Sexual Disorders, What are pathophysiological sexual disorders?, How common is pathophysiologic sexual dysfunction?, How do people know they have pathophysiologic sexual dysfunction?, How do doctors diagnose and treat pathophysiologic sexual disorders?

The term sexual disorders refers to any problem with sexual performance or the function of sexual organs. Many of these problems have psychological origins. Those with a physical or medical origin represent only a small percentage of all cases. A substantial number of cases occur more often than previously thought, probably because many people do not report the problem.

What Are Pathophysiological Sexual Disorders?

Pathophysiological (path-O-fiz-EE-o-loj-eh-cal) (physiological disruption of normal function) sexual disorders include any sexual disorder that results from physical problems. The disorder can be as serious as structural deformities in the male or female sex organs. Further classification involves whether the disorder is congenital (existing from birth) or whether it was acquired (shaped by a traumatic incident). Pathophysiological sexual disorders have symptoms similar to sexual dysfunction * except the causes are different: Sexual dysfunction is often brought on by psychological or psychophysical (the influence of psychological factors on physical function) influences. Only 10 percent of sexual disorders are truly pathophysiological with a clear physical or medical origin. They include intersex conditions (discrepancies between external genitals and internal sex organs), male pathophysiological sexual dysfunction, and female pathophysiological sexual dysfunction.

One of the common causes of intersex conditions in both boys and girls is congenital adrenal hyperplasia, a serious endocrine imbalance in which the adrenal glands * either do not produce enough vital hormones or produce too much of one. This imbalance interferes with normal development and growth in all parts of the body, including the sex organs. In boys, an intersex condition can be caused if the adrenal glands do not produce enough testosterone; in girls, an intersex condition can be caused if the adrenal glands produce too much testosterone.

A fetus * with male chromosomes may appear to be female at birth if the hormonal deficiency occurred during the first 12 weeks of gestation. If the deficiency occurs later in the pregnancy, it may lead to the baby having an extremely small penis, a condition known as microphallus. Masculine features are influenced after birth by the testosterone produced in the testes * . If the testes are missing or weak due to prenatal hormonal deficiencies, they cannot produce enough testosterone for full appearance and functioning of male sex characteristics. Another problem occurs when the male baby cannot produce an enzyme that enables testosterone to influence sex development effectively. Many individuals with this condition have been unknowingly raised as girls until puberty * increased the level of effective testosterone. They then took on more masculine features.

A genetically female fetus may be exposed to male sex hormones from a variety of sources other than congenital adrenal hyperplasia. The mother may have been prescribed progesterone as a means of preventing a miscarriage * . This artificial hormone sometimes crosses the placenta * * in the glands is another source of male hormones. On rare occasions, a tumor may produce male sex hormones in a young female.

MEDICAL MISJUDGMENT

Bruce Reimer was born a healthy boy with an identical twin * brother (Brian) in 1965. Doctors discovered that each infant had a minor penis deformity that doctors said could be solved with circumcision * . The doctor made a serious mistake with Bruce's circumcision, which caused severe disfigurement. Reimer's parents saw John Money (1921–2006) of Johns Hopkins University in Baltimore, a psychologist and sexologist who claimed that boys could be raised as girls if the process was started early enough in life. Doctors removed Bruce's testicles * when he was 21 months old; on discharge from the hospital, Bruce was renamed Brenda and raised as a girl. In the following years, Money claimed that Bruce had adapted well to being female and was living a happy life.

In reality, Bruce, living as Brenda, knew that there was something wrong, and had depression * and a difficult childhood with emotional trauma. He did not seem to fit the norms of boys or girls, and his relationships were affected by his confused identity. At age 14, after threatening to commit suicide, Bruce learned the truth from his father and decided to live his life as a man. He stopped estrogen * injections and began testosterone * (test-TAHS-ter-own) injections to develop male sexual characteristics. He worked from that point on to regain his identity, even marrying. Still, he committed suicide at the age of 39.

Reimer's parents had not received the counseling they needed, and this case was one of several that sensitized medical professionals to both the physical and psychological complications of treating ambiguous genitalia with surgery.

The most common sexual disorder in men is erectile dysfunction. This condition is most often caused by psychological problems or stress. There are several physical causes of the disorder, most of which are associated with aging. Although erectile dysfunction can happen to men of all ages for physical or medical reasons, about one-half of men over age 65 and three-fourths of men over age 80 report erectile dysfunction. Three main causes are: problems with blood flow, problems with the nerves in the penile area, and problems with hormones.

The blood flow problems are of two types: either not enough blood flows into the penis, or the blood in the penis flows out too quickly. To sustain an erection, blood needs to engorge the penis. If the incoming blood vessels are too constricted, then not enough blood can flow into the penis to enlarge and stiffen the penis. If the outgoing blood vessels are not constricted enough, then blood cannot remain in the penis long enough to maintain an erection. These problems are caused by abnormalities in the blood vessels resulting from previous surgery, diabetes * , blood clots * , or arteriosclerosis (hardening of the arteries).

Nerve damage in the penile area can interfere with the neurological communication that stimulates an erection in the penis. The nerve damage might lie in the nerves sending the message from the brain to stimulate the functions that result in an erection. Alternately, the damage may be in the nerves sending sensation to the brain, which diminishes the effects of sexual stimulation. This problem can be caused by spinal cord injuries, infection, external impact, or structural change. Other causes of penile nerve damage include diabetes, previous surgery, and nerve system irregularities.

Problems with hormones are related to failure of the testes to produce testosterone. The two hormones important for normal sexual functioning are testosterone and gonadotropin (GO-nad-oh-TRO-pin). Testosterone is responsible for all male sexual characteristics. Gonadotropin is produced by the pituitary gland * to stimulate production of testosterone. The presence of above-average levels of gonadotropin indicates that the testes are not producing enough testosterone. Too little testosterone and too much gonadotropin can lead to erectile dysfunction.

Dyspareunia (dis-pah-ROO-nee-ah) is the condition in which sexual intercourse is painful for women. Because the pain is greater than any pleasure derived from sexual intercourse, a woman experiencing dyspareunia is likely to avoid sexual relationships. The causes of this condition vary, but they can be grouped according to whether the pain is felt during or after intercourse.

If the pain is felt during intercourse, it may be caused by infection of the vulva * , vagina * , or Bartholin's glands * . Other causes include the aftereffects of surgery from childbirth and congenital irregularities in the hymen (the membrane that covers the opening to the vagina) or the vaginal walls. If the pain is felt after intercourse, its cause may be an infection of the cervix * , uterus * , or fallopian tubes * . Most often the infection is caused by pelvic inflammatory disease * (PID), which is related to sexually transmitted bacteria known as chlamydia (kla-MID-ee-ah) and gonorrhea (gone-ah-ree-ah). Other causes include a pelvic tumor or internal scar tissue that forms after surgery or an infection.

Many women suffer pelvic pain and infertility due to endometriosis (en-do-ME-tree-OH-sis), a condition in which tissue cells similar to the ones lining the uterus are found outside the uterus in the abdominal cavity or in other organs. When these cells line the ovaries * or the fallopian tubes, they can interfere with the normal functioning of these organs, leading to infertility. Endometriosis can also be the cause of other sexual disorders.

Vaginismus (vaj-eh-NIS-mus), the involuntary contractions of vaginal muscles, is a symptom associated with many types of sexual dysfunction. When this symptom occurs, the sexual act is interrupted because penetration becomes difficult or painful for the woman. It can be caused by current infections or by a previous painful vaginal experience, such as surgery or difficult childbirth. It is a natural reaction to anticipated pain during intercourse.

Consistent irritation in the vulva area is referred to as vulvodynia (vulvo-DIN-ee-ah). This condition occurs without warning and continues without relief. It is usually caused by damage to the nerves in that area. It usually begins following any of a number of conditions, including yeast infection, skin disorders, and diabetes. Vulvodynia can be diagnosed only by ruling out any other disorder as the cause.

Sexual arousal disorder is the condition in which a woman cannot be fully aroused to have sexual relations. It is often caused by psychological conditions, such as fear of intimacy or loathing the current sexual partner. Physical conditions that can lead to lack of sexual arousal include vaginitis, endometriosis, diabetes, or aging. If a woman knows that she has no psychological reason to reject sexual relations, she should have a health exam to determine whether any medical problem could be the cause of her sexual arousal disorder.

How Common Is Pathophysiologic Sexual Dysfunction?

Most resources estimate that 43 percent of women and 31 percent of men experience some form of sexual dysfunction. However, less than 10 percent involve a physical cause. A survey of gynecologists found that when the doctor asked the patient about sexual problems, 12 percent reported a problem, presumably of a gynecological origin. Diabetes contributes to sexual dysfunction: 50 percent of men and 35 percent of women with type 2 diabetes report trouble with sexual relations. One-half to twothirds of patients with heart disease also experience sexual disorders. The occurrence of any intersex condition, regardless of how mild or severe, is estimated at 1 percent of all births.

How Do People Know They Have Pathophysiologic Sexual Dysfunction?

Many people live with a below-average sexual drive and live relatively happy lives despite that fact. As many of the conditions of sexual disorders are not life-threatening, these people can lead normal lives without treatment. When individuals participating in a sexual relationship or anticipating a sexual relationship cannot function the way they want, then treatment may be required. Similarly, some people are comfortable in an intersex state and are content to remain the way they were born. However, if the condition is interfering with adapting to life, these individuals may seek medical advice and either consider or undergo a gender reassignment operation.

How Do Doctors Diagnose and Treat Pathophysiologic Sexual Disorders?

The diagnosis of any sexual disorder begins with taking a complete medical history and performing a physical exam. The common causes of sexual disorders are looked into, such as diabetes, heart disease, or endocrine disorders. Blood and urine tests are used to analyze the presence of hormones and to determine the chromosomal sex. Any irregularities in hormonal or chromosomal balance would indicate a disorder. Healthcare professionals would make an effort to identify and treat any underlying medical conditions. Many times the sexual disorder disappears when treatment for the underlying condition is effective. Hormonal imbalances indicate the need for diagnosis and treatment of any disorders in the glands producing the hormone.

A hormonal imbalance in men would be recognized by feminine characteristics, such as a high-pitched voice, and legs and arms that might be unusually large for the patient's age. Other symptoms include physical size below average for age in muscles and sexual organs. For women, a hormonal imbalance would be recognized by a large clitoris * that resembles a penis and a missing or malformed vagina.

For someone suspected of having an intersex condition because the sexual organs are not clearly male or female, a series of tests should be conducted. Blood tests would reveal the chromosomal sex. Sexual organs that are not in the genital area, such as testes that have not descended, can be detected by x-rays or ultrasound * imaging of the pelvic area. Amniocentesis (AM-nee-oh-sen-TEE-sis), which is the analysis of fluids drawn from the uterus of a pregnant woman, can indicate developmental abnormalities of the fetus and the irregular presence of sex hormones.

Any problems with blood flow can be identified through testing the blood pressure in the legs. Any problems with the nerves in the penile area can be detected through rectal exams, which would indicate whether the nerves in that area are healthy and fully functional. Problems with hormonal imbalance can be identified through blood tests. The nature of female sexual disorders needs to be diagnosed by focusing on the specific cause. Endometriosis is identified through a series of tests. An ultrasound of the area can present visual evidence of the effects of endometriosis. A blood test analyzes the presence of a blood protein common in women with endometriosis. For men and women the doctor should do blood tests for specific diseases associated with sexual dysfunction.

Through much of the 20th century, doctors recommended sex reassignment operations at an early age, based on the assumption that young children can adapt to the reassigned sex and experience little trauma and discontinuity in development. Advocates also felt that early reassignment increased the effectiveness of parent/child bonding, as the parents would know to treat the child as a member of the reassigned sex. The child would grow up accepting the gender role of the reassigned sex. For this approach to be effective, the parents had to be strong in their decision from the start and had to continue with that decision through consistent behavior for the rest of the child's life.

Many serious studies of sex reassignment have found that most of the affected people do not adjust well. As much as possible, these individuals should be recognized by their chromosomal sex. If the chromosomal sex is clearly identified, minor operations may be done to reduce genital abnormalities. If the sexual disorder is influenced by hormonal deficiencies, the doctor may recommend hormone treatments. If gender clarification surgery is necessary later in life, it should be at a time when affected individuals can have a voice in the decision-making.

Treatment for other sexual disorders might rely on hormone therapy or other medications. For example, prescription medications are available to help men who have erectile dysfunction. If a sexual disorder causes serious physical or psychological problems, a person might have surgery. Doctors will attempt to choose the surgery that causes the least amount of recovery and preserves fertility. For example, women might have endometrial tissue removed with lasers, have a portion of their reproductive organs removed, or require a total hysterectomy * .

Pathophysiological problems need a medical response. No matter what the cause is, however, there are always psychological implications. Some people who have sexual disorders require psychotherapy. Whereas most sexual disorders have a psychological component, without identifying and treating the physical cause, psychotherapy alone will not be effective.

See also Aging • Arteriosclerosis/Atherosclerosis • Birth Defects: Overview • Diabetes • Endometriosis • Erectile Dysfunction • Heart Disease: Overview • Hormone-Secreting Tumors • Menopause • Pelvic Inflammatory Disease (PID) • Puberty and Sexual Development • Sexually Transmitted Infections (STIs): Overview

Resources

Books and Articles

Davis, Georgiann. Contesting Intersex: The Dubious Diagnosis. New York: New York University Press, 2015.

Kreukels, Baudewijntje P.C., Thomas D. Steensma, and Annelou L.C. de Vries. Gender Dysphoria and Disorders of Sex Development: Progress in Care and Knowledge. New York: Springer Publishing Company, 2014.

Lawrence, Anna A. Men Trapped in Men's Bodies: Narratives of Autogynephilic Transsexualism. New York: Springer Publishing Company, 2014.

Trombetta, Carlo, Giovanni Liguori, and Michele Bertolotto. Management of Gender Dysphoria: A Multidisciplinary Approach. New York: Springer Publishing Company, 2015.

Websites

MedlinePlus. “Erectile Dysfunction.” U. S. National Library of Medicine. https://www.nlm.nih.gov/medlineplus/erectiledysfunction.html (accessed July 7, 2016).

Organizations

Accord Alliance. 531 Route 22 East #244, Whitehouse Station, NJ 08889. Telephone: 908-349-0534. Website: http://www.accordalliance.org (accessed July 7, 2016).

Intersex Initiative. PO Box 40570, Portland, OR 97240. Telephone: 971-244-8698. Website: http://ipdx.org/index.html (accessed July 7, 2016).

* chromosomes (KRO-mo-sohmz) are threadlike structures inside cells on which the genes are located. There are 46 (23 pairs) of chromosomes in normal human cells. Genes on the X and Y chromosomes (known as the sex chromosomes) determine whether a person is male or female. Females have two X chromosomes; males have one X and one Y chromosome.

* diabetes (dye-uh-BEE-teez) is a condition in which the body's pancreas does not produce enough insulin or the body cannot use the insulin it makes effectively, resulting in increased levels of sugar in the blood. This can lead to increased urination, dehydration, weight loss, weakness, and a number of other symptoms and complications related to chemical imbalances within the body.