Sexual arousal disorder is characterized by a lack or absence of sexual fantasies and desire for sexual activity in a situation that would normally produce sexual arousal, or the inability to attain or maintain typical responses to sexual arousal. The disorder is found in the DSM-IV.[rx] The condition should not be confused with a sexual desire disorder.
The term is often used in the diagnosis of women (female sexual arousal disorder), while the term erectile dysfunction (ED) is often used for men.
Sexual arousal disorders can be categorized as subjective, genital, or combined. All definitions are clinically based, distinguished in part by the woman’s response to genital and nongenital stimulation, as follows:
- Subjective – Women do not feel aroused by any type of sexual genital or nongenital stimulation (eg, kissing, dancing, watching an erotic video, physical stimulation), despite the occurrence of physical genital response (eg, genital congestion).
- Genital – Subjective arousal occurs in response to nongenital stimulation (eg, an erotic video) but not in response to genital stimulation. This disorder typically affects postmenopausal women and is often described as genital deadness. Vaginal lubrication and/or genital sexual sensitivity is reduced.
Combined – Subjective arousal in response to any type of sexual stimulation is absent or low, and women report the absence of physical genital arousal (ie, they report the need for external lubricants and may state they know that swelling of the clitoris no longer occurs).
Causes of Sexual Arousal Disorder
Contrary to popular belief, the disorder is not always caused by a lack of sexual arousal. Possible causes of the disorder include psychological and emotional factors, such as depression, anger, and stress; relationship factors, such as conflict or lack of trust; medical factors, such as depleted hormones, reduced regional blood flow, and nerve damage; and drug use. The lack of sexual arousal may be due to a general lack of sexual desire or due to a lack of sexual desire for the current partner (i.e., situational). A person may always have had no or low sexual desire or the lack of desire may have been acquired during the person’s life.
Illnesses that may result in loss of sexual desire
- Gynecological disorders causing pain on sexual intercourse
- Obstetric disorders causing pain on sexual intercourse
- Urological disorders causing pain on sexual intercourse
- Alcohol and substance misuse
- Stress and chronic anxiety
- Endocrine disorders
- Neurological disorders
- Psychiatric disorders
- Depression
- Fatigue
Common psychotropic classes causing sexual dysfunction
TRICYCLIC ANTIDEPRESSANTS |
|---|
| Adapted from Crenshaw TL, Goldberg JP. Sexual Pharmacology: Drugs That Affect Sexual Functioning. New York, NY: W. W. Norton & Company, 1996. |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Positive Increased adrenergic α1 activity Decreased cortisol |
| Negative Decreased β–adrenergic activity Decreased cholinergic activity Decreased histamine Decreased oxytocin Increased prolactin Increased serotonin |
| Direct sexual side effects* |
| Desire disorders Dyspareunia Erection difficulties |
| Orgasm disorders Orgasmic inhibition Anorgasmia Spontaneous orgasm |
| Ejaculation disorders Retarded ejaculation Ejaculation without orgasm Anesthetic ejaculation |
| MONOAMINE OXIDASE INHIBITORS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Positive Increased adrenergic α1 activity Decreased monoamine oxidase |
| Negative Decreased β-adrenergic activity Decreased cholinergic activity Increased prolactin Increased serotonin Decreased testosterone |
| Direct sexual side effects* |
| Desire disorders Erection difficulties |
| Orgasm disorders Orgasmic inhibition Decreased number |
| Ejaculation disorders Retarded, inhibited premature ejaculation diminished |
| SELECTIVE SEROTONIN REUPTAKE INHIBITORS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Negative Increased cortisol Increased opioids Increased prolactin Increased serotonin (5-HT) |
| Direct sexual side effects |
| Desire disorders Hyposexuality Hypersexuality |
| Orgasm disorders Orgasmic inhibition Anorgasmia Spontaneous orgasm |
| Ejaculation disorders Retarded ejaculation Ejaculatory inhibition |
| Erection disorders Inability/difficulty obtaining an erection Decreased quality of erection Decreased or absent nocturnal/morning erections |
| ANTIPSYCHOTICS |
| Mechanism of action (general) |
|
| Mechanism of action (sexual) |
| Negative Decreased adrenergic ·1 activity Decreased cholinergic activity Decreased dopamine Increased prolactin Decreased testosterone Decreased LHRH pulsatile activity |
| Direct sexual side effects |
| Desire disorders Hyposexuality Hypersexuality (rare) |
| Orgasm disorders Orgasmic inhibition Anorgasmia The diminished number of orgasms |
| Ejaculation disorders Retarded ejaculation Ejaculatory inhibition Decreased ejaculatory volume Anesthetic ejaculation Orgasm without ejaculation Dyspareunia |
| Erection disorders Inability/difficulty obtaining an erection Decreased quality of erection Priapism |
* Desipramine appears to have the least amount of sexual side effects of the TCAs
Diagnosis of Sexual Arousal Disorder
A psychologist will first consider any psychological or emotional problems; while a sex therapist will examine relationship issues; after which a medical doctor will investigate medical causes for the disorder. In order to receive this diagnosis, a woman must, for at least 6 months, report at least 3 of the following symptoms: absent or significantly reduced interest in sexual activity, in sexual or erotic thoughts or fantasies, in the initiation of sex or receptiveness to sex, in excitement or pleasure in most sexual encounters, in sexual responsiveness to erotic cues, or in genital or non-genital responses to sexual activity. This can be either lifelong or acquired.[rx]
Treatment of Sexual Arousal Disorder
Depending on the cause of the disorder, hormone therapy or a blood-flow enhancing medication, like Viagra, may be appropriate.
Bremelanotide (formerly PT-141) is being studied in clinical tests to increase sexual desire in women. In 2014, Palatin, the company developing the drug, announced the beginning of Phase 3 clinical trial to determine its effectiveness.[5]
Pharmacotherapy
Multiple hormones have been studied for the treatment of sexual desire disorders. For example, androgen replacement has been studied as a possible treatment for HSDD. “In patients with induced or spontaneous hypogonadism, either pathological withdrawal and re-introduction or exogenous androgens affect the frequency of sexual fantasies, arousal, desire, spontaneous erections during sleep and in the morning, ejaculation, sexual activities with and without a partner, and orgasms through coitus and masturbation.”[rx]
Unfortunately, the evidence for the efficacy of testosterone in eugonadal men is conflicting. Some studies show no benefit,[rx] whereas other studies do show some benefit. For example, a study by O’Carroll and Bancroft showed that testosterone injections did have efficacy for sexual interest, but unfortunately this did not translate into an improvement in their sexual relationships.[rx]
One theory for the lack of efficacy in eugonadal men is that it is more difficult to manipulate endogenous androgen levels with administration of exogenous androgens due to efficient homeostatic hormone mechanisms.[rx]
Androgen supplementation is available in many forms, including oral, sublingual, cream, and dermal patches. Side effects of testosterone supplementation in women include weight gain, clitoral enlargement, facial hair, hypercholesterolemia,[rx] changes in long-term breast cancer risk and cardiovascular factors.[rx] Side effects in men of androgen supplementation include hypertension and prostatic enlargement.[rx] The benefit of androgen therapy in women is also not clear.[rx] Although studies using supraphysiologic levels of androgens have shown increased sex libido, there is the risk of masculinization from chronic use.[rx]
Testosterone therapy has shown to improve sexual function in postmenopausal women in multiple ways, including increased desire, fantasy, sexual acts, orgasm, pleasure, and satisfaction of sexual acts.[rx] Roughly half of all testosterone production in women is from the ovaries.
Estrogen replacement in postmenopausal women can improve clitoral and vaginal sensitivity, increase libido, and decrease vaginal dryness and pain during intercourse. Estrogen is available in several forms, including oral tablets, dermal patches, vaginal rings, and creams. Testosterone supplementation has demonstrated increased libido, increased vaginal and clitoral sensitivity, increased vaginal lubrication, and heightened sexual arousal.[rx]
Dehydroepiandrosterone-sulfate (DHEA-S), a testosterone precursor, has also been studied for the treatment of sexual desire disorders. Low physiologic levels of DHEA-S have been found in women presenting with HSDD.[rx] Increased libido was observed in women with adrenal insufficiency who were given DHEA-S.[rx] women with breast cancer reported increased libido while receiving tamoxifen, which increases gonadotropin-releasing hormone levels and therefore testosterone concentrations.[rx]
Some medications can be used to increase desire due to their receptor profiles. For example, amphetamine and methylphenidate can increase sexual desire by increasing dopamine release. Bupropion, norepinephrine, and dopamine reuptake inhibitor has been shown to increase libido.[rx]
A study by Segraves, et al.,[rx] showed that bupropion treatment in premenopausal women increased desire, but not to a statistically significant level compared to placebo. But, the bupropion SR group did show a statistically significant difference in other measures of sexual function: increased pleasure and arousal, and frequency of orgasms. Multiple herbal remedies, such as yohimbine and ginseng root, are purported to increase desire, but this has not been confirmed in studies.[rx]
Ten myths about sex
- In general, a man should not be seen to express certain emotions
- In sex, as elsewhere, it is a performance that counts
- An erection is essential for a satisfying sexual experience
- All physical contact must lead to sex
- Sex equals intercourse
- Good sex must follow a linear progression of increasing excitement and terminate in orgasm
- Sex should be natural and spontaneous
- On the whole, the man must take charge of and orchestrate sex
- A man wants and is always ready for sex
- We no longer believe the above myths
*Adapted from Zilbergeld B. Men and sex: a guide to sexual fulfillment. London: Harper Collins, 1995
References
