Sexual relationships are central to the lives of most of us. The sexual component of those relationships can go wrong in various ways. This may be secondary to other difficulties in the relationship, mental health problems, specific sexual vulnerabilities of the individual, or the impact of disease or medication on sexual response. This chapter will describe the more common sexual problems and their prevalence. Evidence related to aetiology of sexual problems and treatment evaluation will be briefly reviewed. In the final section of the chapter, guidelines for the assessment and practical management of sexual problems will be presented.

Since 1970, when Masters and Johnson⁽¹⁾ published their groundbreaking book on the treatment of ‘human sexual inadequacy’, there have been two lines of development in this field, relatively detached from each other until recently: psychological methods of treatment, collectively known as ‘sex therapy’ and medical interventions, initially focused on erectile problems in men.

The involvement of the medical profession has been substantial, although predominantly involving urologists. Initially there were surgical procedures to implant penile splints or to improve the vascular supply to the penis, and the use of vacuum devices to induce erection mechanically. This was followed by the discovery that injection of smooth muscle relaxants, such as papaverine, phentolamine, or prostaglandin into the erectile tissues of the corpora cavernosa induced erections. Self-injections became widely prescribed. To avoid the need for penile injections, which were not popular among male patients, preparations of prostaglandin for intra-urethral administration became available. This era of medical intervention was characterized by a veritable industry of investigative procedures in attempts to identify local causes for erectile dysfunction (ED). Erectile problems were clearly differentiated into ‘organic’ and ‘psychogenic’ subtypes. There was, however, a notable lack of attention to how the brain and psychological processes interacted with these peripheral mechanisms.

Then came the ‘Viagra revolution’ in the early 1990s. The first oral phosphodiesterase 5 (PDE-5) inhibitor, sildenafil (Viagra®), was found to be effective in enhancing erectile response to sexual stimulation when taken about 1 h before sexual activity. This led to the next phase in the ‘medicalization’ of male sexual dysfunction, with a shift to the primary care physician as the principle source of treatment and a dramatic reduction in the amount of diagnostic assessment.

The progress of sex therapy has been limited since Masters and Johnson.⁽¹⁾ It has continued to be used, with various adaptations of the original ‘sensate focus’ approach, incorporating principles of psychoanalytic techniques⁽²⁾ and cognitive behaviour therapy.⁽³⁾ The main shortcoming has been inadequate outcome research on the efficacy of these methods.

The next phase in this recent history followed the commercial success of PDE-5 inhibitors for men, with an inevitable quest for a ‘Viagra for women’. This has so far proved elusive, but has confronted the ‘sexual medicine’ community with the complexity of women’s sexuality and the need to conceptualize it differently to the sexuality of men.

At the same time, evidence has emerged that treatment of ED with sildenafil and more recent PDE-5 inhibitors, although initially successful in the majority, was being discontinued by a substantial proportion of men.⁽⁴⁾ In addition, the female partners of men taking these drugs do not always welcome the associated changes in the sexual relationships.⁽⁵⁾ We are now moving into the most recent phase where the ‘psychological’ and ‘organic’ approaches, and the professional groups that have been identified with them, have started to interact. There is increasing recognition of the need to integrate psychological and medical methods of treatment,^(6,7) but with the important proviso that, at least initially, treatment should focus on the couple and not the individual.

One important aspect of this evolving story is how we define a ‘sexual dysfunction’, with connotations of abnormal or impaired function, and how it is distinguished from a ‘sexual problem’ in a more general sense. This issue was epitomized by a publication in the Journal of the American Medical Association on the epidemiology of ‘sexual dysfunction’.⁽⁸⁾ In this widely cited paper, 43 per cent of women and 31 per cent of men were identified as having a ‘sexual dysfunction’, described as ‘a largely uninvestigated yet significant public health problem’ (p. 544). The authors commented, ‘With the affected population rarely receiving medical therapy for sexual dysfunction, service delivery efforts should be augmented to target high-risk populations’(p. 544).

This dramatic example of ‘medicalization’, based on extremely limited information from a national survey not designed to assess sexual dysfunction, was effectively challenged by Mercer and colleagues, using data from the UK National Survey of Sexual Attitudes and Lifestyles (NATSAL).⁽⁹⁾ This used exactly the same questions as in the Laumann et al. study,⁽⁸⁾ with the important difference that it was more specific about duration of problems, asking whether particular problems had lasted ‘at least 1 month’, or ‘at least 6 months’ during the last year (Laumann et al. had asked if symptoms had occurred ‘for several months or more’ during the last year). Overall, 53.8 per cent of women and 34.8 per cent of men reported at least one sexual problem lasting at least 1 month during the previous year. In contrast, the prevalence of problems lasting ‘at least 6 months in the previous year’ was 15.6 per cent for women and 6.2 per cent for men. This showed that transient problems were very common, more persistent ones much less so. In both the American and the British study, such problems were related to other problems in the participants’ lives, particularly involving impaired mental health (e.g. depression), relationship problems, or significant life stresses.

Relevant to the question of when a sexual problem becomes a ‘dysfunction’ is a theoretical approach, called the ‘Dual Control Model’, developed at the Kinsey Institute. This postulates that sexual response results from an interaction between excitation and inhibition, involving relatively discrete neurophysiological systems in the brain.⁽¹⁰⁾ A central assumption of the model is that individuals vary in their propensity for both sexual excitation and sexual inhibition and that ‘normal’ levels of inhibition are adaptive, reducing sexual responsiveness in circumstances where sexual
activity is best avoided. It is predicted that high levels of inhibition may be associated with vulnerability to sexual dysfunction and low levels with an increased likelihood of engaging in high-risk sexual behaviour.⁽¹⁰⁾

This faces us with the seemingly obvious but fundamental challenge of deciding whether a loss of sexual interest or responsiveness is an understandable or even adaptive reaction to current circumstances, or is a result of ‘malfunction’ of the sexual response system, which can appropriately be called a ‘sexual dysfunction’. This challenge is also central to the relatively new phase of integrated treatment, in which assessment identifies the key factors causing the sexual problem and how they should best be treated. A strategy for carrying out such assessment, which we have called the ‘three windows approach’, will be outlined below.

There have been at least 12 representative community-based surveys that have assessed the prevalence of sexual problems.⁽²²⁾ Prevalence rates for specific problems vary considerably and whereas several of the studies claim to be reporting prevalence of sexual ‘dysfunctions’,⁽⁸⁾ it is now accepted that the detailed clinical assessment required to identify a sexual dysfunction cannot be undertaken by large-scale surveys.⁽²³⁾ Consequently, more recent surveys have used terms such as ‘problems’^(9,24) or ‘difficulties’.⁽²⁵⁾ Variability in reported prevalence rates can in part be attributed to variations in how sexual problems are defined, their duration, and how and whether ‘distress’ about changes in sexual functioning is assessed. In studies of female sexual problems, there has been only limited overlap between what women perceive as problematic and what the researcher or clinician identifies as a problem.^(26,27) The variability of prevalence rates is shown in Tables 4.11.2.1 and 4.11.2.2, which compare a number of population-based surveys involving women and men.

There has been more consistency across studies in the associations found between factors of possible aetiological relevance and sexual functioning. In women, sexual problems are more frequent in those with mental health problems and relationship difficulties.⁽⁸⁾ In a survey of women aged 20-65 years, all in heterosexual relationships, 24.4 per cent reported marked distress about their sexual relationship and/or their own sexuality.⁽²⁶⁾ The best predictors of distress were markers of mental health and the quality of the emotional relationship with the partner. Physical aspects of sexual response in women such as arousal and orgasm were poor predictors of distress.

In men, age has a predictable negative effect on erectile function. In one study, complete erectile failure was reported by 5 per cent of men at age 40 and 25 per cent at age 70.⁽²⁸⁾ A similar age effect is found with loss of sexual desire. In another study, absence of any sexual desire was reported by 2 per cent of men aged 45-59 and 18.2 per cent aged 75+.⁽²⁹⁾ Contrary to popular belief, PE does not show a clear negative relationship with age.

The association between age and sexual problems in women is more complex. Whereas level of sexual interest typically decreases with age, older women are less likely to regard this as a problem.⁽²⁶⁾ Older women are much less likely to be in a sexual relationship than older men; the presence or absence of a partner also seems to influence women’s sexuality to a greater extent than it does for men.⁽²⁹⁾ The impact of the menopause is also complex. Although the post-menopausal decline in oestrogens is relevant to vaginal lubrication, other factors such as mental health and the quality of the sexual relationship are more important determinants of sexual well-being.⁽³⁰⁾

Before considering the factors that can cause sexual problems, it is worth underlining the important way that sexual function differs from most other physiological response systems. Although involving physiological mechanisms, sexual responses are most often experienced in the context of a relationship. This highlights the
importance of keeping the interactive relationship components in mind when trying to assess and treat sexual problems. Socio-cultural factors are also crucial to understanding how sexual problems are experienced. Much of the focus in medical treatments of sexual problems has been on the individual patient, with relationship and socio-cultural aspects largely ignored. The more specific aetiological factors can now be considered using the ‘three windows approach’.⁽²⁶⁾