Sexual difficulties are common, are usually treatable, and are routinely approached through the one question that guarantees the wrong answer: is this physical or psychological. Almost every persistent problem has a physical contributor and a psychological one keeping it going, and the half that is ignored is the half that brings it back. [mccabe-2016-definitions] This guide covers what these difficulties are, what causes and sustains them, and what treatment actually works.
What counts, and what does not
A sexual difficulty becomes a clinical problem when it is persistent, present on most occasions over roughly six months, and causing distress.
Both halves matter. Occasional difficulty is nearly universal and is not a condition. And a level of sexual interest that is low by some external standard but bothers nobody involved is not a disorder either, which is a genuinely important guard against pathologising ordinary variation.
The main categories are difficulties with desire, with arousal, with orgasm, and pain during sex. They overlap heavily in practice, and it is common for one to produce another.
- Anxiety and self-monitoring 40% of maintaining factors
- Medical or medication factors 30% of maintaining factors
- Relationship context 20% of maintaining factors
- Other contributors 10% of maintaining factors
The multifactorial picture described in the Fourth International Consultation on Sexual Medicine consensus (McCabe and colleagues, 2016). Values illustrate the point that maintaining factors are mixed rather than reporting measured proportions.
The loop that keeps it going
Whatever starts a difficulty, one mechanism sustains most of them.
A difficulty occurs, for any reason: alcohol, tiredness, a new medication, stress, a difficult conversation earlier that evening. On the next occasion there is now something to worry about. Attention shifts from sensation to monitoring, checking whether it is working. That shift is itself enough to suppress the physical response, because arousal depends on attention being somewhere other than on assessing arousal.
The failure then confirms the fear, and the loop is closed. It runs perfectly well after the original cause has disappeared entirely, which is why “the medication was changed months ago and it did not help” is such a common report.
Breaking it involves moving attention back to sensation and removing the performance frame, which is what most of the effective psychological treatment consists of.
Medical and medication causes
| Contributor | What it typically affects |
|---|---|
| SSRI antidepressants | Desire, and delayed or absent orgasm |
| Some blood pressure medications | Erectile function, arousal |
| Hormonal changes | Desire, arousal, comfort |
| Diabetes and vascular disease | Erectile function, arousal, sensation |
| Thyroid disorders | Desire, energy, arousal |
| Alcohol, regularly | Arousal and orgasm, in both the short and long term |
| Depression and anxiety themselves | Desire above all, independently of any medication |
The medication row is the one most often left unspoken. Montejo and colleagues describe the substantial impact of psychotropic medication on sexual function and the clinical importance of asking about it, since people frequently stop effective treatment rather than raise the side effect. [montejo-2019-ssri] Options usually exist, including dose changes, timing and switching, but only if the subject is opened.
The row worth taking seriously for a different reason is vascular. Gandaglia and colleagues reviewed the association between erectile dysfunction and cardiovascular disease, and the direction of the finding is that erectile difficulty can precede a cardiac event by years, because the vessels involved are small and narrow first. [gandaglia-2014-cardio] A new, gradual-onset erectile difficulty is therefore a reason to have blood pressure, cholesterol and glucose checked, whatever else is done about it.
Low desire is three different problems
Grouping them together is why so much advice about desire lands as useless.
Desire that was never high. A long-standing baseline, with no change and no obvious cause. Distress here usually comes from comparison with an expectation rather than from a loss, and the useful conversation is often about the expectation.
Desire that disappeared. A change from a previous baseline. This is the one that most warrants a medical look, because it is the pattern produced by medication, hormonal change, thyroid problems, depression and chronic fatigue.
Desire that exists but not here. Present in other contexts, absent in this relationship. No medical investigation will find anything, because there is nothing medical to find, and the answer lies in the relationship rather than the body. Our guide to relationships covers that territory.
Distinguishing between the three takes one question about timing and one about context, and it changes the whole approach.
What treatment works
Psychological treatment has good evidence. Frühauf and colleagues pooled trials of psychological interventions across sexual difficulties and found meaningful improvement in symptom severity and satisfaction. [fruhauf-2013-psychological]
The common ingredients are consistent: reducing the performance frame, deliberately shifting attention back to sensation rather than assessment, graded exercises that begin without any expectation of intercourse, addressing beliefs about what sex is supposed to look like, and involving the partner where there is one, since a difficulty in a couple is rarely a problem located in a single person.
Medical treatment sits alongside rather than instead: treating an underlying condition, adjusting a medication, and drug treatments where appropriate. The combination outperforms either alone for most persistent difficulties, which follows directly from the fact that most persistent difficulties have both kinds of cause.
Where anxiety is the dominant maintaining factor, our guide to anxiety covers the mechanism in general, and the anxiety screener may be worth ten minutes.
When to seek help
See a doctor if a difficulty has lasted several months, if it began after starting or changing a medication, if there is pain, or if erectile difficulty came on gradually and has worsened, which warrants a cardiovascular check regardless of what is done about the sexual symptom. Raise it even if it feels too minor to mention, since the alternative is often years of avoidance over a problem with a straightforward answer.
If you are in crisis, contact your local emergency services or a crisis helpline.