Sexual Dysfunctions & Paraphilic Disorders
Time the symptom, find the culprit, match the fix
Principles of sexual dysfunction
Diagnostic threshold. A sexual dysfunction requires symptoms on most occasions for at least 6 months with clinically significant distress, not better explained by another mental disorder, severe relationship distress, a medical condition, or a substance. Each complaint maps to a phase of the sexual response cycle: desire (male hypoactive sexual desire disorder, female sexual interest/arousal disorder), arousal (erectile disorder), orgasm (premature or delayed ejaculation, female orgasmic disorder), and resolution, which includes the male refractory period. Pain with penetration is classified separately.
Sensate focus. This core sex-therapy technique from Masters and Johnson removes performance pressure through graded, non-demand touching and is used across many dysfunctions, alongside CBT and couples work.
Erectile disorder
| Feature | Organic | Psychogenic |
|---|---|---|
| Onset | Gradual | Sudden, often after a stressor |
| Pattern | All situations and partners | Situational or partner-specific |
| Nocturnal, morning, masturbatory erections | Lost | Preserved |
| Typical causes | Atherosclerosis, smoking, diabetes, hypogonadism, medications | Performance anxiety, depression, relationship stress |
Evaluation. ED shares endothelial dysfunction with coronary disease and often precedes it by a few years. Check blood pressure, fasting glucose or A1c, lipids, and smoking status; measure morning total testosterone in men with ED, especially when libido is low, and confirm a low value with a second early morning measurement before diagnosing hypogonadism or starting therapy; and review medications and alcohol. Confirm the patient is fit for the exertion of sexual activity. Nocturnal penile tumescence testing is reserved for unclear cases.
PDE5 inhibitors. Sildenafil, vardenafil, and tadalafil inhibit PDE5, raising cGMP and relaxing penile smooth muscle; they are first-line and require sexual stimulation to work. Sildenafil can tint vision blue through PDE6 cross-reactivity. Second-line options include intracavernosal alprostadil, vacuum devices, and penile prosthesis; testosterone helps only when hypogonadism is confirmed.
PDE5 inhibitors are absolutely contraindicated with any nitrate (nitroglycerin, isosorbide, amyl nitrite "poppers") because of profound hypotension. Avoid nitrates for 24 hours after sildenafil or vardenafil and 48 hours after tadalafil, and use caution with α-blockers.
Other dysfunctions
Female sexual interest/arousal disorder requires at least three of reduced interest, sexual thoughts, initiation, pleasure, responsiveness to cues, or genital sensations for 6 months with distress. Look for depression, relationship conflict, SSRIs, and menopausal vaginal atrophy; treat with sex therapy or CBT, couples work, and targeted fixes such as vaginal estrogen. Female orgasmic disorder responds to CBT and directed masturbation.
Genito-pelvic pain/penetration disorder (including vaginismus) involves one or more of difficulty with penetration, pain during intercourse or attempts, fear of pain, or involuntary pelvic floor tightening for 6 months. After excluding infection, atrophy, and endometriosis, treat with pelvic floor physical therapy, graded vaginal dilators, and CBT or sex therapy.
Premature ejaculation is ejaculation within about 1 minute of penetration and before the person wishes, on most occasions for 6 months. Treatment uses the stop-start and squeeze techniques, topical anesthetics, and daily or on-demand SSRIs (paroxetine, sertraline) or clomipramine. Delayed ejaculation most often reflects SSRIs, diabetic neuropathy, alcohol, or psychological factors; α-blockers impair ejaculation.
Medication-induced dysfunction
| Drug | Mechanism or effect | Management |
|---|---|---|
| SSRIs, SNRIs | Delayed orgasm, low libido, ED | Lower dose; switch to bupropion or mirtazapine; add bupropion or sildenafil |
| Risperidone, haloperidol | D2 block → ↑ prolactin → ↓ GnRH: low libido, ED, amenorrhea, galactorrhea, gynecomastia | Switch to aripiprazole; adding a dopamine agonist risks worsening psychosis |
| Spironolactone | Androgen receptor blockade; gynecomastia | Switch to eplerenone |
| Finasteride, dutasteride | ↓ Dihydrotestosterone | Weigh stopping |
| Opioids | ↓ GnRH → hypogonadism | Taper; check testosterone |
| β-blockers, thiazides | Erectile dysfunction | Consider alternative agents |
Paraphilic disorders
Paraphilia versus disorder. A paraphilia is an intense, persistent atypical sexual interest. It becomes a paraphilic disorder only when it causes distress or impairment or has been acted on with a nonconsenting person, for at least 6 months. Pedophilic disorder requires the person to be at least 16 and at least 5 years older than the prepubescent child.
- Voyeuristic: watching unsuspecting people undress or have sex.
- Exhibitionistic: exposing the genitals to unsuspecting strangers.
- Frotteuristic: touching or rubbing against a nonconsenting person, often in crowds.
- Sexual masochism and sadism: being humiliated, beaten, or bound, versus inflicting suffering.
- Fetishistic: nonliving objects or nongenital body parts.
- Transvestic: sexual arousal from cross-dressing, distinct from gender dysphoria, which concerns identity.
Treatment. CBT with relapse prevention is the foundation, and SSRIs reduce urges and compulsivity. For severe or high-risk cases, antiandrogens such as medroxyprogesterone acetate or the GnRH agonist leuprolide lower testosterone and sexual drive.