can the failure of various organ systems (such as the heart and lungs), endocrine disorders (thyroid, pituitary, or adrenal gland problems), hormonal deficiencies (low testosterone, other androgens, or estrogen), and some birth defects. in the context of heterosexual relationships, one of the main reasons for the decline in sexual activity among these couples is the male partner experiencing erectile dysfunction. this can be very distressing for the male partner, causing poor body image, and it can also be a major source of low desire for these men. in aging women, it is natural for the vagina to narrow and atrophy. if a woman does not participate in sexual activity regularly (in particular, activities involving vaginal penetration), she will not be able to immediately accommodate a penis without risking pain or injury if she decides to engage in penetrative intercourse. this can turn into a vicious cycle that often leads to female sexual dysfunction. according to emily wentzell, american culture has anti-aging sentiments that have caused sexual dysfunction to become "an illness that needs treatment" instead of viewing it as a natural part of the aging process. not all cultures seek treatment; for example, a population of men living in mexico often accept ed as a normal part of their maturing sexuality. post ssri sexual dysfunction main article: post-ssri sexual dysfunction sexual problems are common with ssris, which can cause anorgasmia, erectile dysfunction, diminished libido, genital numbness, and sexual anhedonia (pleasureless orgasm). poor sexual function is also one of the most common reasons people stop the medication. in some cases, symptoms of sexual dysfunction may persist after discontinuation of ssris.: 14 this combination of symptoms is sometimes referred to as post-ssri sexual dysfunction (pssd). pelvic floor dysfunction main article: pelvic floor dysfunction pelvic floor dysfunction can be an underlying cause of sexual dysfunction in both women and men, and is treatable by pelvic floor physical therapy, a type of physical therapy designed to restore the health and function of the pelvic floor and surrounding areas. female sexual dysfunction several theories have looked at female sexual dysfunction, from medical to psychological perspectives. three social psychological theories include: the self-perception theory, the overjustification hypothesis, and the insufficient justification hypothesis: self-perception theory: people make attributions about their own attitudes, feelings, and behaviours by relying on their observations of external behaviours and the circumstances in which those behaviours occur overjustification hypothesis: when an external reward is given to a person for performing an intrinsically rewarding activity, the person's intrinsic interest will decrease insufficient justification: based on the classic cognitive dissonance theory (inconsistency between two cognitions or between a cognition and a behavior will create discomfort), this theory states that people will alter one of the cognitions or behaviours to restore consistency and reduce distress the importance of how a woman perceives her behavior should not be underestimated. many women perceive sex as a chore as opposed to a pleasurable experience, and they tend to consider themselves sexually inadequate, which in turn does not motivate them to engage in sexual activity. several factors influence a women's perception of her sexual life. these can include race, gender, ethnicity, educational background, socioeconomic status, sexual orientation, financial resources, culture, and religion. cultural differences are also present in how women view menopause and its impact on health, self-image, and sexuality. a study found that african american women are the most optimistic about menopausal life; caucasian women are the most anxious, asian women are the most inhibited about their symptoms, and hispanic women are the most stoic. about one-third of the women experienced sexual dysfunction, which may lead to these women's loss of confidence in their sexual lives. since these women have sexual problems, their sexual lives with their partners can become a burden without pleasure, and may eventually lose complete interest in sexual activity. some of the women found it hard to be aroused mentally, while others had physical problems. several factors can affect female dysfunction, such as situations in which women do not trust their sex partners, the environment where sex occurs being uncomfortable, or an inability to concentrate on the sexual activity due to a bad mood or burdens from work. other factors include physical discomfort or difficulty in achieving arousal, which could be caused by aging or changes in the body's condition. sexual assault has been associated with excessive menstrual bleeding, genital burning, and painful intercourse (attributable to disease, injury, or otherwise), medically unexplained dysmenorrhea, menstrual irregularity, and lack of sexual pleasure. physically violent assaults and those committed by strangers were most strongly related to reproductive symptoms. multiple assaults, assaults accomplished by persuasion, spousal assault, and completed intercourse were most strongly related to sexual symptoms. assault was occasionally associated more strongly with reproductive symptoms among women with lower income or less education, possibly because of economic stress or differences in assault circumstances. associations with unexplained menstrual irregularity were strongest among african american women; ethnic differences in reported circumstances of assault appeared to account for these differences. assault was associated with sexual indifference only among latinas. menopause the most prevalent of female sexual dysfunctions that have been linked to menopause include lack of desire and libido; these are predominantly associated with hormonal physiology. specifically, the decline in serum estrogens causes these changes in sexual functioning. androgen depletion may also play a role, but current knowledge about this is less clear. the hormonal changes that take place during the menopausal transition have been suggested to affect women's sexual response through several mechanisms, some more conclusive than others. aging in women whether or not aging directly affects women's sexual functioning during menopause is controversial. however, many studies, including hayes and dennerstein's critical review, have demonstrated that aging has a powerful impact on sexual function and dysfunction in women, specifically in the areas of desire, sexual interest, and frequency of orgasm. in addition, dennerstien and colleagues found that the primary predictor of sexual response throughout menopause is prior sexual functioning, which means that it is important to understand how the physiological changes in men and women can affect sexual desire. despite the apparent negative impact that menopause can have on sexuality and sexual functioning, sexual confidence and well-being can improve with age and menopausal status. the impact that a relationship status can have on quality of life is often underestimated. testosterone, along with its metabolite dihydrotestosterone, is important to normal sexual function in men and women. dihydrotestosterone is the most prevalent androgen in both men and women. testosterone levels in women at age 60 are on average about half of what they were before the women were 40. although this decline is gradual for most women, those who have undergone bilateral oophorectomy experience a sudden drop in testosterone levels, as the ovaries produce 40% of the body's circulating testosterone. sexual desire has been related to three separate components: drive, beliefs and values, and motivation. particularly in postmenopausal women, drive fades and is no longer the initial step in a woman's sexual response. diagnosis list of disorders dsm the fourth edition of the diagnostic and statistical manual of mental disorders lists the following sexual dysfunctions: hypoactive sexual desire disorder (see also asexuality, which is not classified as a disorder) sexual aversion disorder (avoidance of or lack of desire for sexual intercourse) female sexual arousal disorder (failure of normal lubricating arousal response) male erectile disorder female orgasmic disorder (see anorgasmia) male orgasmic disorder (see anorgasmia) premature ejaculation dyspareunia vaginismus additional dsm sexual disorders that are not sexual dysfunctions include: paraphilias ptsd due to genital mutilation or childhood sexual abuse other sexual problems sexual dissatisfaction (non-specific) lack of sexual desire anorgasmia impotence sexually transmitted diseases delay or absence of ejaculation, despite adequate stimulation inability to control timing of ejaculation inability to relax vaginal muscles enough to allow intercourse inadequate vaginal lubrication preceding and during intercourse burning pain on the vulva or in the vagina with contact to those areas unhappiness or confusion related to sexual orientation transsexual and transgender people may have sexual problems before or after surgery. persistent sexual arousal syndrome sexual addiction hypersexuality all forms of female genital cutting post-orgasmic diseases, such as dhat syndrome, pct, pois, and sexual headaches. treatment males several decades ago, the medical community believed most sexual dysfunction cases were related to psychological issues. although this may be true for a portion of men, the vast majority of cases have now been identified to have a physical cause or correlation. if the sexual dysfunction is deemed to have a psychological component or cause, psychotherapy can help. situational anxiety arises from an earlier bad incident or lack of experience, and often leads to development of fear towards sexual activity and avoidance which enters a cycle of increased anxiety and desensitization of the penis. in some cases, erectile dysfunction may be due to marital disharmony. marriage counseling sessions are recommended in this situation. lifestyle changes such as discontinuing tobacco smoking or substance use can also treat some types of ed. several oral medications like viagra, cialis, and levitra have become available to alleviate ed and have become first line therapy. these medications provide an easy, safe, and effective treatment solution for approximately 60% of men. in the rest, the medications may not work because of wrong diagnosis or chronic history. another type of medication that is effective in roughly 85% of men is called intracavernous pharmacotherapy, which involves injecting a vasodilator drug directly into the penis to stimulate an erection. this method has an increased risk of priapism if used in conjunction with other treatments, and localized pain. premature ejaculations are treated by behavioural techniques squeeze technique and stop start technique. in squeeze technique the area between head and shaft of penis is pressed using index finger and thumb just before ejaculation. in stop start technique the male partner stops having sexual intercourse just before ejaculation and waits for the sense of ejaculation to pass away. both techniques are repeated many times. when conservative therapies fail, are an unsatisfactory treatment option, or are contraindicated for use, the insertion of a penile implant may be selected by the patient. technological advances have made the insertion of a penile implant a safe option for the treatment of ed, which provides the highest patient and partner satisfaction rates of all available ed treatment options. pelvic floor physical therapy has been shown to be a valid treatment for men with sexual problems and pelvic pain. the 2020 guidelines from the american college of physicians support the discussion of testosterone treatment in adult men with age-related low levels of testosterone who have sexual dysfunction. they recommend yearly evaluation regarding possible improvement and, if none, to discontinue testosterone; intramuscular treatments should be considered rather than transdermal treatments due to costs and since the effectiveness and harm of either method is similar. testosterone treatment for reasons other than possible improvement of sexual dysfunction may not be recommended. females in 2015, flibanserin was approved in the us to treat decreased sexual desire in women. while it is effective for some women, it has been criticized for its limited efficacy, and has many warnings and contraindications that limit its use. women experiencing pain with intercourse are often prescribed pain relievers or desensitizing agents; others are prescribed vaginal lubricants. many women with sexual dysfunction are also referred to a counselor or sex therapist. menopause estrogens are responsible for the maintenance of collagen, elastic fibers, and vasculature of the urogenital tract, all of which are important in maintaining vaginal structure and functional integrity; they are also important for maintaining vaginal ph and moisture levels, both of which help to keep the tissues lubricated and protected. prolonged estrogen deficiency leads to atrophy, fibrosis, and reduced blood flow to the urogenital tract, which cause menopausal symptoms such as vaginal dryness and pain related to sexual activity and/or intercourse. it has been consistently demonstrated that women with lower sexual functioning have lower estradiol levels. women experiencing vaginal dryness who cannot use commercial lubricants may be able to use coconut oil as an alternative. androgen therapy for hypoactive sexual desire disorder has a small benefit but its safety is not known. it is not approved as a treatment in the united states. it is more commonly used among women who have had an oophorectomy or are in a postmenopausal state. however, like most