sexual dysfunction sexual dysfunction sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. the world health organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". this definition is broad and is subject to many interpretations. a diagnosis of sexual dysfunction under the dsm-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months (except for substance- or medication-induced sexual dysfunction). sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. the term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference. sexual dysfunctionother namessexual malfunction, sexual disorderspecialtysexology, gynecology, andrology a thorough sexual history and assessment of general health and other sexual problems (if any) are important when assessing sexual dysfunction, because it is usually correlated with other psychiatric issues, such as mood disorders, eating and anxiety disorders, and schizophrenia. assessing performance anxiety, guilt, stress, and worry are integral to the optimal management of sexual dysfunction. many of the sexual dysfunctions that are defined are based on the human sexual response cycle proposed by william h. masters and virginia e. johnson, and modified by helen singer kaplan. types sexual dysfunction can be classified into four categories: sexual desire disorders, arousal disorders, orgasm disorders, and pain disorders. dysfunction among men and women are studied in the fields of andrology and gynecology respectively. sexual desire disorders main article: hypoactive sexual desire disorder sexual desire disorders or decreased libido are characterized by a lack of sexual desire, libido for sexual activity, or sexual fantasies for some time. the condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. the condition may start after a period of normal sexual functioning, or the person may always have had an absence or a lesser intensity of sexual desire. the causes vary considerably but include a decrease in the production of normal estrogen in women, or testosterone in both men and women. other causes may be aging, fatigue, pregnancy, medications (such as ssris), or psychiatric conditions, such as depression and anxiety. while many causes of low sexual desire are cited, only a few of these have ever been the object of empirical research. sexual arousal disorders main article: sexual arousal disorder sexual arousal disorders were previously known as frigidity in women and impotence in men, though these have now been replaced with less judgmental terms. impotence is now known as erectile dysfunction, and frigidity has been replaced with a number of terms describing specific problems that can be broken down into four categories as described by the american psychiatric association's diagnostic and statistical manual of mental disorders: lack of desire, lack of arousal, pain during intercourse, and lack of orgasm. for both men and women, these conditions can manifest themselves as an aversion to and avoidance of sexual contact with a partner. in men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity. there may be physiological origins to these disorders, such as decreased blood flow or lack of vaginal lubrication. chronic disease and the partners' relationship can also contribute to dysfunction. additionally, postorgasmic illness syndrome (pois) may cause symptoms when aroused, including adrenergic-type presentation: rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness, and fatigue. from the onset of arousal, symptoms can persist for up to a week in patients. the cause of this condition is unknown; however, it is believed to be a pathology of either the immune system or autonomic nervous systems. it is defined as a rare disease by the national institute of health, but the prevalence is unknown. it is not thought to be psychiatric in nature, but it may present as anxiety relating to coital activities and may be incorrectly diagnosed as such. there is no known cure or treatment. erectile dysfunction main article: erectile dysfunction erectile dysfunction (ed), or impotence, is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis. there are various underlying causes of ed, including damage to anatomical structures, psychological causes, medical disease, and drug use. many of these causes are medically treatable. psychological ed can often be treated by almost anything that the patient believes in; there is a very strong placebo effect. physical damage can be more difficult to treat. one leading physical cause of ed is continual or severe damage taken to the nervi erigentes, which can prevent or delay erection. these nerves course beside the prostate arising from the sacral plexus and can be damaged in prostatic and colorectal surgeries. diseases are also common causes of erectile dysfunction. diseases such as cardiovascular disease, multiple sclerosis, kidney failure, vascular disease, and spinal cord injury can cause erectile dysfunction. cardiovascular disease can decrease blood flow to penile tissues, making it difficult to develop or maintain an erection. due to the shame and embarrassment felt by some with erectile dysfunction, the subject was taboo for a long time and is the focus of many urban legends. folk remedies have long been advocated, with some being advertised widely since the 1930s. the introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (trade name viagra), in the 1990s caused a wave of public attention, propelled in part by the newsworthiness of stories about it and heavy advertising. it is estimated that around 30 million men in the united states and 152 million men worldwide have erectile dysfunction. however, social stigma, low health literacy, and social taboos lead to under reporting which makes an accurate prevalence rate hard to determine. the latin term impotentia coeundi describes the inability to insert the penis into the vagina, and has been mostly replaced by more precise terms. ed from vascular disease is seen mainly amongst older individuals who have atherosclerosis. vascular disease is common in individuals who smoke or have diabetes, peripheral vascular disease, or hypertension. any time blood flow to the penis is impaired, ed can occur. drugs are also a cause of erectile dysfunction. individuals who take drugs that lower blood pressure, antipsychotics, antidepressants, sedatives, narcotics, antacids, or alcohol can have problems with sexual function and loss of libido. hormone deficiency is a relatively rare cause of erectile dysfunction. in individuals with testicular failure, as in klinefelter syndrome, or those who have had radiation therapy, chemotherapy, or childhood exposure to the mumps virus, the testes may fail to produce testosterone. other hormonal causes of erectile failure include brain tumors, hyperthyroidism, hypothyroidism, or adrenal gland disorders. anorgasmia main article: anorgasmia anorgasmia is classified as persistent delays or absence of orgasm following a normal sexual excitement phase in at least 75% of sexual encounters.: 368 the disorder can have physical, psychological, or pharmacological origins. ssri antidepressants are a common pharmaceutical culprit, as they can delay orgasm or eliminate it entirely. a common physiological cause of anorgasmia is menopause; one in three women report problems obtaining an orgasm during sexual stimulation following menopause. premature ejaculation main article: premature ejaculation premature ejaculation is when ejaculation occurs before the partner achieves orgasm, or a mutually satisfactory length of time has passed during intercourse. there is no correct length of time for intercourse to last, but generally, premature ejaculation is thought to occur when ejaculation occurs in under two minutes from the time of the insertion of the penis. for a diagnosis, the patient must have a chronic history of premature ejaculation, poor ejaculatory control, and the problem must cause feelings of dissatisfaction as well as distress for the patient, the partner, or both. premature ejaculation has historically been attributed to psychological causes, but newer theories suggest that premature ejaculation may have an underlying neurobiological cause that may lead to rapid ejaculation. post-orgasmic disorders post-orgasmic disorders cause symptoms shortly after orgasm or ejaculation. post-coital tristesse (pct) is a feeling of melancholy and anxiety after sexual intercourse that lasts for up to two hours. sexual headaches occur in the skull and neck during sexual activity, including masturbation, arousal or orgasm. in men, pois causes severe muscle pain throughout the body and other symptoms immediately following ejaculation. these symptoms last for up to a week. some doctors speculate that the frequency of pois "in the population may be greater than has been reported in the academic literature", and that many with pois are undiagnosed. pois may involve adrenergic symptoms: rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness, and fatigue. the etiology of this condition is unknown; however, it is believed to be a pathology of either the immune system or autonomic nervous systems. it is defined as a rare disease by the nih, but the prevalence is unknown. it is not thought to be psychiatric in nature, but it may present as anxiety relating to coital activities and thus may be incorrectly diagnosed as such. there is no known cure or treatment. dhat syndrome is another condition which occurs in men: it is a culture-bound syndrome which causes anxious and dysphoric mood after sex. it is distinct from the low-mood and concentration problems (acute aphasia) seen in pois. sexual pain disorders sexual pain disorders in women include dyspareunia (painful intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal wall that interferes with intercourse). dyspareunia may be caused by vaginal dryness. poor lubrication may result from insufficient excitement and stimulation, or from hormonal changes caused by menopause, pregnancy, or breastfeeding. irritation from contraceptive creams and foams can also cause dryness, as can fear and anxiety about sex. it is unclear exactly what causes vaginismus, but it is thought that past sexual trauma (such as rape or abuse) may play a role. another female sexual pain disorder is vulvodynia, or vulvar vestibulitis when localized to the vulval vestibule. in this condition, women experience burning pain during sex, which seems to be related to problems with the skin in the vulvar and vaginal areas. its cause is unknown. in men, structural abnormalities of the penis like peyronie's disease can make sexual intercourse difficult and/or painful. the disease is characterized by thick fibrous bands in the penis that lead to excessive curvature during erection. it has an incidence estimated at 0.4–3% or more, is most common in men 40–70, and has no certain cause. risk factors include genetics, minor trauma (potentially during cystoscopy or transurethral resection of the prostate), chronic systemic vascular diseases, smoking, and alcohol consumption. priapism is a painful erection that occurs for several hours and occurs in the absence of sexual stimulation. this condition develops when blood is trapped in the penis and is unable to drain. if the condition is not promptly treated, it can lead to severe scarring and permanent loss of erectile function. the disorder is most common in young men and children. individuals with sickle-cell disease and those who use certain medications can often develop this disorder. causes there are many factors which may result in a person experiencing a sexual dysfunction. these may result from emotional or physical causes. emotional factors include interpersonal or psychological problems, which include depression, sexual fears or guilt, past sexual trauma, and sexual disorders. sexual dysfunction is especially common among people who have anxiety disorders. ordinary anxiety can cause erectile dysfunction in men without psychiatric problems, but clinically diagnosable disorders such as panic disorder commonly cause avoidance of intercourse and premature ejaculation. pain during intercourse is often a comorbidity of anxiety disorders among women. physical factors that can lead to sexual dysfunctions include the use of drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives, antihistamines, and some psychotherapeutic drugs. for women, almost any physiological change that affects the reproductive system—premenstrual syndrome, pregnancy and the postpartum period, and menopause—can have an adverse effect on libido. back injuries may also impact sexual activity, as can problems with an enlarged prostate gland, problems with blood supply, or nerve damage (as in sexual dysfunction after spinal cord injuries). diseases such as diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis may also impact activity, as