Figure 6-1.
Biospychosocial model of sexual dysfunction.
Biological
Physical Health
Aging
Sexual problems are common in older adults, but physical health and aging tend to impact male sexual health more than female sexual health. Challenges with lubrication are a common challenge for older adult women, where for men it can include decreased libido, erectile dysfunction, and ability to achieve orgasm [21].
For older adults, emphasis on what does not work sexually must be balanced with a curiosity about “what does”—the resiliencies and capabilities of the individual and couple in a broader context than that based solely on “sexual performance” [1].
There is no common agreement about when older age actually begins. In this chapter, 65 years—the onset in the USA for Medicare health coverage—is used to demarcate the socially defined beginning of older age. Older adults are the fastest growing segment of the population in the USA. In 2000, one in ten persons was over 65, and in 2030, one in five will be over 65. Currently, 14.1% of the US population is 65 or older [1].
Rosemary Basson and colleagues have introduced a nonlinear model of the female sexual response cycle that includes physical and emotional satisfaction and sexual pleasure. The Basson model is well researched and represents an accurate understanding of sexual arousal and responsivity for many women. The model emphasizes willingness, motivation, intentionality, and individual sexual satisfaction rather than a performance model. Although the triphasic model continues to be endorsed by some, the Basson model calls into question the need for “desire” to exist as a separate distinct category prior to arousal. By indicating that interest/desire and arousal are neither distinctly separate nor exactly the same for all, Basson’s model supports individual variances in sexual response and also endorses the biopsychosocial nature of sexual response. In assessment of older adult females, it is vital to assess desire through the lens of the Basson model, as opposed to a linear model with desire as the starting point [1, 22–24].
AARP conducts semi-decennial research on “Sex, Romance, and Relationships: AARP Survey of Midlife and Older Adults.” The 2009 survey employs a representative sample of the US population aged 45 and older. Thirty percent of men report that they “never” or “just sometimes” are able to maintain erections sufficient for penetrative sex, indicating a high correlation with illness and medication related problems [25]. Despite promising integrative treatments for erectile dysfunction (ED) , older men will continue to have treatment resistant ED due to confounding factors [4]. Interestingly, many men in the AARP study continue to report sexual satisfaction even if they are not able to have penetrative sex [25]. The more “performance” or “erection focused” male models simply do not reflect all older men’s experiences of continued sexual satisfaction even if erection does not occur [26–28]. Wittmann describes a model for survivors of prostate cancer and their partners, a model with more emphasis on pleasure and satisfaction that could well be adapted. It is important for clinicians in their assessment of sexual functioning to be aware of the differing models, as well as clinician bias, as we work to understand, assess, and help our patients [1].
As men age, they often experience a decrease in their testosterone levels, and often an increase in their Body Mass Index (BMI). Weight gain and muscle loss are factors in sexual dysfunction. Older adult men experience lower libido/sexual desire due to both low testosterone and to higher BMI. Low testosterone however is not a contributing factor to erectile dysfunction issues for most men. Benign enlarged prostate, diabetes, hypertension are also all factors that can negatively impact male sexual function. All of these are common factors impacting men’s health as they age.
At menopause , some women experience a decrease in arousal when masturbating or engaging in partnered sex. Many remark that the pleasant sense of “fullness, tingling, and swelling” in and around the vulva is only vaguely represented [29]. Several valuable studies reflect the growing interest in understanding and treating postmenopausal changes for older women, especially those associated with vaginal atrophy (VA) and vulvar vaginal atrophy (VVA) [30–33]. REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey [31] found VVA symptoms negatively affected sexual enjoyment (59%), including problems with spontaneity, intimacy, and partner relationship. Loss of sexual intimacy was of “concern” for 47% of women with a partner, with 85% stating “some problems” related to loss of intimacy due to VVA . Most common concerns were dryness (55%), dyspareunia (44%), and irritation (33%). This study and others confirm that vulvovaginal changes—and, for some, decreased sensitivity and increased dryness and thinning of vaginal walls—are associated with vaginal pain, negatively affecting sexual activity , with decreases in desire, arousal, and pleasure [31].
Sexual function for older women includes the passage through menopause and, for most, changes in sensation and some decreased sensitivity as well as vulvovaginal changes with increased dryness and thinning of vaginal walls. There may be increases in vaginal pain associated with drying thinning tissues. The associated discomfort often results in increased avoidance of sexual thought or activity—both penetration and vulvar stimulation—since it is no longer pleasurable and pain free [1].
Illness
Cancer in Women
Sexual issues related to women in all stages of cancer are very common. The cancer diagnosis and resulting treatment can bring about many sexuality related social/emotional issues in addition to the physical side effects that treatment can have on self-esteem, desire, and sexual function. The sexual issues associated with cancer (such as dyspareunia, poor body image, and relationship distress) can be on-going and can get worse over time if not addressed. Sexuality is an integral part of what makes up quality of life for most female cancer survivors. However, these concerns for women dealing with cancer related sexual issues are rarely asked about or addressed. Providers can ask simple questions, such as: “Do you have any questions/concerns about: fertility, menopause, or sexual health?” Or questions that are a little more specific, such as: “Are you experiencing any vaginal dryness, pain, or sexual issues?” [34–42]
Breast Cancer
Breast cancer , and the treatments for it, cause many women to have significant changes in their relationship to their body and their body image. This holds true for both women who have had breast reconstruction and those that have not. These changes can impact sexual self-esteem, body image, and self-efficacy, from a mental health stand point. Physical effects come from chemotherapy and hormone therapy causing vulvovaginal atrophy, loss of libido, and dyspareunia. Prescribed medications also contribute to vulvar and vaginal atrophic change, especially when used long term [43].
Prostate Cancer
Post recovery from prostate cancer surgery, 90% of men will experience issues with erectile dysfunction. What that exactly looks like depends on a variety of factors, the key ones being: the age and overall health of the individual, their preoperative erectile functioning , and the skill/expertise of the surgeon. Even with an experienced surgeon, using a nerve sparing procedure, patients will likely experience erectile function issues post-surgery. Erectile function is treatable in a variety of ways when aggressively approached from a biopsychosocial perspective, as all areas can be impacted. Many men and their partners, however, are often unprepared for and unaware of the post-surgical impacts to sexual health, and the approaches to recovery, leaving 75% of prostate cancer survivors with unresolved sexual problems 5 years post-surgery [44–46].
It is important for providers to understand the sexual hopes of the individual and their partner, when appropriate, around the importance of sexual connection to the individuals and within the relationship. According to Daniela Wittmann, “There are many psychological and relationship strengths that people can employ to get back or retain their sex lives.” Satisfaction with sex life and not erectile function is the focus in sexual dysfunction interventions with this population. Feelings of grief and loss are a normative part of this process and if not dealt with can leave patients more susceptible to depression and anxiety, which in turns can negatively impact sexual desire [44, 47–49].
According to Dr. Wittmann, “After PCa treatment, all aspects of sexual health are affected, including the man’s erectile function, self-image, mental health, and relationship with his partner; therefore, it affects not only his quality of life but also that of his partner. Furthermore, most PCa survivors’ partners are postmenopausal women whose sexual function also requires assistance. The challenge is to help men and partners restore sexual health in the context of significant functional loss. For men and partners to recover sexual health in survivorship, all components of sexuality and sexual health must be addressed because known psychological barriers, such as overly optimistic expectations about erectile function outcomes, unresolved grief about functional loss, poor sexual communication, and difficulty accepting sexual aids, may lead survivors and their partners to reject the idea of a sexual relationship that does not rely on a natural erection” [47, 50].
Benign Prostatic Hyperplasia/Lower Urinary Tract
Approximately 50% of men in their 50s and 90% of men in their 80s are impacted by an enlarged prostate of benign prostatic hyperplasia (BPH) . Often men who experience BPH also are impacted by lower urinary tract symptoms (LUTS) . Sexual dysfunction is a known symptom of lower urinary tract symptoms in men. The sexual dysfunction primarily shows up as erectile dysfunction or ejaculatory dysfunction falling in the range of 50–70% of the male population affected. Additionally, some of the treatments for both BPH and LUTS also are known to have significant sexual side effects as well, including erectile dysfunction, ejaculatory dysfunction, and hypoactive sexual desire, which can make the sexual dysfunction issues more complex [51].
Two 5-a reductase inhibitors can be used to treat BPH, with two of them also being used to treat male pattern hair loss (MPHL) . Finasteride is one that is used for treatment of both issues, and in multiple randomized studies significant sexual dysfunction was found to be associated with its use. According to Irwig and Korokula, “A subset of otherwise healthy men taking finasteride for MPHL developed persistent sexual side effects in temporal association with the medication. Most men developed sexual dysfunction in multiple domains with 94% experiencing low libido, 92% experiencing erectile dysfunction, 92% experiencing decreased arousal, and 69% experiencing problems with orgasm. The mean duration of the persistent sexual side effects was at least 40 months, with 20% of subjects reporting durations of over 6 years. The mean number of sexual episodes per month dropped from 25.8 before finasteride to 8.8 after finasteride” [52].
Diabetes
Diabetes is a chronic disease that has become increasingly common, impacting more than 371 million people around the world in 2012. It is associated with sexual dysfunction in both women and men. Diabetes is a known risk factor for sexual dysfunction in men, with a threefold increased risk of erectile dysfunction over nondiabetic men. Evidence showing an association between diabetes and sexual dysfunction in women is less conclusive. Female sexual function is more connected to social and psychological components than to the physical impacts of diabetes, but most studies do report a higher prevalence of female sexual dysfunction in diabetic women [53]. Sexual disorders reported in women with diabetes include decreased libido, difficulties with lubrication and arousal, dyspareunia, and for some anorgasmia [53–55].
Heart Disease
Sexual dysfunction and a decrease in sexual activity are common in people living with cardiovascular disease. Often times there is significant psychological stress connected to being sexual and fear that sexual activity will worsen the heart health or possibly even cause death. This anxiety can be experienced by patient or partner, but leads to decreased sexual activity and satisfaction. It can be the decline in sexual satisfaction that may bring about other issues, such as strain in romantic or marital relationships. Depression and anxiety are not uncommon and often are a significant factor, when coupled with age and other health issues, leading to erectile dysfunction in men, and of a variety of sexual function issues in women, including dyspareunia, decreased desire, and difficulty with arousal and orgasm [56–63].
People with cardiovascular disease are able to engage in sexual activity, but it is often suggested for them to have a complete physical beforehand to ensure their symptoms are controlled and stable, and if not they should be treated and stabilized first. Medications for heart disease are often a cause of ED in men, but can be countered with PDE5 inhibitors. PDE5 inhibitors should never be used in conjunction with nitrates [56, 57].
Other Health Issues
Sexual issues commonly associated with Parkinson’s disease in women include difficulty with desire, arousal, and orgasm. Men living with Parkinson’s disease can experience erectile dysfunction and premature ejaculation, in addition to overall sexual dissatisfaction. Some of the other physical issues associated with Parkinson’s disease, such as challenges with speech and posture can also make sexual behavior more challenging. As with other health issues, many people also experience depression with Parkinson’s disease, which further exacerbates sexual difficulties, as do many antidepressants [64].
People living with Multiple Sclerosis often experience symptoms including pain, numbness, fatigue, coordination, and body image. All of which have a significant impact on sexual functioning both physically, as well as emotionally [65].
On the other hand, achieving orgasm through sexual activity can alleviate pain for some people. A European study of 63 women living with fibromyalgia found that sexual intercourse actually gave relief from continuous pain [66].
Ability Issues
When working with people with disabilities (PWD) around sexual issues, it is important for the provider to be cognizant of their biases toward these populations. Society has created negative or dismissive narratives around the sexuality of PWD, which can be infantilizing, stigmatizing, or both, and many providers have unconsciously internalized those same societal biases [67].
Dr. Mitchell Tepper, in his work on sexuality and disability, encourages providers to recognize that the discourse surrounding sexuality and disability focuses on deviance and inappropriate behavior, abuse and victimization, as well as reproductive issues in women and men. He notes that there seems to be missing a discourse around pleasure. Pleasure is an important part of sexual health for all people, including people who are living with a range of ability issues , and it is an important factor for which to assess in an evaluation [68].
Physical
A spinal cord injury’s (SCI) impact upon sexual function depends on where the injury takes place in the spine and the level of severity [69, 70]. Men and women who have experienced an SCI frequently report both lower libido and a decreased frequency of sexual behavior [71]. Dealing with both the psychological elements (e.g., body image, self-esteem) and sociocultural elements (gender, age, and religion) all impact the conceptualization of the sexual self of the person with an SCI [72]. Problems with both orgasm and arousal due to struggles with coordination and self-image also significantly impact people with SCIs [73, 74].
Men who experience spinal cord injuries can also have sexual dysfunction issues, with erectile function being a significant impact factor upon quality of life. Studies have shown success for men in this area with penile injections, sildenafil, and for more challenging cases penile implants. All have shown success in helping men as one part of rehabilitation.
Many aspects of physical sexual functioning can be impacted for women following an SCI. A few of the important areas for clinicians to assess include: sexual arousal and vaginal lubrication, orgasm, urinary incontinence, bowel incontinence, and spasticity—particularly with regard to stiffness and pain [75].
Intellectual
Sexual health knowledge and attitudes in people living with intellectual disabilities (ID) is poor, but they express sexual health needs and desires comparable to the general population. There is less sexual activity among people with moderate to severe intellectual disabilities, but they remain very vulnerable to sexual abuse [76].
According to Eastgate, “People with intellectual disability experience the same range of sexual needs and desires as other people. With appropriate education and good social support, people with intellectual disability are capable of safe, constructive sexual expression and healthy relationships. Providing such support is an essential part of supporting people with an intellectual disability” [77].
The sexuality of people living with intellectual disabilities can be a challenge for the people that work with them [78]. For the individual with the disability, they may find barriers to their sexual expression from an institutionalized living system that does not afford them access to privacy or even information about healthy sexuality and healthy sexual expression, and in many scenarios they are given misinformation about their sexuality [79]. Some care providers maintain the idea of people with intellectual disabilities as eternal children and thus restrict their social and relational opportunities, thus denying them the right to self-fulfillment [80, 81].
People with intellectual disabilities will have normative desires and feelings around sex as they develop. It is normal for them to want to masturbate and can be a healthy form of expression. Masturbation can be used as a way of self-soothing or having pleasure when bored. It may also seem to happen sometimes in inappropriate places. All of this can be dealt with through attention to the overall well-being and healthy education of the person with the intellectual ability. They will also benefit by understanding self-care for the body, good sexual expression, and what constitutes inappropriate behavior or abuse [78, 81–83].
Although a lot of the current discourse for people with ID focuses on sexual rights, in evaluating the sexual needs of this population there is also a strong need for reproductive health information to help with unplanned pregnancy, as well as information around safer sex to help prevent STIs including HIV. Sexual hygiene, gynecological care, and sexual abuse are other areas that consistently need to be addressed for overall sexual health [76].
Medications
Sexual dysfunction issues that are already common in the general population are often increased for people being treated for mental health issues. Many people being treated for mental health issues are prescribed psychotropic medications. Psychotropic medications, which are often helpful to deal with a patient’s mental health, frequently have a negative effect on a person’s sexual health or sexual functioning. Looking at a sexual history from a biopsychosocial perspective can help to separate out what sexual function issues are connected to mood, what is related to antidepressant medication , and what might be related to other medical or social factors [84].
Antidepressants
Antidepressants can affect the same areas of sexual functioning that depressive disorder does, mainly desire, arousal, and orgasm. There is some evidence to suggest that delayed orgasm is the most significant side effect. Selective serotonin reuptake inhibitors (SSRIs) are a group of antidepressant medications that increase the availability of serotonin in the synapse by inhibiting the serotonin transporters. Increased synaptic serotonin has an inhibitory effect on sexual functioning. Individual SSRIs vary in their exact pharmacological impact, with a range of impact on the serotonin transporter, and some impacting other receptors [84].
Antipsychotics
Similarly to antidepressants and depression, antipsychotic medication and schizophrenia both will have significant impact on a person’s sexual functioning. Antipsychotics, although impacting libido, arousal, and orgasm, seem to have the most significant impact upon sexual desire. The first generation of antipsychotic medications has greater impact upon sexual functioning than the second generation, but both have significant impact [84].
Mood Stabilizers
Studies looking at the impact of lithium upon people living with bipolar disorder found that there is sexual dysfunction reported, but the frequency is low and the severity of the impact upon sexual functioning is mild [84].
Blood Pressure Medications
Sexual dysfunction is a common issue that arises for patients living with hypertension . The available data suggests that sexual function issues are more common for patients that have been treated for the condition than in those patients that remain untreated. This would indicate that antihypertensive therapy is correlated with sexual dysfunction issues. Several studies indicate differences on the impact of sexual function for various antihypertensive drugs. The older antihypertensive drugs (diuretics, beta blockers) have more of a negative impact upon erectile function whereas the newer drugs (nebivolol, angiotensin receptor blockers) have little or in some cases beneficial effects upon sexual function [85].
Alcohol and Other Drugs
The initial connection between drugs and sex was one that attempted to enhance sexual functioning . Some drugs can indeed enhance sexual response in the early stages of their use, particularly with people who have had previous sexual function issues. Most significantly, males with early ejaculation often report increased satisfaction with the delayed orgasm caused by many drugs. For women, alcohol and drugs can cause an initial heightened sense of relaxation or pain management. Chronic use of substances tends to negatively impact sexual function in every stage (desire, arousal, orgasm) of sexual function over time for both male and female users [86].
Tobacco
Cigarette smoking has a negative impact on erectile function. It can have an immediate effect on a man’s ability to get and maintain a good erection. Male smokers have a 1.5 greater probability of developing erectile dysfunction then nonsmokers. The physical components of the arousal phase require blood to flow to the genital areas for both males and females, but Nicotine is a potent vasoconstrictor and reduces blood circulation in these areas. The more a person smokes, the longer they have been smoking, and increased age all are significant risk factors for sexual dysfunction [86].
Alcohol
Alcohol is often used as a precursor to sexual activity , because it can be a dis-inhibitor and make people more open to sexual activity. However, alcohol used in large quantities can bring about significant sexual function issues. It can cause erectile dysfunction and inhibit orgasm in men (even in young men). Women who use alcohol heavily may have difficulty with vaginal lubrication, inhibited orgasm, menstrual irregularities , and dyspareunia. More chronic users may experience inhibited desire, arousal and orgasm [86].
Cannabis
There are pros and cons to the use of marijuana when it comes to sexual function. Marijuana is reported by many users, both male and female, to increase sexual desire and arousal. THC, for some users, can help them to feel more relaxed, and stimulate sexual fantasy. There are mixed results in terms of sexual dysfunction with some studies showing that ongoing use can cause erectile dysfunction, and daily use can lead to trouble achieving orgasm for some men, while other studies show no significant negative impact on sexual function [86].
Cocaine
As with marijuana usage, cocaine usage can have differing impacts on sexuality based upon how it is used. People who use this drug infrequently may feel an enhanced sense of sexual desire, arousal, and sensuality, but may also experience their ability to achieve orgasm as delayed. Some male users who have concerns about PE may like this side effect, while other male users and most female users find delayed orgasm distressing. For more chronic users, their cardiovascular system may be negatively impacted, which speaks to the increased reports of erectile dysfunction in men, along with an ultimate decrease in sexual desire for many long-term users, and further delays in achieving orgasm [86].
Methamphetamine
Most users of methamphetamine strongly connect it to sexual experiences. The drug itself does not impact the sexual response cycle, but it is rather an overall nervous system stimulator bringing about increased senses of confidence, energy, and reducing inhibitions. The general sense of well-being and excitement provided can enhance a user’s sense of sexual pleasure. This drug is highly addictive, and for many users turns quickly to more habitual usage. The chronic stage of methamphetamine use is correlated with more sexual dysfunction. As more of the drug is consumed, users are more likely to not be able to achieve orgasm, and ultimately see their overall interest in sexual behavior decline significantly [86].
Opiates
Many users report that heroin can bring about intense feelings of pleasure, similar to those experienced through orgasm. Women who experience vaginismus or dyspareunia may feel greater levels of relaxation and reduced pain as a result of the analgesic qualities of this drug. And men with rapid ejaculation may also see initial benefit with orgasm delayed. There are also many sexual dysfunctions caused by the ongoing usage of heroin. In one study of regular users, decreased libido was reported in 68% of women and 75% of men. Sixty percent of women and 71% of men felt that their sexual arousal was negatively impacted by heroin use over time. Also, 60% of female and male users reported difficulty achieving orgasm with prolonged use of opiates. A second study found erectile dysfunction in over 50% of regular opiate users. Both heroin and methadone usage cause a decrease in testosterone levels which can quickly rebound once use of the drugs are stopped [86].
Psychological
Mental Health
People living with mental health issues have higher rates of sexual dysfunction issues than those people without them. This is particularly true for the people whose mental health issues are being treated with psychotropic medications. Sexual dysfunction negatively impacts between 30 and 60% of people living with schizophrenia who are treated with antipsychotic medications, up to 78% of those living with depression and being treated with antidepressants, and up to 80% of people who are living with anxiety disorders. Working with the challenges and complexities of mental health and sexual function, it is important for the clinician to identify the specific sexual dysfunctions and how it is impacted by the individual’s mental health condition, current medications, and their interpersonal relationships [2].
As discussed, many patients living with mood disorders have sexual difficulties. An estimated half of all people with mood disorders will experience some form of sexual dysfunction [84]. Loss of sexual interest is the most common form of sexual dysfunction . Often this will have a substantial negative effect upon interpersonal romantic relationships, as withdrawal from partners is common, thus demonstrating the multidirectional impact of various factors involved in sexual dysfunction [84]. Depression can also impact a patient’s level of arousal, as well as their ability to achieve orgasm. All of which can lead to subsequent sexual performance anxiety [84].
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