid dependence. However, methadone is commonly discontinued due to its sexual side effects. Buprenorphine (Suboxone) may be prescribed as an alternative treatment to methadone. One study reviewed patients on maintenance therapy with methadone and buprenorphine. Patients who were in the methadone (Dolophine) group voiced significantly lower sexual desire and overall sexual satisfaction compared to the buprenorphine (Suboxone) group. Patients on methadone (Dolophine) also noted lower orgasmic function. This is important to note, particularly since opioid abusers that discontinue medication maintenance are at significant risk for relapse (Yee, Danaee, Loh, Sulaiman, & Ng, 2016)
With the sexual organs being highly vascular, it stands to reason that cardiovascular issues would lead to erectile or other sexual dysfunctions. One study strongly correlated age, cardiovascular disease, and erectile dysfunction. There appear to be several similarities between cardiovascular disease and erectile dysfunction. This correlation traces back to endothelial dysfunction, which allows an inflammatory response and corresponding plaque formation that can contribute to vascular dysfunction, both systemically and within the sexual organs themselves. There is also a hypothesis related to penile artery size: penile arteries are around 1-2 mm, while coronary arteries are 3-4 mm. This may explain why many people note erectile dysfunction before the cardiovascular disease is diagnosed; the arteries in the penis being smaller and more easily occluded than the ones in the heart. One study noted that 49% of 300 men with acute chest pain and diagnosed coronary artery disease had erectile dysfunction, with 67% of those reporting erectile dysfunction prior to the onset of cardiac symptoms. It is also noted that female sexual dysfunction and cardiovascular disease have a more complex relationship; the study noted a need for more research on the matter (Roushias & Ossei-Gerning, 2019).
Another study correlated cardiac dysfunction with sexuality. It found that men aged 50 and older with a history of heart disease were less likely to be sexually active and more likely to report erectile problems than those without heart disease, especially those diagnosed in the last four years. Sexual satisfaction and concerns about sex appeared similar to the non-heart disease group. This leads researchers to believe that the primary issue in patients suffering from heart disease is not necessarily the sexual activity itself, but the time between a cardiac event and the resumption of sexual activity after said event. This is important for providers to keep in mind, especially when educating the patient after a cardiac event as to when it is safe to begin sexual activity again (Steptoe, Jackson & Wardle, 2016)
Obesity can cause multiple complications, from diabetes to heart disease; sexual dysfunction is also a potential complication. Higher rates of dysfunction are noted in those in poor physical health. A large, multicenter, observational study surveyed those who were waiting to undergo bariatric surgery. It noted that 26% of women and 12% of men reported no sexual desire, while 33% of women and 25% of men were not sexually active, either alone or with a partner. About half of the participants in the study were moderately or very dissatisfied with their sex life. Obesity and its complications can severely limit sexual function. It was noted that many of the patients assessed were also being treated for depression, which may also affect sexual desire and functioning. The study did not address treatment for this situation but identified this as an area for further research, as well as an implication for research regarding weight loss increasing sexual desire (Steffen et al., 2017).
Chronic sleep restriction is rampant in today’s society. Studies have found that 43.8% of Americans get six hours or less of sleep a night. This is typically related to the lifestyle choices of the patient and may directly correlate to an increase in technological advances (i.e., time spent on a smartphone or tablet rather than sleeping). Insufficient sleep is directly related to a decrease in testosterone, thereby linking it to sexual dysfunction. Common sleep disorders, including obstructive sleep apnea, insomnia, shift work disorder, and restless legs disorder, can contribute to sexual dysfunction; this may include erectile dysfunction and other urological disorders. Obstructive sleep apnea is the physical collapse, either partially or completely, of the upper airway during sleep. This causes apneic events (an inability to breathe for at least 10 seconds while chest movement continues), hypopnea, and oxygen desaturation. As this obstruction continues, the patient’s body triggers arousal, in which the patient will physically reopen the airway via gasping. Obstructive sleep apnea is related to many serious medical complications aside from sexual dysfunction, including cardiac dysfunction (atrial fibrillation, congestive heart failure, and myocardial infarction), cerebrovascular accident, chronic obstructive pulmonary disease, depression, and type 2 diabetes. Patients with obstructive sleep apnea report a higher level of erectile dysfunction, between 47.1% and 80%. The mechanisms between this disorder and sexual dysfunction are unknown; however, the theories echo that of the cardiovascular component of inflammation and endothelial dysfunction (Cho & Duffy, 2018).
Restless leg syndrome is another sleep-related disorder that can result in erectile dysfunction, with a correlation to a dopaminergic deficiency and autonomic dysfunction. It is noted that if restless leg syndrome is controlled, erectile dysfunction improves. Circadian rhythm sleep disorders include jet lag and shift work disorder. Jet lag happens with rapid travel to a different time zone (i.e., flying from the United States to Australia). Jet lag is typically self-correcting and responds to an adjustment in sleep schedule and time zone, although it may greatly impact productivity in the initial stages. Shift work disorder is commonly noted in law enforcement and healthcare workers and occurs when the person works at hours that most people would be asleep. Shift workers comprise more than 15% of the workforce worldwide. Shift work disorder can negatively impact a person’s health, putting them at a higher risk for cardiovascular disease, cancer, metabolic syndrome, safety risks such as motor vehicle accidents, and gastrointestinal disorders. Females experiencing shift work disorder may experience irregular menstrual cycles and fertility issues. Thereby, this lack of sleep and disruption of the normal circadian rhythms can greatly impact a patient’s sexual health, causing hypogonadal symptoms and increased sexual dysfunction (Cho & Duffy, 2018).
Cancer can greatly affect every body system. Due to oncologic emergencies such as tumor lysis syndrome, cardiac tamponade, pleural effusions, and superior vena cava syndrome, it is little wonder that the sexual health of cancer patients, particularly those with advanced cancer, is affected. One study questioned patients with advanced cancers about their sexuality. Advanced cancer was noted as stage three or four, and central nervous system involvement, small cell lung cancer, or leukemia. More than half of the patients who responded had not been sexually active in the previous month despite having the desire to do so and noted that their condition impaired their sexual activity, especially in those with prostate or gynecological cancers. Of these patients, more than half noted an unmet need from the healthcare system (Bond, Jensen, Groenvold & Johnsen, 2018).
As cancer moves from treatment to survivorship, special care must be taken to address sexual health in all phases of oncological care. Physiological effects of cancer treatment, such as chemotherapy-induced sexual dysfunction may be more obvious than the psychological effects of cancer treatment. Patients who have had cancer, particularly of the reproductive organs (i.e., testicular or breast cancer), may deal with changes in body image, such as mastectomy or orchiectomy. Chemotherapy can cause mucosal lining damage, most ostentatiously in the mouth. It is important to bear in mind that the mucous membranes run the entire length of the gastrointestinal tract. The vaginal lining is composed of mucous membrane, which can be detrimentally affected by chemotherapy. Radiation either to the reproductive area or the systemic effects of radiation can affect the sexual functioning of the patient with cancer. Side effects of radiation include desquamation, either wet or dry. Patients with breast and ovarian cancers commonly receive chemotherapy, including brachytherapy, which is the insertion of radiation-containing materials into the organ itself in order to provide radiation in closer proximity. One study noted that only one-third of gynecological cancer survivors experiencing sexual dysfunction had initiated a conversation with a professional. Complaints related to sexuality included pelvic floor dysfunction, difficulty with arousal and orgasm, as well as incomplete/improper communication with partners about issues, and coping with sexual complaints. A qualitative aspect was brought to this study, in which participants were invited to make comments regarding certain aspects of their care. The general consensus of the comments was that priority is not given to sexuality during the diagnosis and treatment of gynecological cancers and that education is needed regarding the recovery and outlook of sexual function after treatment is completed (Vermeer, Bakker, Stiggelbout, & Kuile, 2016).
Patients with type 1 and 2 diabetes are at very high risk for cardiac, vascular, and neuropathic complications. Among these complications, erectile and sexual dysfunction is very common; this is due to the vascular changes brought on by abnormal blood levels of glucose and the chronic inflammatory processes. Aside from erectile dysfunction, ejaculatory dysfunction and loss of libido may be present in men, while women may experience decreased libido, reduced lubrication, and painful intercourse. One study noted the emotional toll that sexual dysfunction can have on a diabetic patient’s wellbeing, correlating sexual dysfunction with depressive symptoms, anxiety, and diabetes-specific distress. It confirmed a significant need for sexual function assessments by healthcare professionals during routine and follow up visits (Ventura, Browne, Pouwer, Speight, & Byrne, 2017).
Psychological Conditions: Depression
Depression is one of the most commonly diagnosed psychiatric disorders, affecting about 17% of people at some point in their lifetime. Depression is “an alteration in mood that is expressed by feelings of sadness, despair, and pessimism” (Townsend & Morgan, 2017, p. 378). Patients who are depressed exhibit a loss of interest in normal activities as well as changes in appetite, sleep patterns, and cognition. A major depressive disorder is one of the primary causes of disability in America. Depression is higher in women and affects all races and social classes. Depression is a common cause of sexual dysfunction in both males and females, with symptoms reported as a loss of interest in sexual desire or a lack of genital response. Medications commonly prescribed to treat depression have side effects that are detrimental to a healthy sexual experience (see above section regarding medications). This has a twofold negative effect, in that the patient may not be compliant with medications to fix their depressive state, thereby putting them at a higher risk for complications from the depressive disorder itself (i.e., suicide) (Townsend & Morgan, 2017).
Schizophrenia is a serious and potentially life-threating psychiatric disorder. Many texts note that no psychological disorder is more crippling than schizophrenia. With a lifetime incidence rate of about 1% in the general population, schizophrenia has a range of phases from premorbid, prodromal, actively psychotic, to residual. In the active phase of schizophrenia, the patient presents with delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and/or diminished or absent emotional response (Townsend & Morgan, 2017). Many patients with schizophrenia may suffer from paranoia and hallucinations, oftentimes with a sexual undertone or thought. Although little is known about the causative factors of such symptoms, it is severely detrimental to the sexual health of both the patient and their partner. Patients may distrust or reject their partner’s advances. Depending on the specific patient, high-risk sexual behaviors may be present, putting them at risk for sexually transmitted infections. As schizophrenia is very difficult to treat, a multimodal approach and counseling may be beneficial for these patients. As with depressive disorders, sexual dysfunction is a very prevalent adverse effect of many of the medications used for schizophrenia; this is a primary reason for medication noncompliance and relapse of symptoms (Rokach, 2019).
According to Townsend and Morgan (2017), more than one in three women (35.6%) and one in four men (28%) have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Physical abuse between partners is known as spousal abuse or intimate partner violence. Any form of abuse (rape, neglect, family violence, etc.) can contribute to anxiety and depression in a patient, thereby contributing to sexual dysfunction. One study investigated the associations between urological issues such as pelvic floor weakness, pain, and dyspareunia with bullying and abuse. Out of the 338 patients that responded to the survey, 191 (56%) noted that they were victims of bullying. 91 (24%) of respondents reported a history of abuse. Women who had experienced both abuse and bullying had a higher prevalence of anxiety, migraines, fibromyalgia, bullying, and irritable bowel syndrome. They were also noted to have higher overall pain and decreased sexual satisfaction. The study concluded that bullying and abuse lead to more pain, urological symptoms, sexual dysfunction, anxiety, and depression. This study conveys future implications for further research on the matter, particularly on the treatment of the patient’s emotional state to potentially improve the physical symptoms experienced (Nault, Gupat, Ehlert, Dove-Medow, & Seltzer, 2016).
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a reaction to an event that the person perceives as traumatic. Traumatic instances include combat, natural disasters, rape, accidents, torture, abuse (see above), or other crimes. Typically, the patient may re-experience the event mentally and sustain severe anxiety or dissociation. Symptoms of anxiety and depression typically accompany PTSD. Variables within PTSD include the patient’s coping mechanisms, behavioral tendencies, demographic factors, and psychological co-morbidities (Townsend & Morgan, 2017). With such serious complications as psychosis and suicide, sexual function among those suffering from PTSD is often overlooked. One study reviewing sexual function among veterans with PTSD found a link between the disorder and decreased sexual intimacy, impairments in sexual satisfaction, and marital dissatisfaction among respondents. The study defined sexual dysfunction as a problem (erectile dysfunction, etc.) in at least 75% of sexual activity occasions. Within these parameters, it was noted that sexual dysfunction was present in 64.9% of patients with PTSD. This demonstrates a need for more research into treatment for PTSD, not only for veterans but for other patients who have experienced trauma in their lifetime. As with other psychological disorders, it is important to remember that the adverse effects of medications commonly used for this disorder (SSRIs) often contribute to sexual dysfunction (Letica-Creulja et al., 2019).
Assessment and Diagnosis
It is vital to perform a complete assessment of sexual health when evaluating patients, especially those with high-risk diagnoses discussed above. Establishing a therapeutic relationship with the patient is essential for communication and the comfort of the patient. After establishing this connection, the nurse or provider should obtain specific details about the suspected sexual dysfunction at hand. Important notations should include the client’s sexuality, marital status, current understanding of sexual function, as well as duration and frequency of the dysfunction. This may indicate potential causes of the dysfunction, as discussed above. Focused assessment of suspected causes of sexual dysfunction is vital. For example, questions related to possible endocrine disorders are important- if hyper or hypothyroidism is present, it could be a potential causative factor of sexual dysfunction. Obtaining a thorough health history, including surgeries, elective procedures, and cosmetic implants, is important as well, as this can impact sexual functioning. Functional health patterns are important as well- health perception, nutritional status, stress/coping, and values and beliefs are important as well in order to provide a significant baseline for treatment, as well as readiness for education (Harding et al., 2020).
Diagnostic tests for sexual dysfunction vary and are generally used to verify causative factors of sexual dysfunction rather than the dysfunction itself. For instance, testosterone and other sex hormones may be evaluated via a blood test, computerized tomography (CT) may be used to rule out tumor involvement, and psychological exams may be used if PTSD is suspected (Townsend & Morgan, 2017).
Treatment may be a multi-faceted multidisciplinary course, depending on the cause and nature of the sexual dysfunction itself. For instance, diabetics with sexual dysfunction will benefit from controlled blood glucose levels, exercise, and a healthy diet. Hyper and hypoglycemic episodes during sex can greatly affect sexual satisfaction. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, 2018) recommends monitoring blood sugar closely around the times that sexual intimacy is expected, particularly if those times are around the administration of insulin or other diabetic medications. The main course of treatment for sexual disorders in the patient with diabetes is phosphodiesterase type 5 inhibitors or testosterone replacement (used judiciously due to the detrimental side effects of steroid usage). It is noted that diabetic-related sexual dysfunction treatment should consist of a multidisciplinary approach, including urology, gynecology, endocrinology, and psychiatry (Kizilay, Gali, & Serrefoglu, 2017). The NIDDK (2018) notes that women who keep their blood glucose levels within an appropriate range are less likely to have nerve damage, thereby maintaining sexual health. Sexual counseling, along with phosphodiesterase-5-inhibitors, intracorporal injection, transurethral suppositories, or vacuum pump devices, may be effective treatments for patients experiencing sexual dysfunction related to a surgical procedure (Modh et al., 2015). Continuous positive airway pressure (CPAP) is the gold-standard treatment for obstructive sleep apnea. Treatment of sleep apnea with CPAP has been shown to increase follicle-stimulating hormone, luteinizing hormone, and testosterone, thereby increasing sexual functioning and satisfaction. The study also reviewed sildenafil (Viagra), which was found to help erectile dysfunction in those with obstructive sleep apnea, and testosterone, which was found to be minimally effective. Treatment with uvulopalatopharyngoplasty (UPPP) lead to even better results than CPAP for erectile dysfunction; however, more research is needed (Cho & Duffy, 2018).
Many medications are approved by the Food and Drug Administration (FDA) for sexual dysfunction, particularly erectile dysfunction. These drugs include sildenafil (Viagra), avanafil (Stednra), tadalafil (Cialis), and vardenafil (Levitra). These medications block phosphodiesterase-5, the enzyme that breaks down cyclic guanosine monophosphate, which is required for an erection. This action only occurs in the presence of nitrous oxide, which is released during sexual arousal. Therefore, phosphodiesterase inhibitors only work to achieve an erection in the presence of arousal, meaning that this group of medications is not effective for those with hypoactive arousal disorder. These medications come with significant adverse effects: headache, flushing, dizziness, along with an FDA black box warning of the potential for sudden vision and hearing loss. These medications are also contraindicated with the use of nitrates, which is a common group of medications for those with cardiovascular disease. The nurse should inquire about the use of herbal supplements and alternative medications when assessing the patient. For example, Yohimbe is a natural remedy used for erectile dysfunction that can cause a hypertensive crisis when taken with tyramine-containing foods (cured meats, red wine, caffeine, aged cheeses, overripe fruit, etc.). Other supplements and products sold at convenience stores (i.e., “horny goat weed”) should also be noted, as they are not regulated by the FDA and can contain ingredients that may be harmful to the patient (Townsend & Morgan, 2017).
Hormonal therapy, such as estrogen replacement therapy for women experiencing menopausal symptoms, has been controversial due to links to increased mortality during randomized studies conducted. However, new research indicates no link to increased mortality related to cancer or cardiovascular disease in relation to postmenopausal hormone therapy. This implies a potential resurgence, particularly with the benefits of hormone replacement therapy's benefits of decreased hot flashes, protection against fractures, in addition to the increase in sexual function. It is important to note that the women surveyed in this longitudinal study had no incidence of cancer- which can be a contraindication against hormone replacement therapy (Jensen, 2019).
Other treatments for erectile disorder include intraurethral suppositories, intracavernosal injections, vacuum tumescence therapy, or penile-prosthesis surgery. Penile prostheses are generally reserved for those patients that are not responsive to other therapies. Treatments for other sexual disorders include methods to decrease anxiety, communication skills training, and Kegel exercises. For those who have traumatic experiences that cause sexual dysfunction, cognitive behavioral therapy, biofeedback, and intensive exposure therapy may effectively reduce the symptoms of PTSD (Townsend & Morgan, 2017).
In the case of surgical menopause, androgen replacement therapy may be considered; however, these patients should be monitored carefully due to the risk of complications associated with such treatment. Treatment for symptomatic vulvovaginal atrophy may include hormonal therapy, such as estrogen. It is important to note that estrogen therapy has not been proven to increase sexual desire; however, it does help decrease vaginal dryness and dyspareunia. Applications of this medication include vaginal creams, rings, and tablets. Patients who cannot partake in hormonal treatment due to a history of hormone-receptive cancers, or who do not care for hormone therapy, may be treated with water-based lubricants and moisturizers to help with dryness and discomfort (Thornton et al., 2018).
Many studies support the benefit of a combination approach to treatment with psychotherapy and medication. It is also important for the patient’s partner to be included in the treatment plan (if indicated) in order to provide holistic care for all involved (Townsend & Morgan, 2017).
Indications for Future Research and Education
Current research is being conducted for female sexual dysfunction, as it is more nebulous and difficult to treat. Medications and treatments offered for sexual dysfunction are not without adverse effects and are contraindicated in some populations. Sexual dysfunction is also underdiagnosed due to underreporting by patients and a lack of assessment from healthcare providers. It is essential for providers to establish a therapeutic, open relationship with patients and perform a comprehensive sexual health assessment in order to identify and treat sexual dysfunction. There are also many medications and disease processes that were not mentioned in this educational module that could be causative factors when evaluating for sexual dysfunction. The healthcare provider should evaluate the potential for adverse sexual effects when reviewing a patient’s health history as well.
Two medications currently being researched for the treatment of HSDD include Lorexys (bupropion and trazodone), and Addyi (flibanserin). Lorexys consists of two common medications, trazodone, and bupropion, that work together to regulate the neurotransmitters thought to be misaligned in HSDD. This medication is currently in a phase 2a clinical study. Addyi (flibanserin) is an agonist of certain serotonin receptors. It is currently FDA-approved for the treatment of HSDD in premenopausal women and is seeking approval for postmenopausal women (Thornton et al., 2018).
Sexual health has progressed greatly since the mythology of the Egyptians and the institutionalization of “female hysterics” during the 19th century. However, patient care providers can continue to march onward toward a more compassionate, appropriate, and empathetic culture when caring for those suffering from sexual dysfunction. By using appropriate communication and being a patient advocate, providers can carefully and compassionately address the “elephant in the room” that is sexual dysfunction.
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