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Sexual dysfunctions, disorders in which people cannot respond normally in key areas of sexual functioning, make it difficult or impossible to enjoy sexual intercourse. Studies suggest that as many as 30 percent of men and 45 percent of women around the world suffer from such a dysfunction during their lives (Lewis et al., 2010). Sexual dysfunctions are typically very distressing, and they often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems (Faubion & Rullo, 2015; McCarthy & McCarthy, 2012). Often these dysfunctions are interrelated; many patients with one dysfunction have another as well. Sexual dysfunctioning is described here for heterosexual couples, the majority of couples seen in therapy. Gay and lesbian couples have the same dysfunctions, however, and therapists use the same basic techniques to treat them.

The human sexual response can be described as a cycle with four phases: desire, excitement, orgasm, and resolution (see Figure 11.1). Sexual dysfunctions affect one or more of the first three phases. Resolution consists simply of the relaxation and reduction in arousal that follow orgasm. Some people struggle with a sexual dysfunction their whole lives; in other cases, normal sexual functioning preceded the dysfunction. In some cases the dysfunction is present during all sexual situations; in others it is tied to particular situations (APA, 2013).

The desire phase of the sexual response cycle consists of an interest in or urge to have sex, sexual attraction to others, and, for many people, sexual fantasies. Two dysfunctions affect the desire phase—male hypoactive sexual desire disorder and female sexual interest/arousal disorder. The latter disorder actually cuts across both the desire and excitement phases of the sexual response cycle. It is considered a single disorder in DSM-5 because, according to research, desire and arousal overlap particularly highly for women, and many women express difficulty distinguishing feelings of desire from those of arousal (APA, 2013).

A number of people have normal sexual interest but choose, as a matter of lifestyle rather than sexual desire, to avoid engaging in sexual relations (see InfoCentral on page 350). These people are not diagnosed as having one of the sexual desire disorders.

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Men with male hypoactive sexual desire disorder persistently lack or have reduced interest in sex and engage in little sexual activity (see Table 11.1). Nevertheless, when they do have sex, their physical responses may be normal and they may enjoy the experience. While most cultures portray men as wanting all the sex they can get, as many as 18 percent of men worldwide have this disorder, and the number seeking therapy has increased during the past decade (Martin et al., 2014; Lewis et al., 2010).

Women with female sexual interest/arousal disorder also lack normal interest in sex and rarely initiate sexual activity (see Table 11.1 again). In addition, many such women feel little excitement during sexual activity, are unaroused by erotic cues, and have few genital or nongenital sensations during sexual activity (APA, 2013). As many as 38 percent of women worldwide have reduced sexual interest and arousal (Christensen et al., 2011; Laumann et al., 2005, 1999, 1994). It is important to note that many sex researchers and therapists believe it is inaccurate to combine desire and excitement symptoms into a single female disorder (Sungur & Gündüz, 2014).

A person’s sex drive is determined by a combination of biological, psychological, and sociocultural factors, any of which may reduce sexual desire. Most cases of low sexual desire are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly.

Biological Causes of Low Sexual Desire A number of hormones interact to help produce sexual desire and behavior (see Figure 11.2), and abnormalities in their activity can lower a person’s sex drive (Randolph et al., 2015; Giraldi et al., 2013; Laan et al., 2013). In both men and women, a high level of the hormone prolactin, a low level of the male sex hormone testosterone, and either a high or low level of the female sex hormone estrogen can lead to low sex drive. Low sex drive has been linked to the high levels of estrogen contained in some birth control pills, for example. Conversely, it has also been tied to the low level of estrogen found in many postmenopausal women or women who have recently given birth. Long-term physical illness can also lower a person’s sex drive (Berry & Berry, 2013). The reduced drive may be a direct result of the illness or an indirect result because of stress, pain, or depression brought on by the illness.

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Clinical practice and research have further indicated that sex drive can be lowered by certain pain medications, psychotropic drugs, and illegal drugs such as cocaine, marijuana, amphetamines, and heroin (Glina et al., 2013). Low levels of alcohol may enhance the sex drive by lowering a person’s inhibitions, but high levels may reduce it (George et al., 2011).

Psychological Causes of Low Sexual Desire A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women (Rajkumar & Kumaran, 2015; Štulhofer et al., 2013). Frequently, as cognitive theorists have noted, people with low sexual desire have particular attitudes, fears, or memories that contribute to their dysfunction, such as a belief that sex is immoral or dangerous (Giraldi et al., 2013). Other people are so afraid of losing control over their sexual urges that they try to resist them completely. And still others fear pregnancy.

Certain psychological disorders may also contribute to low sexual desire. Even a mild level of depression can interfere with sexual desire, and some people with obsessive-compulsive symptoms find contact with another person’s body fluids and odors to be highly unpleasant (Rubio-Aurioles & Bivalacqua, 2013).

Sociocultural Causes of Low Sexual Desire The attitudes, fears, and psychological disorders that contribute to low sexual desire occur within a social context, and thus certain sociocultural factors have also been linked to disorders of sexual desire. Many people who have low sexual desire are feeling situational pressures—for example, divorce, a death in the family, job stress, infertility difficulties, or having a baby (Hamilton & Meston, 2013). Other people may be having problems in their relationships (Witherow et al., 2015; Brenot, 2011). People who are in an unhappy relationship, have lost affection for their partner, or feel powerless and dominated by their partner can lose interest in sex. Even in basically happy relationships, if one partner is a very unskilled, unenthusiastic lover, the other can begin to lose interest in sex (Jiann, Su, & Tsai, 2013). And sometimes partners differ in their needs for closeness. The one who needs more personal space may develop low sexual desire as a way of keeping distance.

Cultural standards can also set the stage for low sexual desire. Some men adopt our culture’s double standard and thus cannot feel sexual desire for a woman they love and respect (Maurice, 2007). More generally, because our society equates sexual attractiveness with youthfulness, many middle-aged and older men and women lose interest in sex as their self-image or their attraction to their partner diminishes with age (Leiblum, 2010).

The trauma of sexual molestation or assault is especially likely to produce the fears, attitudes, and memories found in disorders of sexual desire. Some survivors of sexual abuse may feel repelled by sex, sometimes for years, even decades (Turchik & Hassija, 2014; Giraldi et al., 2013). In some cases, survivors may have vivid flashbacks of the assault during adult consensual sexual activity.

The excitement phase of the sexual response cycle is marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing. In men, blood pools in the pelvis and leads to erection of the penis; in women, this phase produces swelling of the clitoris and labia, as well as lubrication of the vagina. As you read earlier, female sexual interest/arousal disorder may include dysfunction during the excitement phase. In addition, a male disorder—erectile disorder—involves dysfunction during the excitement phase only.

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Erectile Disorder Men with erectile disorder persistently fail to attain or maintain an erection during sexual activity (see Table 11.2). This problem occurs in as much as 25 percent of the male population, including Robert, the man whose difficulties opened this chapter (Martin et al., 2014; Christensen et al., 2011). Carlos Domera also has erectile disorder:

Unlike Carlos, most men with an erectile disorder are over the age of 50, largely because so many cases are associated with ailments or diseases of older adults (Regal, 2015). Around 7 percent of men who are under 40 years old also have the disorder; that number increases to as many as 40 percent of men in their sixties and 75 percent of those in their seventies and eighties (Lewis et al., 2010; Rosen, 2007). Moreover, according to surveys, half of all adult men experience erectile difficulty during intercourse at least some of the time. Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes.

BIOLOGICAL CAUSES The same hormonal imbalances that can cause male hypoactive sexual desire disorder can also produce erectile disorder (Glina et al., 2013; Hyde, 2005). More commonly, however, vascular problems—problems with the body’s blood vessels—are involved (Lewis et al., 2010; Rosen, 2007). An erection occurs when the chambers in the penis fill with blood, so any condition that reduces blood flow into the penis, such as heart disease or clogging of the arteries, may lead to erectile disorder (Glina et al., 2013). It can also be caused by damage to the nervous system as a result of diabetes, spinal cord injuries, multiple sclerosis, kidney failure, or treatment by dialysis (da Silva et al., 2015; Berry & Berry, 2013). In addition, as is the case with male hypoactive sexual desire disorder, the use of certain medications and various forms of substance abuse, from alcohol abuse to cigarette smoking, may interfere with erections (Glina et al., 2013; Herrick et al., 2011).

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Medical procedures, including ultrasound recordings and blood tests, have been developed for diagnosing biological causes of erectile disorder. Measuring nocturnal penile tumescence (NPT), or erections during sleep, is particularly useful in assessing whether physical factors are responsible. Men typically have erections during rapid eye movement (REM) sleep, the phase of sleep in which dreaming takes place. A healthy man is likely to have two to five REM periods each night, and several penile erections as well. Abnormal or absent nightly erections usually (but not always) indicate some physical basis for erectile failure. As a rough screening device, a patient may be instructed to fasten a simple “snap gauge” band around his penis before going to sleep and then check it the next morning. A broken band indicates that he has had an erection during the night. An unbroken band indicates that he did not have nighttime erections and suggests that his general erectile problem may have a physical basis. A newer version of this device further attaches the band to a computer, which provides precise measurements of erections throughout the night (Wincze et al., 2008). Such assessment devices are less likely to be used in clinical practice today than in past years. As you’ll see later in the chapter, Viagra and other drugs for erectile disorder are typically given to patients without much formal evaluation of their problem (Rosen, 2007).

PSYCHOLOGICAL CAUSES Any of the psychological causes of male hypoactive sexual desire disorder can also interfere with arousal and lead to erectile disorder. As many as 90 percent of all men with severe depression, for example, experience some degree of erectile dysfunction (Montejo et al., 2011; Stevenson & Elliott, 2007).

One well-supported psychological explanation for erectile disorder is the cognitive-behavioral theory developed by William Masters and Virginia Johnson (1970). The explanation emphasizes performance anxiety and the spectator role. Once a man begins to have erectile problems, for whatever reason, he becomes fearful about failing to have an erection and worries during each sexual encounter. Instead of relaxing and enjoying the sensations of sexual pleasure, he remains distanced from the activity, watching himself and focusing on the goal of reaching erection. Instead of being an aroused participant, he becomes a judge and spectator. Whatever the initial reason for the erectile dysfunction, the resulting spectator role becomes the reason for the ongoing problem. In this vicious cycle, the original cause of the erectile failure becomes less important than fear of failure.

SOCIOCULTURAL CAUSES Each of the sociocultural factors that contribute to male hypoactive sexual desire disorder has also been tied to erectile disorder. Men who have lost their jobs and are under financial stress, for example, are more likely to develop erectile difficulties than other men (Štulhofer et al., 2013). Marital stress, too, has been tied to this dysfunction (Brenot, 2011; Rosen, 2007; LoPiccolo, 2004, 1991). Two relationship patterns in particular may contribute to it. In one, a wife provides too little physical stimulation for her aging husband, who, because of normal aging changes, now requires more intense, direct, and lengthy physical stimulation of the penis in order to have an erection. In the second relationship pattern, a couple believes that only intercourse can give the wife an orgasm. This idea increases the pressure on the man to have an erection and makes him more vulnerable to erectile dysfunction. If the wife reaches orgasm manually or orally during their sexual encounter, his pressure to perform is reduced.

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During the orgasm phase of the sexual response cycle, a person’s sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract, or draw together, rhythmically (see Figure 11.3). The man’s semen is ejaculated, and the outer third of the woman’s vaginal wall contracts. Dysfunctions of this phase of the sexual response cycle are premature ejaculation and delayed ejaculation in men and female orgasmic disorder in women.

Premature Ejaculation Eduardo is typical of many men in his experience of premature ejaculation:

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A man suffering from premature ejaculation (also called early, or rapid, ejaculation) persistently reaches orgasm and ejaculates within one minute of beginning sexual activity with a partner and before he wishes to (see Table 11.3). As many as 30 percent of men worldwide ejaculate early at some time (Lewis et al., 2010; Laumann et al., 2005, 1999, 1994). The typical duration of intercourse in our society has increased over the past several decades, which has caused more distress among men who ejaculate prematurely. Although many young men certainly contend with the dysfunction, research suggests that men of any age may suffer from it (Sansone et al., 2015; Rowland, 2012).

Psychological, particularly behavioral, explanations of premature ejaculation have received more research support than other kinds of explanations. The dysfunction is common, for example, among young, sexually inexperienced men such as Eduardo, who simply have not learned to slow down, control their arousal, and extend the pleasurable process of making love (Althof, 2007). In fact, young men often ejaculate prematurely during their first sexual encounter. With continued sexual experience, most men acquire more control over their sexual responses. Men of any age who have sex only occasionally are also prone to ejaculate early.

Clinicians have also suggested that premature ejaculation may be related to anxiety, hurried masturbation experiences during adolescence (in fear of being “caught” by parents), or poor recognition of one’s own sexual arousal (Althof, 2007). However, these theories have only sometimes received clear research support.

There is a growing belief among many clinical theorists that biological factors may also play a key role in many cases of premature ejaculation. Three biological theories have emerged from the limited investigations done so far (Althof, 2007; Mirone et al., 2001). One theory states that some men are born with a genetic predisposition to develop this dysfunction. Indeed, one study found that 91 percent of a small sample of men suffering from early ejaculation had first-degree relatives who also had the dysfunction. A second theory, based on animal studies, argues that the brains of men who ejaculate prematurely contain certain serotonin receptors that are overactive and others that are underactive. A third explanation holds that men with this dysfunction have greater sensitivity or nerve conduction in the area of their penis, a notion that has received inconsistent research support thus far.

Delayed Ejaculation A man with delayed ejaculation (previously called male orgasmic disorder or inhibited male orgasm) persistently is unable to ejaculate or has very delayed ejaculations during sexual activity with a partner (see Table 11.3 again). Around 10 percent of men worldwide have this disorder (Lewis et al., 2010; Laumann et al., 2005, 1999). It is typically a source of great frustration and upset, as in the case of John:

A low testosterone level, certain neurological diseases, and some head or spinal cord injuries can interfere with ejaculation (Lewis et al., 2010; Stevenson & Elliott, 2007). Substances that slow down the sympathetic nervous system (such as alcohol, some medications for high blood pressure, and certain psychotropic medications) can also affect ejaculation (Herrick et al., 2011). For example, certain serotonin-enhancing antidepressant drugs appear to interfere with ejaculation in at least 30 percent of men who take them (Glina et al., 2013; Montejo et al., 2011).

A leading psychological cause of delayed ejaculation appears to be performance anxiety and the spectator role, the cognitive-behavioral factors also involved in erectile disorder (Kashdan et al., 2011). Once a man begins to focus on reaching orgasm, he may stop being an aroused participant in his sexual activity and instead become an unaroused, self-critical, and fearful observer (Rowland, 2012; Wiederman, 2001). Another psychological cause of delayed ejaculation may be past masturbation habits. If, for example, a man has masturbated all his life by rubbing his penis against sheets, pillows, or other such objects, he may have difficulty reaching orgasm in the absence of the sensations tied to those objects (Wincze et al., 2008). Finally, delayed ejaculation may develop out of male hypoactive sexual desire disorder (Apfelbaum, 2000). A man who engages in sex largely because of pressure from his partner, without any real desire for it, simply may not get aroused enough to ejaculate.

Female Orgasmic Disorder Janel and Isaac, married for three years, went for sex therapy because of her lack of orgasm.

Women with female orgasmic disorder persistently fail to reach orgasm, have very low intensity orgasms, or have a very delayed orgasm (see Table 11.3 again). As many as 25 percent of women apparently have this problem to some degree—including more than a third of postmenopausal women (Lewis et al., 2010; Heiman, 2007, 2002). Studies indicate that 10 percent or more of women have never had an orgasm, either alone or during intercourse, and at least another 9 percent rarely have orgasms (Bancroft et al., 2003). At the same time, half of all women experience orgasm in intercourse at least fairly regularly (de Sutter et al., 2014; SOGC, 2014). Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly (Carrobles et al., 2011; Hurlbert, 1991). Female orgasmic disorder appears to be more common among single women than among women who are married or living with someone (Lewis et al., 2010; Laumann et al., 2005, 1999, 1994). In one study, when participants with female orgasmic disorder were asked to pick a word that best describes their feelings about it, two-thirds of them chose “frustration” (Kingsberg et al., 2013).

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Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning (Meana, 2012). Many women instead reach orgasm with their partners by direct stimulation of the clitoris. Although early psychoanalytic theory considered a lack of orgasm during intercourse to be pathological, evidence suggests that women who rely on stimulation of the clitoris for orgasm are entirely normal and healthy (Laan, Rellini, & Barnes, 2013; Heiman, 2007).

Biological, psychological, and sociocultural factors may combine to produce female orgasmic disorder (Berry & Berry, 2013; Jiann, Su, & Tsai, 2013). Because arousal plays a key role in orgasms, arousal difficulties often are featured prominently in explanations of female orgasmic disorder.

BIOLOGICAL CAUSES A variety of physiological conditions can affect a woman’s orgasm. Diabetes can damage the nervous system in ways that interfere with arousal, lubrication of the vagina, and orgasm. Lack of orgasm has sometimes been linked to multiple sclerosis and other neurological diseases, to the same drugs and medications that may interfere with ejaculation in men, and to changes, often postmenopausal, in skin sensitivity and structure of the clitoris, vaginal walls, or the labia—the folds of skin on each side of the vagina (Cordeau & Courtois, 2014; Blackmore et al., 2011; Lombardi et al., 2011).

PSYCHOLOGICAL CAUSES The psychological causes of female sexual interest/arousal disorder, including depression, may also lead to female orgasmic disorder (Kalmbach et al., 2014; Laan et al., 2013). In addition, as both psychodynamic and cognitive theorists might predict, memories of childhood traumas or problematic childhood relationships have sometimes been associated with orgasm problems. In one large study, memories of an unhappy childhood or loss of a parent during childhood were tied to lack of orgasm in adulthood (Raboch & Raboch, 1992). In other studies, childhood memories of a dependable father, a positive relationship with one’s mother, affection between the parents, the mother’s positive personality, and the mother’s expression of positive emotions were all predictors of positive orgasm outcomes (Heiman, 2007; Heiman et al., 1986).

SOCIOCULTURAL CAUSES For years many clinicians have believed that female orgasmic problems may result from society’s recurrent message to women that they should repress and deny their sexuality, a message that has often led to “less permissive” sexual attitudes and behavior among women than among men. In fact, many women with both arousal and orgasmic difficulties report that they had an overly strict religious upbringing, were punished for childhood masturbation, received no preparation for the onset of menstruation, were restricted in their dating as teenagers, and were told that “nice girls don’t” (Laan et al., 2013; LoPiccolo & Van Male, 2000).

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A sexually restrictive history, however, is just as common among women who function well during sexual activity (LoPiccolo, 2002, 1997). In addition, cultural messages about female sexuality have been more positive in recent years, while the rate of arousal and orgasmic problems remains the same for women. Why, then, do some women and not others develop such problems? Researchers suggest that unusually stressful events, traumas, or relationships may help produce the fears, memories, and attitudes that often characterize these sexual problems (Meana, 2012; Westheimer & Lopater, 2005). For example, many women molested as children or raped as adults have female orgasmic disorder (Hall, 2007; Heiman, 2007).

Research has also related orgasmic behavior to certain qualities in a woman’s intimate relationships (Laan et al., 2013; Brenot, 2011). Studies have found, for example, that the likelihood of reaching orgasm may be tied to how much emotional involvement a woman had during her first experience of intercourse and how long that relationship lasted, the pleasure the woman felt during the experience, her current attraction to her partner’s body, and her marital happiness. Interestingly, the same studies have found that orgasmic women more often have erotic fantasies during sex with their current partner than do nonorgasmic women.

Certain sexual dysfunctions are characterized by enormous physical discomfort during intercourse, a difficulty that does not fit neatly into a specific part of the sexual response cycle. Women have such dysfunctions, collectively called genito-pelvic pain/penetration disorder, much more often than men do (APA, 2013).

For some women with genito-pelvic pain/penetration disorder, the muscles around the outer third of the vagina involuntarily contract, preventing entry of the penis (see Table 11.4). This problem, known in medical circles as vaginismus, can prevent a couple from ever having intercourse. The problem has received relatively little research, but estimates are that fewer than 1 percent of all women have vaginismus (Christensen et al., 2011). A number of women with vaginismus enjoy sex greatly, have a strong sex drive, and reach orgasm with stimulation of the clitoris (Cherner & Reissing, 2013). They just fear the discomfort of penetration of the vagina.

Most clinicians agree with the cognitive-behavioral position that this form of genito-pelvic pain/penetration disorder is usually a learned fear response, set off by a woman’s expectation that intercourse will be painful and damaging (Simonelli et al., 2014; Cherner & Reissing, 2013). A variety of factors apparently can set the stage for this fear, including anxiety and ignorance about intercourse, exaggerated stories about how painful and bloody the first occasion of intercourse is for women, trauma caused by an unskilled lover who forces his penis into the vagina before the woman is aroused and lubricated, and the trauma of childhood sexual abuse or adult rape (Jiann et al., 2013; Fugl-Meyer et al., 2013).

Alternatively, women may have this form of genito-pelvic pain/penetration disorder because of an infection of the vagina or urinary tract, a gynecological disease such as herpes simplex, or the physical effects of menopause. In such cases, the dysfunction can be overcome only if the women receive medical treatment for these conditions.

Other women with genito-pelvic pain/penetration disorder do not have involuntary contractions of their vaginal muscles, but they do experience severe vaginal or pelvic pain during sexual intercourse, a pattern known medically as dyspareunia (from Greek words meaning “painful mating”). Surveys suggest that more than 14 percent of women suffer from this problem to some degree (Antony & Barlow, 2010, 2004; Laumann et al., 2005, 1999). Women with dyspareunia typically enjoy sex and get aroused but find their sex lives very limited by the pain that accompanies what used to be a positive event (Huijding et al., 2011).

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This form of genito-pelvic pain/penetration disorder usually has a physical cause (Fugl-Meyer et al., 2013). Among the most common is an injury (for example, to the vagina or pelvic ligaments) during childbirth. The scar left by an episiotomy (a cut often made to enlarge the vaginal entrance and ease delivery) also can cause pain. Around 16 percent of women have severe vaginal or pelvic pain during intercourse for up to a year after giving birth (Bertozzi et al., 2010). More generally, such pain has also been tied to the penis colliding with remaining parts of the hymen, vaginal infections, wiry pubic hair rubbing against the labia during intercourse, pelvic diseases, tumors, cysts, allergic reactions to the chemicals in vaginal douches and contraceptive creams, the rubber in condoms and diaphragms, and the protein in semen (Tripoli et al., 2011).

Although psychological factors (for instance, heightened anxiety or overattentiveness to one’s body) or relationship problems may contribute to dyspareunia (Granot et al., 2011), psychosocial factors alone are rarely responsible for it (Dewitte, Van Lankveld, & Crombez, 2011). In cases that are truly psychogenic, the woman may in fact be suffering from female sexual interest/arousal disorder. That is, penetration into an unaroused, unlubricated vagina is painful (Fugl-Meyer et al., 2013). It also is the case that at least 3 percent of men suffer from pain in the genitals during intercourse, and many of these men also qualify for a diagnosis of genito-pelvic pain/penetration disorder.