Source: Abnormal Psychology Textbook (University of Florida)
Difficulty: Intermediate | Prerequisites: Part 1 notes (Sexual Response Cycle and Sexual Dysfunctions). Familiarity with biological, psychological, and sociocultural models of psychopathology.
Tags: causes of sexual dysfunction, biological causes, psychological causes, trauma, performance anxiety, spectatoring, sociocultural factors, Koro, sex therapy, sensate focus therapy, stop-start technique, squeeze technique, Viagra, sildenafil, cognitive-behavioural therapy, CBT, hormone therapy, bupropion
Knowing the diagnoses is only half the picture. Exams test heavily on aetiology (causes) and treatment, and this chapter covers both from multiple angles: biological, psychological, interpersonal, cultural, and lifespan. The causes are genuinely biopsychosocial, meaning you need to think across levels rather than picking one explanation. Treatment likewise spans medication, psychotherapy, couples therapy, and specific behavioural techniques (sensate focus, stop-start, squeeze). This is the material that ties the chapter together clinically.
Sexual dysfunctions arise from biological factors (medical conditions, hormones, medications, substances), psychological factors (mental disorders, attitudes, performance anxiety, trauma), and interpersonal/cultural factors (relationship problems, communication gaps, cultural beliefs). Treatments range from pharmacological interventions (sildenafil, hormone therapy, antidepressants) to psychotherapy and specialised sex therapy techniques such as sensate focus therapy and the stop-start method.
Performance anxiety
Excessive worry about whether one will become aroused or reach orgasm, to the point that the worry itself interferes with sexual functioning. The person is so focused on the outcome that they cannot be present for the experience, which reduces arousal. Think of it as stage fright, but for sex.
Spectatoring
A pattern in which a person anxiously monitors their own reactions and performance during sex as though they were an outside observer rather than a participant. This self-surveillance distracts from pleasure and compounds the dysfunction.
Sensate focus therapy
A structured sex therapy technique developed by Masters and Johnson. Partners progress through phases of non-genital touching, then genital stimulation, then intercourse, with the explicit instruction to focus on pleasure and sensation rather than performance or orgasm. Designed to reduce performance anxiety.
Stop-start technique
A behavioural method for treating premature ejaculation. Stimulation is paused just before the point of ejaculation until the man regains control, then resumed. Progresses through phases from masturbation alone, to non-thrusting intercourse, to slow intercourse.
Squeeze technique
An alternative to the stop-start method in which the penis is firmly squeezed near the point of ejaculation to reduce arousal. Less commonly used because it is harder to teach to partners.
Koro
A culture-bound depersonalisation syndrome, reported in Southeast Asian, Malaysian, and southern Chinese cultures, in which a man experiences acute panic and a delusion that his penis is shrinking into his body and disappearing. Thought to stem from cultural beliefs about the dangers of semen loss.
Substance-induced sexual dysfunction
Sexual dysfunction directly caused by substance use, including recreational drugs and prescribed medications. Diagnosed when the substance is identified as the primary cause.
Vaginal photoplethysmography
A device used to measure changes in vasocongestion (blood flow to the vagina) during sexual arousal in women. The male equivalent involves strain gauges to measure erectile capability.
The DSM-5 diagnostic criteria require that no medical condition fully accounts for the dysfunction, but many medical conditions can contribute to or directly cause sexual problems.
Diabetes is a major contributor: it lowers sexual drive, arousal, enjoyment, and satisfaction, especially in men. It can go undiagnosed, leading people to attribute the dysfunction to psychological causes.
Other medical conditions implicated: cardiovascular disease, multiple sclerosis, kidney failure, vascular disease, spinal cord injury, and injury to the autonomic nervous system from surgery or radiation.
In men, disease can cause dysfunction directly (by reducing blood flow to the penis) or indirectly (through the psychological impact of living with a serious illness).
Hormonal factors
In men: low androgen levels (especially testosterone) or high levels of oestrogen and prolactin can produce dysfunction.
In women: the hormonal picture is less straightforward. Oestrogen problems can reduce vaginal lubrication and lower arousal. Oestrogen drops at menopause commonly reduce sex drive. A radical hysterectomy (removing the ovaries, the main oestrogen source) often leads to reduced desire. Androgens also play a role in maintaining sex drive and vaginal tissue function in women.
Vaginal dryness or irritation, from any cause, can create a pain-then-avoidance cycle that lowers desire.
Causes of vaginal dryness or pain include antihistamines, douches, vaginal contraceptives, radiation therapy, endometriosis, infections, poorly healed episiotomy injuries, and gynaecological cancer.
Medications and substances
Several classes of medication diminish sex drive and interfere with orgasm: antihypertensives, antipsychotics, antidepressants (especially SSRIs), lithium, and tranquillisers.
Recreational substance use can also cause sexual dysfunction, and discontinuing the substance can often resolve the problem.
When medication or substance use is the primary cause, the appropriate diagnosis is substance/medication-induced sexual dysfunction.
Assessment devices
In men, strain gauges can measure erectile capability to help determine whether the cause is biological or psychological.
In women, vaginal photoplethysmography measures changes in vasocongestion during arousal.
Mental disorders
The DSM-5 formally excludes sexual dysfunction caused by another mental disorder from being diagnosed as a separate sexual dysfunction, but mental disorders can and do cause sexual problems.
Depression is a common culprit, and the medications used to treat it (SSRIs) can independently worsen sexual functioning.
Anxiety disorders (generalised anxiety, panic disorder, OCD) and schizophrenia are also associated with sexual dysfunction.
Attitudes and cognitions
People raised to view sex as sinful or shameful may have difficulty enjoying sex or lack desire.
Fear of losing control, embarrassment, distrust of a partner, shame about sex, and poor body image can all contribute.
Performance anxiety creates a self-defeating cycle: worry about performance reduces arousal, which increases worry.
Spectatoring compounds the problem by pulling the person out of the experience and into self-monitoring.
Over time, repeated difficulties can produce avoidance of sex altogether.
Trauma
Personal trauma, particularly trauma that damages self-esteem, is linked to reduced desire and sexual dysfunction.
Depression often follows trauma and can itself cause sexual dysfunction; clinicians typically prioritise treating the depression first.
Unemployment, bereavement, and sexual abuse or assault are common precipitating stressors.
Women who have been sexually abused may develop a conditioned aversion to all forms of sexual contact, tied to feelings of vulnerability and loss of control.
Partners of sexual assault survivors sometimes withdraw from sexual encounters because they cannot cope with the trauma, which can leave the survivor feeling re-victimised and further reduce their interest in sex.
Sexual dysfunction can be both a cause and a consequence of relationship problems, whether sexual or non-sexual.
Poor communication is a significant contributor. For example, women who need clitoral stimulation to reach orgasm may not communicate this, and partners may not understand it, leading to anorgasmia.
Cultural expectations play a role: the assumption that women should reach orgasm through penetration alone can prevent couples from exploring what works.
Some women fake orgasms to protect a partner's feelings, which prevents the underlying issue from being addressed.
Women seeking treatment for sexual dysfunction most commonly report marital problems or high-stress life events.
Men seeking treatment are more likely than women to present with multiple types of sexual dysfunction simultaneously (e.g. low desire alongside erectile problems).
Different cultures recognise sexual dysfunctions not listed in the DSM-5.
Traditional Chinese and Ayurvedic medicine hold that loss of semen is harmful to men's health.
Koro, seen in Southeast Asian, Malaysian, and southern Chinese cultures, involves acute panic and a delusion that the penis is retracting into the body. Patients or relatives may physically hold the penis until the episode passes.
Polynesian cultures have no word for erection problems; difficulties are interpreted as simply not wanting sex.
Some African cultures prefer vaginal dryness during sex and use herbal preparations to achieve it.
Less educated and lower-income populations tend to experience more sexual dysfunction, likely due to greater psychological stress, poorer physical health, and less access to education about sexual health and relationships.
Sexual desire generally declines with age, though older adults remain sexually active.
Age-related biological changes (lower testosterone and oestrogen) contribute to dysfunction in later life, often compounded by medical problems.
Psychosocial factors in older adults include loss of a spouse, loss of friends and family, health concerns, and discomfort with ageing bodies.
Relationship conflicts can worsen after retirement, when couples spend more time together.
Older couples may need to adapt their expectations and learn new approaches.
When dysfunction results directly from a medical condition, treating the condition often improves sexual functioning.
If a medication is causing the dysfunction, adjusting the dosage or switching medications can help.
Discontinuing recreational drugs can often resolve substance-induced dysfunction.
Pharmacological treatments for men
Sildenafil (Viagra), along with tadalafil (Cialis) and vardenafil (Levitra), is the primary pharmacological treatment for erectile disorder. Effective in men without an organic cause. Side effects include headaches, flushing, and stomach irritation. Does not always work.
Sildenafil can also help men whose erectile dysfunction is caused by antidepressants, allowing them to continue their psychiatric medication.
Certain drugs can be injected directly into the penis to induce an erection (effective, but with obvious practical drawbacks).
Premature ejaculation can be treated with some antidepressants (e.g. fluoxetine/Prozac, clomipramine/Anafranil, sertraline/Zoloft), which reduce ejaculation frequency as a side effect.
Men with low testosterone-driven desire can be treated effectively with hormone replacement therapy. This is not effective when low desire has other causes.
Pharmacological treatments for women
Hormone therapy (testosterone supplementation) in women has variable results and carries side effects, including masculinisation. Moderate testosterone doses do not consistently improve sex drive.
Bupropion (Wellbutrin) has shown promise in treating low sex drive in women.
Sildenafil increases vasocongestion and lubrication in women but does not consistently lead to greater subjective arousal, highlighting that for women, sexual arousal and pleasure involve more than physiological response alone.
Bupropion can also be used alongside SSRIs to counteract their sexual side effects.
Mechanical interventions
A vacuum pump (cylinder fitted over the penis connected to a manual or battery-powered pump) draws blood into the penis to produce engorgement.
Prosthetic devices (e.g. a pair of rods) can be surgically implanted to produce a permanent erection that can be positioned up or down. These achieve full erection but do not produce the bodily or mental experience of arousal.
Individual and couples therapy
Therapists assess attitudes, beliefs, personal history, and relationship dynamics to identify thoughts and feelings driving the dysfunction.
Cognitive-behavioural interventions (the most commonly used and most effective approach) address unhelpful attitudes and beliefs about sex.
Because sexual dysfunction is often both a cause and result of relationship problems, therapists frequently treat both partners together.
Therapists help couples communicate about their sexual needs, which may have become routine or neglected in long-term relationships.
Psychodynamic and family systems approaches are also used, particularly for non-sexual relationship conflicts.
Sex therapy (behavioural techniques)
Focuses on teaching and practising sexual skills, helping couples develop regular patterns of satisfying sexual activity.
Masturbation training: clients are encouraged to explore their bodies and discover what produces pleasure. Particularly helpful for women with anorgasmia, many of whom have never masturbated and have limited knowledge of their own arousal patterns. Outcomes include increased enjoyment, more relaxed attitudes toward sex, and better body acceptance.
Cognitions that arise during these exercises (e.g. guilt about masturbation) become therapeutic material. A CBT therapist would examine the accuracy of such thoughts; a psychodynamic therapist might explore their developmental origins.
Sensate focus therapy
Developed by Masters and Johnson. Partners are instructed not to attempt intercourse but to focus on the pleasure created by structured exercises.
Phase 1: extended touching of each other's bodies, avoiding genitals. Focus on sensation and communication about what feels good. The goal is intimate connection without pressure for intercourse.
Phase 2: stimulation around breasts and genitals until arousal and orgasm come regularly, but still no intercourse. The partner with the dysfunction guides the other in how to arouse them.
Phase 3: intercourse is reintroduced, with the focus on enhancing and sustaining pleasure rather than on orgasm or performance.
Techniques for premature ejaculation
Stop-start technique:
Phase 1: stimulation (via masturbation or partner) is stopped just before ejaculation until control is regained. If ejaculation happens, the focus is on enjoying it and reflecting, not on failure.
Phase 2: penetration without movement. The man can touch and engage with his partner but pauses if close to ejaculation. Lasts about 10–15 minutes.
Phase 3: slow thrusting, usually with the partner on top using long, slow strokes. Typically results in pleasurable orgasm for both.
This technique also benefits women, because the man maintains an erection throughout rather than losing it immediately after ejaculation.
Squeeze technique: the penis is squeezed firmly when close to ejaculation. Used less often because it is harder to teach partners.
Techniques for pelvic muscle tightening (vaginismus)
Deconditioning the involuntary tightening response through education about the muscular tension, relaxation training, and gradual insertion exercises (finger, then silicone or metal dilators, then partner's finger or penis).
Some approaches also address pelvic floor weakness, blood flow problems, joint dysfunction, and pain through muscle re-education, nerve and joint mobilisation, and massage.
Gay, lesbian, and bisexual individuals
Experience sexual dysfunction for the same reasons as heterosexual individuals, with additional stressors related to stigma and discrimination.
Therapists need to be sensitive to these unique stressors and their contribution to dysfunction.
Sex therapy techniques can be readily adapted for same-sex couples.
Ego-dystonic homosexuality (distress about one's sexual orientation) was listed in early editions of the DSM but has been removed. There is no evidence that psychotherapy can change sexual orientation.
"Performance anxiety only affects men." Women also experience performance anxiety and spectatoring, which can interfere with arousal and orgasm.
"Viagra solves all erectile problems." Sildenafil is most effective in men without an organic cause, and it does not always work. It also does not address psychological contributors.
"Sildenafil works the same way for women as for men." In women, sildenafil increases physiological arousal (vasocongestion, lubrication) but does not consistently improve subjective arousal or pleasure. Female arousal involves more than blood flow.
"Sexual dysfunction in older adults is inevitable and untreatable." While age-related changes are real, many older adults remain sexually active, and dysfunction at any age can often be treated with appropriate interventions.
⚠️ Be able to list biological, psychological, and sociocultural causes of sexual dysfunction with specific examples for each.
⚠️ Know the key medications: sildenafil for erectile disorder, SSRIs for premature ejaculation (and as a cause of dysfunction), bupropion as a counterbalance to SSRI side effects, and testosterone replacement for hormone-related low desire in men.
⚠️ Understand sensate focus therapy's phased structure and purpose (reducing performance anxiety).
⚠️ Know the stop-start and squeeze techniques for premature ejaculation.
⚠️ Be prepared to discuss Koro as a culture-bound syndrome and what it illustrates about cultural framing of sexual function.
⚠️ Remember that for women, physiological arousal does not automatically translate to subjective arousal. This is a recurring theme in the chapter.
True or False: Spectatoring refers to watching a partner during sex to increase arousal.
Fill in the blank: The phased behavioural technique in which partners progress from non-genital touching to intercourse while focusing on sensation rather than performance is called ________.
True or False: Testosterone replacement therapy is effective for all men with low sex drive, regardless of cause.
Fill in the blank: ________ is a culture-bound syndrome involving panic and a delusion that the penis is retracting into the body.
True or False: Sildenafil consistently improves subjective sexual arousal in women.
Answers: 1. False (spectatoring is anxiously self-monitoring one's own performance). 2. Sensate focus therapy. 3. False (only effective when low desire is caused by low testosterone). 4. Koro. 5. False (it increases physiological arousal but not consistently subjective arousal).
Q: Explain the self-reinforcing cycle created by performance anxiety.
A: A person worries about whether they will become aroused or reach orgasm. This worry distracts them from sexual stimulation and reduces their arousal, which confirms the fear and increases anxiety for the next encounter. Over time, this can lead to avoidance of sex altogether.
Q: Describe the three phases of sensate focus therapy.
A: Phase 1: partners touch each other's bodies while avoiding genitals, focusing on sensation and communicating what feels good, with no pressure for intercourse. Phase 2: stimulation expands to breasts and genitals until arousal comes regularly, but intercourse is still avoided; the partner with the dysfunction guides the process. Phase 3: intercourse is reintroduced with the focus on pleasure and connection rather than orgasm or performance.
Q: Why is sildenafil considered less effective for women than for men?
A: Sildenafil increases vasocongestion and lubrication in women (physiological arousal), but this does not consistently translate into greater subjective arousal or pleasure. For women, feeling sexually aroused involves more than the physiological response alone.
Q: What is Koro, and what does it illustrate about the cultural context of sexual dysfunction?
A: Koro is a culture-bound syndrome found in Southeast Asian, Malaysian, and southern Chinese cultures, characterised by acute panic and a delusion that the penis is shrinking into the body. It illustrates that sexual dysfunction is not defined the same way across all cultures, and that cultural beliefs about sexuality shape both the experience and the interpretation of sexual problems.
Q: Name three classes of medication that can cause sexual dysfunction as a side effect.
A: Antihypertensives (blood pressure drugs), SSRIs (antidepressants), and antipsychotic drugs. Other correct answers include lithium and tranquillisers.
The biological causes here link to health psychology and psychopharmacology chapters: understanding medication side effects is essential for any clinician managing psychiatric medication. The cognitive and behavioural models of performance anxiety connect to the anxiety disorders chapter and to CBT principles covered throughout the course. The cultural factors section connects to cross-cultural psychology and the broader discussion of how the DSM-5 handles cultural variation in diagnosis.
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