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Psychiatric Descriptions

Sex and Sexual Disorders


Sex enhances intimacy and connectedness, and adds comfort, security, and pleasure to loving couples. And, of course, sex is necessary for propagation. As sex is such a large component of normal life, when it is disrupted, wide ranges of problems develop. From a medical standpoint, these problems are addressed by maneuvers to mend any type of physiological or psychological disruption that may be present. This approach is not complete - human sexual behavior is too complex to be viewed only through a medical prism - but is helpful to alleviate common types of problems patients have during sex.

Human sexual behavior can be divided into four stages: drive, arousal, orgasm and resolution. Sexual drive is the impetus that makes individuals think about and want sex. The brain regulates this process through a number of mechanisms. Sexual arousal is the stage of sexual pleasure and excitement preceding orgasm. In males, the blood enters the penis, which becomes erect. In females, blood flow increases to the clitoris, labia, and vagina. Orgasm is the climax of pleasure during sex. In males, this coincides with ejaculation. In females, orgasm is accompanied by contractions of the vagina and uterus. Orgasm is a sensation in the brain. In males, impending ejaculation triggers orgasm. In females either vaginal or clitoral stimulation triggers orgasm. The last stage of sex is resolution. Five to fifteen minutes after orgasm, the body returns to baseline. In men there is a refractory period that may last from minutes to hours, in which they cannot be stimulated to orgasm. This period is not seen in women, many of whom are able to have multiple, consecutive orgasms.

Sexual Disorders

  • Impotence
  • Medication-induced sexual dysfunction
  • Orgasmic Disorder
  • Premature Ejaculation
  • Vaginismus


Impotence is the inability to attain or sustain an erection to complete sexual intercourse. Impotence can be psychological in origin; however, it is also a common symptom in many physical conditions and drugs. The easiest way to sort out and treat impotence is to group the causes into physical or psychological categories.

One way to differentiate if the cause of impotence is physical or psychological is to ask when the impotence occurs. If impotence happens only at certain times, for example, only with one's wife - not with one's mistress - there is a strong indication for a psychological cause. However, diagnosis is not usually that simple as the insidious nature of impotence in medical conditions, such as diabetes, allows for psychological contributions. Commonly, anxiety will confound the cause of impotence in patients who have an underlying physical cause. The treatment of impotence begins by adequately treating the underlying physical or psychological condition.

Medication-induced sexual dysfunction

This is the most common cause of sexual dysfunction that psychiatrists encounter. Many medications and most substances of abuse cause sexual problems. Unfortunately, many of the medications that are prescribed for psychiatric illnesses cause sexual dysfunction.

One of the most prevalent diseases in psychiatry is depression, and the most popular antidepressants, which work exceptionally well for depression, can cause sexual dysfunction. The most common sexual problems encountered with antidepressant therapy are delayed ejaculation and delayed orgasm. Also, decreased sexual desire and arousal may be seen. The effect on sex is dose-related, that is, higher doses of medication cause higher levels of dysfunction.

The first step in appraising if the antidepressant is contributing to sexual dysfunction is to ask patients if they are taking the medication. Most depressed patients respond to medication and may stop taking medicine when they feel better. A reemerging depression can decrease sexual function. If patients are compliant with medication and their depression is controlled, the next step is to assess if there are other possible causes, for example, exacerbation of a medical illness or new stressful encounters. Once the problem is addressed, most patients will respond to treatment strategies.

Orgasmic Disorder

Orgasmic disorder is the absence of orgasm following a normal excitement phase. It is more prevalent in females than in males. In the workup of a patient with orgasmic disorder it is necessary to inquire about physical and psychological manifestations associated with the orgasm. Lack of knowledge of the function of sexual anatomy, that is, the understanding of the physiology of an orgasm, decreased awareness of sexual sensations, anxiety, and distractibility can contribute to the condition. In addition, these areas are targets of treatments - which typically incorporate multiple approaches. These approaches are best applied and most successful when coupled with communication with the sex partner.

Premature Ejaculation

Premature ejaculation probably would not be considered a problem if there were no refractory period in males. One of the glaring differences in sexual activity between males and females is that females are capable of multiple, consecutive orgasms, while males are not.

So, what is the "premature" in premature ejaculation? Attempts have been made to count pelvic thrusts and measure the time it takes to orgasm. However, using these criteria as a part of diagnostic evaluation can greatly decrease sexual pleasure when males are asked to count the number of pelvic thrusts or the duration of sex.

The current criterion for diagnosis only recognizes dysfunction if the time to ejaculate causes distress in the partner. If premature ejaculation is considered a problem, then there are a variety of successful treatments. As with all sexual disorders, patients more readily respond to treatment when their sex partner is included in the treatment plan.


Vaginismus is an involuntary, painful muscle spasm of the outer third of the vagina that occurs with the attempted insertion of an object into the vagina. Vaginismus can occur in nonsexual situations such as during gynecological examination or with insertion of a tampon; however it is considered a sexual disorder when the item is a penis.

The exact cause of vaginismus is unknown. Physical causes, such as infection and surgical adhesions, have been noted in vaginismus. The psychological view is that vaginismus is caused or confounded by fear from past negative sexual or imagined sexual experiences. This fear is expressed via the involuntary muscle spasms. The treatment of vaginismus consists of interventions to decrease the pain and muscle spasms, as well as interventions to address an underlying problem if present.