bubble_chart Overview

Sexual disorders include two major categories: sexual physiological dysfunction and sexual psychological disorders. The medical community's concern about sexual issues has only emerged in recent decades, and in our country, it is just beginning. Since sexual disorders are often related to psychological factors, psychiatrists have been more involved in this area. Patients with sexual physiological dysfunction mostly visit urology clinics, while female patients rarely seek medical attention or go to gynecology departments. In recent years, due to the increase in popular science articles on this topic, more people have sought sexual psychological counseling, but many still remain in a state of "concealing their illness and avoiding treatment." Even in countries like the United States, it was estimated in 1980 that less than 10% of patients in general clinics voluntarily reported sexual function issues. However, if doctors actively guide the conversation toward this topic during medical history inquiries, about 50% of patients may express concerns about their sexual function. Yet, most doctors avoid addressing this issue for fear of violating patients' privacy, and many are not very familiar with the topic themselves, so they refrain from mentioning it. Therefore, it is currently crucial to popularize this knowledge among doctors before scientific sexual education can be effectively promoted in society.

bubble_chart Clinical Manifestations

1. Normal Sexual Function

Both humans and animals possess sexual function, which is considered an instinct for perpetuating the species (another being the instinct for self-preservation). However, in humans, this instinct is largely influenced by psychosocial factors, leading to many sexual dysfunctions not caused by defects in the sexual organs. To facilitate understanding these dysfunctions, the process of normal sexual activity is briefly described here.

The sexual process can be divided into four stages:

(1) Initiation of Sexual Desire: Sexual desire can be aroused by contact with a preferred partner of the opposite sex or related imagery, which is a necessary prerequisite for sexual activity. However, many psychosocial factors can inhibit the generation or development of sexual desire.

(2) Sexual Organ Response: After sexual desire is aroused, if conditions permit, sexual organ responses occur. In males, this primarily involves penile erection, while in females, it involves the secretion of lubricating fluids in the vagina, facilitating penile insertion and subsequent intercourse.

(3) Orgasm: After repeated penile movements within the vagina, males ejaculate, followed by relaxation of the pelvic muscles and the entire body, reaching sexual climax (i.e., orgasm). Females generally also transition from tension to relaxation, achieving orgasm. However, females have a longer sexual latency period, so their orgasm may occur slightly later than in males.

(4) Relaxation: After achieving orgasm, the relaxation phase begins. Males often require a period of time before they can achieve another erection and orgasm, known as the refractory period. Females may have a very short refractory period or even achieve consecutive orgasms (with continuous stimulation).

Sexual desire typically begins during puberty, peaks in young adulthood, and females may experience a second peak in their thirties. After menopause, female sexual desire gradually declines, while males can maintain it into old age. There is no absolute "normal standard" for the frequency and duration of intercourse; as long as both partners find it satisfactory, it cannot be considered abnormal.

2. Sexual Dysfunction

This refers to functional impairments of the sexual organs without anatomical damage. Common forms include:

(1) Lack of Sexual Desire: This can result from poor relationships between partners. If there was once a good relationship, psychological counseling may help restore desire. If there was never any mutual attraction, it is not a medical issue. If one partner is interested while the other is not, it may be due to fatigue or other reasons, or insufficient "foreplay." Fear of intercourse in females can also inhibit desire. Treatment primarily involves explaining the causes to both partners to seek appropriate solutions.

(2) Lack of Sexual Organ Response: In males, this mainly involves the inability to achieve or maintain an erection sufficient for vaginal penetration (known as erectile dysfunction or impotence). In females, it manifests as a lack or insufficiency of vaginal lubrication. Primary impotence refers to those who have never achieved an erection, but most cases are secondary and temporary. If impotence occurs only with a spouse, it is often due to anxiety, and treatment should address the underlying causes. If impotence is not "selective," other conditions (including mental illnesses) or substance use (e.g., drugs or alcohol) should be investigated. Lack of vaginal lubrication in females is primarily due to a lack of desire or insufficient foreplay.

(3) Anhedonia This is more common in women because the male quickly loses erection after ejaculation and can no longer move within the vagina, while the female has not yet reached orgasm. If sexual intercourse is appropriately prolonged or ejaculation is delayed, both partners can achieve orgasm simultaneously. The primary treatment involves helping both partners understand each other's sensations. The penis should be inserted into the vagina only after the female has developed sufficient genital response, or movement should be paused when the sensation of impending ejaculation occurs to delay ejaculation. If the male ejaculates before the penis is inserted into the vagina, it is termed premature ejaculation, which also affects pleasure. This condition may occur during the first few instances of intercourse or after a long period of abstinence and usually requires no intervention. There is no strict standard for how long the penis must remain in the vagina before ejaculation to avoid being considered premature. Even if the duration is very short, it does not count as premature ejaculation if the female has already achieved orgasm. In Western grade I, the "squeezing and pressing manipulation" is recommended for treating premature ejaculation. However, it is now considered better to pause movement or withdraw the penis when ejaculation is imminent and resume after a brief interval (referred to as the "start-stop method"). Of course, mutual understanding and cooperation between partners are crucial during such treatment and serve as the foundation for success.

(4) Dyspareunia Mainly seen in women, it can be caused by insufficient vaginal secretion during intercourse, local inflammation, or rough actions by the male partner. A single painful experience can lead to vaginal spasms due to fear during subsequent intercourse, resulting in pain. Strengthening mutual care, improving sexual techniques, and treating local conditions can often alleviate or improve the pain.

The above describes common sexual physiological dysfunctions, primarily involving disorders in the second and third stages of the normal sexual response cycle. A good marital relationship is a necessary condition for successful treatment. Of course, if the relationship issues are caused by these dysfunctions, the first step is to build confidence in the possibility of recovery, as successful treatment can restore the relationship. Educating both partners with correct sexual knowledge is an essential step in fostering confidence in treatment.

Many factors can contribute to sexual physiological dysfunction, and often patients are affected by multiple factors. After experiencing sexual dysfunction, patients may delay seeking help for some time (even years), hoping for spontaneous improvement. By the time they finally seek treatment, some triggering factors may no longer be accurately recalled. Below are some common contributing factors:

(1) Sociocultural background factors Scientific knowledge about sex has historically been understudied and poorly disseminated. As a result, people often acquire sexual knowledge through hearsay, and discussing sexual matters is generally considered "vulgar." Even between spouses, there may not be sufficient communication, leading to uncertainty about appropriate sexual behavior and reluctance to seek help when problems arise.

(2) Personal factors The most common issue is anxiety, such as fear of inadequate sexual performance to satisfy the partner, fear of pregnancy, fear of sexual behavior being discovered, or fear of being perceived as promiscuous due to a lack of emotional connection.

(3) Relationship factors Examples include excessive respect, fear, or aversion toward the partner, lack of emotional connection, or poor communication between partners.

(4) Misinformation For instance, beliefs that sexual activity should cease after menopause, that sexual ability disappears at a certain age, or that certain diseases inherently impair sexual function. In the past, masturbation was thought to cause sexual dysfunction, but this is a misconception. Masturbation generally only leads to sleep deprivation, affecting energy levels the next day, and does not cause specific diseases.

(5) Other diseases Certain illnesses or medications can indeed affect sexual ability, particularly male erection (see Table 1). Generally, acute sexually transmitted diseases or short-term medication use may temporarily impair sexual function but often go unnoticed. Chronic sexually transmitted diseases, due to their prolonged nature, attract more attention. Other diseases account for only a minority of sexual dysfunction cases, and some are anxiety-related, such as fear that intercourse might worsen the condition.

Those who have never experienced sexual satisfaction are considered to have primary sexual dysfunction, while those who previously had normal sexual experiences are classified as having secondary sexual dysfunction. Clinically, the latter is more common.

Table 1 Common Causes Affecting Penile Erection

Physical Diseases
Atherosclerosis	Pelvic diseases or surgeries
Heart failure	Sympathetic nerve surgery
Renal failure	Radiation therapy
Liver cirrhosis	Severe systemic diseases
Pulmonary failure
Malnutrition	Mental illness
Diabetes	Anxiety disorder
Pituitary disease	Depression
Adrenal disease	Schizophrenia
Hyperthyroidism or hypothyroidism	Organic mental disorder
Multiple sclerosis	Drug use
Spinal cord injury	Most antidepressants
Tremor paralysis	Most antipsychotics
Temporal lobe epilepsy	Some antihypertensive drugs
Brain syphilis	Sedatives
Peripheral nerve disease	Alcohol
Klinefelter syndrome	Digoxin, propranolol

III. Psychosexual disorders

From a biological perspective, human sexual activity is directed toward the opposite sex, involves genital contact, and aims to produce offspring, which is a commonality shared with other animals. However, as higher animals, humans have long since ceased to make reproduction the goal of every sexual encounter, yet the process of being oriented toward the opposite sex and engaging in intercourse remains the norm for the vast majority. Any deviation from this process, in the absence of anatomical or physiological defects in the genitalia, is termed a psychosexual disorder (also known as sexual perversion or paraphilia). The causes of most psychosexual disorders are unknown, though some may be linked to childhood experiences. Treatment is often challenging, but behavioral therapy has shown some success in recent years. The more common or frequently mentioned manifestations of psychosexual disorders include the following:

(1) Homosexuality As previously mentioned, the majority of people's sexual attraction is directed toward the opposite sex and repelled by the same sex (referred to as heterosexuality). If this antagonism is reversed, it is called homosexuality. Not all homosexuals completely reject the opposite sex. In a homosexual pair, one is often more active and the other more passive. The passive partner tends to have a weaker aversion to the opposite sex, so some may eventually leave homosexuality and marry someone of the opposite sex, causing the active partner to experience "heartbreak." Complete, lifelong homosexuals are relatively rare. More common are those who are attracted to the same sex but marry someone of the opposite sex due to societal traditions, or those who are primarily heterosexual but also have some sexual attraction to certain individuals of the same sex. Homosexuals exist among both men and women. While reports are more frequent in Western countries, they also exist in China, though reports are fewer. Homosexuals can adopt lifestyles similar to heterosexual couples, engaging in sexual flirtation and simulated intercourse; however, some relationships are purely "platonic." In China, male homosexuals discovered engaging in sexual acts are often treated as engaging in hooliganism. Homosexuality is generally regarded as an abnormal phenomenon contrary to biological norms and has been a subject of psychiatric study. However, in some places (such as the United States), due to the large number of homosexuals, they argue that labeling homosexuality as abnormal violates their human rights, creating significant advocacy. As a result, the American Psychiatric Association was compelled to remove homosexuality from its classification of mental disorders. In recent years, because Acquired Immune Deficiency Syndrome (AIDS) has been found to be closely linked to homosexuality, the prevalence of homosexuality has somewhat declined.

Homosexuality has no specific treatment at present because the cause is unknown.

(II) Transvestism refers to heterosexual adult males who repeatedly wear female clothing to achieve sexual arousal, excluding cases where such dressing does not elicit arousal, is due to special needs, or follows social trends. Transvestism should actually be termed cross-dressing fetishism, but it generally does not include women wearing male clothing.

(III) Exhibitionism usually involves males who suddenly expose their genitals to unfamiliar women, fleeing immediately after gaining the woman's attention, at which point they achieve sexual arousal without seeking further sexual activity.

(IV) Fetishism typically involves males who are fixated on objects closely associated with the female body (such as underwear) or female hair. Obtaining these items triggers sexual arousal, leading them to go to great lengths to collect, even steal or snatch such objects.

(V) Sadism and Masochism refer to the repeated use of abusing a member of the opposite sex or being abused by them as a means of achieving sexual satisfaction. This abuse involves actions that can cause physical injury or severe psychological humiliation, with the resulting sexual satisfaction often surpassing that obtained from intercourse. Playful "hitting" or "teasing" as foreplay, since it does not cause psychological or physical harm, does not qualify as sadism or masochism.

(VI) Transsexualism involves individuals with a strong desire to become the opposite sex, occurring in both men and women. They undergo surgical procedures and hormone therapy to transition. Such surgeries have been performed in Western countries for decades, and China has also seen such procedures in recent years. Gender reassignment surgery is currently the only effective treatment for transsexualism. Surgeons must carefully assess whether the desire to transition is linked to any mental illness and thoroughly explain the potential social pressures post-surgery.

There are other manifestations of psychosexual disorders, which are not detailed here.

Psychosexual disorders are primarily treated with psychotherapy. The principle of treatment is "to reinforce normal heterosexual relationships to reduce abnormal psychosexual behaviors." Specific symptoms may be addressed with behavioral therapy, often requiring specialized medical professionals.