You would think I'd feel comfortable writing about sex. After all, I'm a middle-aged
family doctor, married for over thirty years with grown-up kids. But I find this
subject a little embarrassing. I can understand why, even though a third of
them have sexual problems, my patients seldom ask for help solving them.
Stats and definitions
According to the Journal of the American Medical Association and the Foundation
for Urological Diseases, sexual problems are common. For women, over 20% report
lack of sexual desire, 14% have problems with arousal or reaching orgasm, and
for 7%, sexual intercourse is painful. Men have it slightly better, but over
20% complain of premature ejaculation, 5% report erectile dysfunction (previously
called impotence), and 5% just aren't much interested in sex. These sexual problems
can be serious enough to hinder important relationships and hurt self-esteem.
Painful intercourse in women (dyspareunia) might be due to vaginismus, vaginitis
or lack of lubrication. Vaginismus refers to painful spasm of the muscles around
the vagina making intercourse difficult and painful. This is usually due to
fear, sometimes because of previous trauma. Vaginitis or inflammation of the
delicate tissues of the vagina is due to infection or irritation. Erectile dysfunction
is more common in older men and of the more than 20 million North American
men who suffer from this, fewer than 10% ever receive treatment.
Some sexual problems have less to do with organs and chemistry than they have
to do with emotions and previous experiences. Sexual dysfunction might be caused
by drugs such as antidepressants, blood pressure medications and alcohol, or
other mood-altering drugs including nicotine. Medical causes include diabetes,
heart disease, neurological disorders, pelvic scarring, or menopause. Loss of
sexual interest and function might also be due to reduced levels of hormones
such as testosterone.
Chronic stress, anxiety, or depression will often diminish a person's sexual
interest or sexual response. Sometimes sexual problems develop and worsen simply
because one partner doesn't understand the other's needs, and the other person either assumes
the partner should know, or the person is too shy to tell the partner. Often sexual problems have nothing
to do with sex: especially for a woman, sexual receptiveness and response
requires first a relationship of emotional intimacy with her partner.
Diagnosis and assessment
There are specialty clinics dedicated to the investigation and treatment of
sexual problems. It's important to be evaluated with a thorough history and
physical exam. From the medical evaluation, further investigations such as hormone
tests or other diagnostic investigations might be ordered.
Treatment and recovery
If the problem is due to mood disorder or even premature ejaculation, effective treatment will be a combination of cognitive-behavioral therapy and perhaps medications. One man's poison might be another's potion: the same antidepressants whose pesky side effects include loss of libido, erectile dysfunction, or delayed orgasm sometimes prove effective in treating premature ejaculation. A history of previous emotional trauma or sexual abuse requires sensitive counseling by a skilled professional. If an underlying medical or psychiatric disorder is the cause, then effective treatment of that problem will often restore healthy sexual function. Education about the sexual needs and sexual response of women and of men helps both members of a couple understand the others' behaviors and responses. Sometimes hormone replacement both in men and women can restore sexual function. For persistent erectile dysfunction there are a number of effective procedures and medications. Programs, retreats, and couples therapy that improve communication and emotional intimacy will usually improve the couple's sex life. Sometimes couples need to learn and practice techniques, such as sexual touching without penetration or orgasm, in order to develop new ways to please their partners.