Input: Write an informative section on the topic of sexual problems among adolescents and young adults, focusing on the lack of research on this topic, the high rates of sexual dysfunctions among this age group, and the challenges in diagnosing and treating these issues due to societal views on sexual development and the limitations of current diagnostic criteria. Discuss the impact of DSM-5 diagnostic criteria on this population and the potential benefits and drawbacks of applying these labels. Also, mention any relevant studies on this topic and provide recommendations for clinicians working with adolescents and young adults who are experiencing sexual problems.

Response:
Su, J. R., Beltrami, J. F., Zaidi, A. A., & Weinstock, H. S. (2011). Primary and secondary syphilis among Black and Hispanic men who have sex with men: Case report data from 27 states. Annals of Internal Medicine, 155, 145–

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Winer, R. L., Hughes, J. P., Feng, Q., OReilly, S., Kiviat, N. B., Holmes, K. K., et al. (2006). Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine, 354. 2645–2654.

Xu, F., Sternberg, M. R., Kottiri, B. J., McQuillan, G. M., Lee, F. K., Nahmias, A. J., et al. (2006). Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. Journal of the American Medical Association, 296, 964–973.

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**Lifespan Changes**

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**CHAPTER 23**

Sexual Problems in Adolescents and Young

Adults

Lucia F. OSullivan and Vickie Pasterski

**"A** sexually active adolescent female who feels no desire, has never had an orgasm, and experiences no pleasure from her sexual life is unlikely to be viewed as experiencing sexual problems," OSullivan and Pasterski point out. They say that what constitutes a sexual dysfunction in adulthood is often viewed as normative (or perhaps even ideal) in adolescence. Their review of the available research on adolescent sexuality finds that it is narrowly focused on high-risk behaviors and problematic outcomes (e.g., STIs, pregnancy, rape). OSullivan and Pasterski nevertheless do a masterful job of integrating the adult treatment literature with an understanding of the unique issues facing adolescents in order to provide sound treatment recommendations for conducting sex therapy with young adults and teens. Improving our understanding of adolescent sexuality (normal, healthy, ideal, and dysfunctional) will necessarily improve our understanding of how sexual problems develop and have a positive impact on therapeutic efficacy.

**Lucia F. OSullivan, Ph,D,** is Professor of Psychology at the University of New Brunswick in Canada. She also holds a Canada Research Chair in Adolescents Sexual Health Behaviour. Her work centers primarily on sexual functioning, health, and risk behavior among adolescents and young adults. Dr. OSullivan serves on the editorial boards of eight journals, has published over 72 scientific articles and chapters, and has also won outstanding teaching awards from Columbia University and the University of New Brunswick.

**Vickie Pasterski, PhD,** is a recognized authority on normative and non-normative psychosexual development in children and adolescents and has published widely on these topics. She is a Research Psychologist in Paediatrics at Addenbrookes Hospital, University of Cambridge, where she has most recently focused on outcomes in disorders of sex development (DSD). She also holds affiliated lecturer status in the Department of Psychology, University of Cambridge.

**OVERVIEW OF SEXUAL PROBLEMS AMONG ADOLESCENTS**

**AND YOUNG ADULTS**

Despite the wealth of research on the sexual lives of adolescents and young adults, it is surprising how little is known about the sexual functioning of young people.

"Adolescence" refers here to the period of development between childhood and adulthood and captures the teenage years. "Young adulthood" typically refers to the period between late adolescence through the mid-20s (Centers for Disease Control and Prevention, 2012; UN Population Information Network, 1997). The gap in this literature is also notable in light of the high rates of sexual dysfunctions among adults. Sexual experiences in adolescence and young adulthood are the foundation on which adult 461

sexual lives are based. Positive sexual functioning is clearly an essential component of sexual health; however, there is a dearth of research on the sexual functioning of young adult populations and almost none among adolescents. Although their sexual lives have garnered considerable research attention, it has been through a very selective prism focusing on high-risk behaviors and problem outcomes, such as early onset of partnered activity, unwanted pregnancy, sexually transmitted infections (STIs), and coercion. In some respects, the same sexual problems that are considered to be indicative of dysfunction among adults, such as lack of pleasure, rapid ejaculation, anorgasmia, and pain, are viewed as normative conditions among young people.

Society fosters a deep and abiding distrust and discomfort about issues related to sexual development, privileging sexual experience to the realm of adulthood. Thus sexually active young people are viewed with some disdain, their sexual behaviors referred to as irresponsible or problems in themselves, and they are not viewed as having rights to sexual pleasure (or absence of pain). Sexual problems that arise are in some respects viewed as if they are deserved or to be expected ("the wages of sin"). This period of life is replete with many related psychosocial and relational challenges, including establishing ones sexual identity, learning to negotiate issues such as contraceptive access and use, fear of pregnancy or contraceptive/condom failure, use and exposure to sexually explicit media, and changes in dating norms. Problems in sexual functioning may compromise young peoples romantic and sexual relationships and exacerbate questions relating to gender identity, body image, and fertility—all factors central to positive development, identity, and adjustment in this period of life. We use a developmental focus and a sexual-rights perspective to address issues relevant to sexual functioning among adolescents and young adults and explore the challenges and limitations to advancing treatment among this population.

**EPIDEMIOLOGY**

Several large-scale studies of sexual functioning have included late adolescents or young adults. However, they tend to be small in number and include rates that are obscured in the analyses of older adults (e.g., Mercer et al., 2003). For example, a U.S. national probability sample analyzed rates from men and women 18–29 years of age (Laumann, Paik, & Rosen, 1999). These rates combine those of late adolescents, young adults, and adults. Even so, the following rates were obtained for men and women, respectively, for the preceding year in several domains: lack of interest in sex (14%, 32%), inability to orgasm (7%, 26%), experience of pain during sex (30%, 21%), finding sex not pleasurable (10%, 27%), anxiety about performance (19%, 16%), trouble lubricating (19%, women only), and trouble maintaining or achieving an erection (7%, men only).

Sexual difficulties were more prevalent among women (43%) than among men (31%).

In an analysis of data from the National Longitudinal Study of Adolescent Health, researchers examined the regularity of orgasm among 3,237 respondents ages 18–26

years, who reported being in heterosexual relationships of at least 3 months duration 462

(Galinsky & Sonenstein, 2011). Ages, again, were not separated for adolescents and young adults alone, as the range includes those up to 26 years of age. Sex was defined as including vaginal, oral, or anal sex. Fifteen percent of the young women reported having orgasms less than half the time or never compared with 2.6% of the young men. A survey of 18 to 24-year-old women found that 31% were unable to have orgasms during intercourse, 33% reported low sexual desire, and 22% reported physical pain during intercourse (Fisher, Boroditsky, & Morris, 2004). No data on men were available.

Although unclear, these studies suggest moderate to high rates of problems in sexual functioning among young people and possibly rates that are comparable to those of adults.

In one of the few known studies addressing sexual problems among young people directly, 171 late-adolescent men and women (17–21 years) were surveyed regarding lifetime experiences of sexual difficulties (OSullivan & Majerovich, 2008). The prevalence of difficulties among men that occurred "sometimes" or "always" included: climaxing too quickly (41.9%), anxiety about performing sexually (32.6%), difficulty maintaining an erection (23.1%), engaging in unwanted sexual activity (18.7%), and inability to climax (16.3%). Chronic difficulties were uncommon in this sample of men, although occasional experiences of sexual difficulties, such as rapid ejaculation and performance anxiety, were fairly common. Problems reported "sometimes" or "always"

for women were: inability to climax (53.1%) or climaxing too quickly (23.2%), insufficient lubrication (31.3%), performance anxiety (31.2%), painful intercourse (25.8%), unwanted sexual activity (23.5%), and lack of interest (22.9%) or pleasure (11.2%). Like the young men, few young women reported "always" experiencing a given sexual problem. The most common persistent difficulty was inability to have an orgasm.

Follow-up qualitative interviews with 30 of these individuals revealed that (1) pleasure increased with sexual experience; (2) sexual difficulties frequently led to sex avoidance; (3) sexual activity may have been high even when sexual interest was low; and (4) pain was often linked to low arousal. A female participant said, "If we dont do it for a couple days itll hurt sometimes, just starting off . . . or actually on the inside wall sometimes it hurts after Ive reached orgasm. I dont know why. . . . I just work through it." A man explained, "Her sex drive is still very, um, high and mines falling off. Which is kind of ironic, since the guys supposed to be the sexual animal. . . . Its a point of stress, which makes it worse, so Im beginning to hide out, avoid even touching her." A young woman explained, "Uh, one of the reasons why I believe I cant orgasm during sex is because I havent . . . theres not much to it. I dont feel a whole lot during sex."

Another young woman told us: "He has [laughs] a very large penis. And it hurt. . . . It wasnt enjoyable. I thought he hit an organ for gods sake. [Laughs] So, we only had sex twice. I . . . I . . . I just wasnt happy with the relationship in many ways and that was one of them." Additional research is needed to explore further the impact of sexual problems on the psychological and relationship functioning of young people.

An ongoing longitudinal study of 406 youth (16–21 years) is under way to help track the onset and progression of sexual problems among adolescents and young adults (OSullivan, Brotto, Byers, Majerovich & Wuest, in press). Analyses of baseline data for sexually active youth revealed that 50% reported a sexual problem and 50% of those 463

reported distress associated with a sexual problem. Using a standard measure of sexual dysfunction (Rosen et al., 2000), young womens scores revealed problems in desire, arousal and satisfaction, lubrication, orgasm, and genital pain that more closely resembled those of women with sexual dysfunction than those of controls. The young mens scores more closely resembled those obtained from the adult controls (Rosen et al., 1997). Overall, 19% of the young men were classified as having symptoms of premature ejaculation (PE) or possible PE. No other studies that address a range of sexual problems among adolescents and young adults were found.

Finally, there are several studies linking specific sexual dysfunctions among young people to medical disorders; gynecological or genitourinary problems or abnormalities (e.g., pelvic inflammatory disease, testicular cancer, endometriosis); conditions requiring surgical treatments, such as congenital anomalies or ovarian cysts or tumors (Greydanus & Matytsina, 2010), complications of medications, such as selective serotonin reuptake inhibitors (SSRIs); antipsychotic medication; and long-term oral contraceptive use. Other studies provide less direct evidence of sexual dysfunctions, such as sildenafil use among late adolescent males (Peters, Johnson, Kelder, Meschack,

& Jefferson, 2007).

**ASSESSMENT AND DIAGNOSTIC ISSUES**

A sexually active adolescent female who feels no desire, has never had an orgasm, and experiences no pleasure from her sexual life is unlikely to be viewed as experiencing sexual problems. Tolman argues, "Female adolescent sexual dysfunction is an oxymoron" (Tolman, 2001, p. 197). Sexual problems among adolescent males are frequently the object of ridicule or depicted humorously in popular books or movies, such as American Pie and Fast Times at Ridgemont High. Adolescence is viewed as a period in which young people transform from sexually inexperienced to sexually inept to sexually competent. Upon reaching adulthood, they are expected to have sexual experience, expertise, even prowess (for men at least), perhaps contributing in part to the high rates of adult sexual dysfunctions.

These assumptions are particularly clear when reviewing the diagnostic criteria of the DSM. There are no age criteria for any of the sexual dysfunctions included in DSM-5

(American Psychiatric Association, 2013) or its predecessors. As we argued earlier, many of the hallmark features of the dysfunctions appear to be typical of many young people, especially early in their sexual lives, such as "marked delay in, marked infrequency of or absence of orgasm" (female orgasmic disorder, p. 429); "persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately one minute following vaginal penetration and before the individual wishes it" (early ejaculation, p. 443); "absent/reduced interest in sexual activity" (sexual interest/arousal disorder in women, p. 433); "persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity" (male hypoactive sexual desire disorder, p. 440); and "persistent or recurrent difficulties with 464

vaginal penetration during intercourse" (p. 437); or "marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts" (genito-pelvic pain/penetration disorder, p. 437). Even if there were age-related specifiers (e.g., age at onset), underlying assumptions within the DSM-5 criterion-based diagnostic system present challenges to the case of adolescence and/or early adulthood.

The DSM diagnoses require that an individual experience the symptoms for at least 6

months for a diagnosis to be warranted. Thus many adolescents and young adults in their first half year following the onset of sexual activity could meet this requirement for diagnosis of a sexual dysfunction. We recommend that clinicians not be put off by the lack of specificity and review presenting symptoms in the context of an individuals broader sexual and relationship life. Particularly important in the case of young people is to take into account patterns of sexual functioning from the onset of their sexual lives

—across partners, if applicable—while bearing in mind that many young people have little consistency in sexual frequency and experience long periods of abstinence at first.

The 6-month criterion assumes regular sexual activity to assess frequency of symptoms, which is much less likely in younger adolescents. It may be a year or two once activity has commenced before there is a sustained period across which one may judge the course of the complaint. Thus clinicians should apply that criterion cautiously. It is likely that some problems are encountered in the process of learning how to control timing and to communicate effectively with a partner in order to maximize pleasure and while developing preferences for positions and activities in general. We recommend that clinicians always be cognizant of the potentially strong stigmatizing or inhibiting impact of applying diagnostic labels at this (early) point of life. Clinicians should communicate these labels cautiously, if at all.

Central to the diagnostic system is an assessment in each case that an individual has experienced "clinically significant distress or impairment" as a result of the problem.

This feature likely ensures that many young people who are learning "how sex works,"

developing skills, learning how to communicate about sexual matters with a partner, and overcoming various sexual problems across partners, activities, and time are unlikely to report the high level of distress that warrants diagnosis. This is only an assumption based on our own research, however, as there is scant research to indicate whether distress is characteristic of their early sexual lives, and certainly no discourse on this matter in the field. A challenge to clinicians is to assess the nature and severity of distress related to established problems in sexual functioning among adolescents and young adults.

We recommend that clinicians employ existing measures designed for adults, with a few changes (e.g., wording to reflect the knowledge or lexicon of a teenager) as necessary. We like the comprehensiveness of the Golombok–Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 1985), but it has a strong relationship focus, which may not always be appropriate. We have also used successfully the Female Sexual Functioning Inventory (Rosen et al., 2000), and the Brief Index of Sexual Functioning for Women (Taylor, Rosen, & Leiblum, 1994). For young men, we recommend the International Index of Erectile Function (IIEF; Rosen et al., 1997), the Premature Ejaculation Diagnostic Tool (Symonds et al., 2007) or the Brief Sexual Function 465

Questionnaire (Reynolds et al., 1988). The Female Sexual Distress Scale (FSDS; Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002) can measure sexual functioning distress in both young women and men.

The potential impact of DSM-5 diagnostic criteria on adolescents and young adults is likely minimal, given that the dysfunctions have unknown applicability. However, in the case of the new diagnoses for female orgasmic disorder and sexual interest/arousal disorder in women, changes recognizing the substantial variation across women in sexual response cycles will likely benefit young women who may have response cycles that look quite different from adult womens. There is also now greater recognition of variation in the expression of interest and desire, especially in the form of fantasy and erotic thoughts. Researchers find both overlap in interest, arousal, and desire, inconsistent sequencing, and variation in spontaneity/responsiveness (Graham, Sanders, Milhausen, & McBride, 2004). The new genito-pelvic pain/penetration disorder is far more expansive and descriptive than before and now may capture young peoples experiences, given the high rates of sexual pain among both male and female adolescents (OSullivan & Majerovich, 2008). The new "other specified sexual dysfunction" category addresses fear and anxiety related to sexual contact rather than loss of sexual feelings despite "otherwise normal" arousal and orgasm. Once again, there is no comparative model to capture "normal" response cycles in young people, but fear and anxiety are known components of early sexual expression and avoidance for adolescents, if not young adults.

**ETIOLOGY/THEORIES/MODELS OF THE SEXUAL PROBLEM**

Young people face a host of age-related factors that appear to be linked to the experience of sexual problems. These include inadequate sex education and family communication concerning issues pertaining to sexual functioning, lack of experience across time and partners, less sophisticated communication and intimacy/relationship skills, and high rates of compromising health factors, such as STIs, and anxiety and depression.

Compared with adults, sexual problems among young people might be less attributable to organic breakdown associated with long-term medical conditions, although we simply do not yet know.

Important to understanding etiology is the host of psychosocial factors central to the experience of youth, including the sexual objectification of girls to represent targets of male desire; socialization with heavy emphasis on a range of romantic myths surrounding sex, such as that sex should always be perfect, spontaneous, and fulfilling; and the myriad messages that young people receive through the media equating sex with personal value. There continues to be strong endorsement of what Simon and Gagnon (1986) have termed the traditional sexual script, which positions men as adversarial sexual agents in heterosexual encounters with girls and positions girls as sexual ascetics, targets of male sexual attention, or negotiators of sex for love and security. Endorsing such scripts has negative consequences for both young women and men, such as 466


Input: Write an informative section on the topic of sexual health and aging, focusing on the physiological, psychological, and relational changes that affect sexuality in older adults. Discuss the impact of menopause on women's sexuality and the decline in testosterone production in men. Mention any relevant studies and statistics on the prevalence of sexual activity in later life, and discuss the major predictors of sexual activity for older men and women. Also, touch on the topic of homosexuality in older adults and the challenges faced by older gay and lesbian individuals and couples. Finally, discuss sexuality in long-term care settings, including the barriers to sexuality and the responsibilities of long-term care facilities to educate staff and residents about residents' rights to privacy and intimate relationships.

Response:
agreeing to unwanted or painful sex, silencing oneself concerning sexual interests and needs, abuse and coercion, poor body image, guilt, resignation, resentment, and anxiety (Dworkin & OSullivan, 2005; Elmerstig, Mijma, & Berterö, 2008).

Dysfunctions may also be the result of biomedical factors, such as inherent pathophysiological abnormalities. These would include mild congenital defects, such as hypospadias in males or the more complex case of abnormalities of the urogenital tract due to a disorder of sex development (DSD; Pasterski, Prentice, & Hughes, 2010).

Genetic impairments may also result in the inability to reduce inflammatory responses or in variations in pain-regulatory mechanisms or thresholds (Landry & Bergeron, 2011).

**APPROACHES TO TREATMENT**

Young people are not expected to have sexual lives, so it is expected, if not subtly reinforced, that they may experience pain or lack of desire. Standard approaches to the treatment of sexual problems among young people are often medical ones, and health care providers are the first (and often only) to know of sexual problems (Brown & Brown, 2006). Although desire and arousal are important components of a healthy sexual life, the focus with youth tends to be on issues of contraception and reproductive health. Young people require assurances that the care they receive is confidential, yet it is only when the provider suspects that the individual has a sexual problem to discuss that clinicians typically request that a parent leave the room, offer time alone, or assure an adolescent or young person that the information that they provide is kept private (McKee, Rubin, Campos, & OSullivan, 2011).

Because youth may not present with sexual problems, clinicians need to ask the essential questions that can uncover problems in sexual functioning. An excellent approach is to incorporate this line of questioning into inquiries for related presenting issues, backed by more random and comprehensive inquiries into all areas of medical or psychosocial functioning that include sexuality. Neither parental nor partner consent is required to talk to or counsel an individual below the age of majority about sexual problems or to discuss a young persons relationship. Clinicians need to be aware of age-of-consent laws relevant to sexual activity, as they vary regionally (e.g., 16 in Canada and the United Kingdom; 16–18 in the United States) and need to clarify the limitations of their privacy assurances with the youth whom they counsel. Similarly, the issue of parental involvement for adolescents can be a difficult one. We recommend encouraging open communication with a parent or other trusted family member or offering to facilitate communication about sexual problems that require more serious intervention or treatment.

Without a body of literature upon which to draw, it is exceedingly difficult to outline treatment approaches. Tailoring standard psychological therapies that are used with adults with dysfunctions to address the unique issues faced by adolescents and young adults (as described earlier) is a sound starting point. Therapy might best be combined 467

with pharmacological management of cases, but we know of no medications that are approved for treatment of sexual dysfunctions among young people and recommend again that clinicians take a longer term perspective to truly understand the sexual problem in the context of a young persons developing sexual life. In the absence of a literature to which to refer, treatment protocols may be developed drawing on other related bodies of literature or by developing theoretical models. In the case of structural anomalies in sexual functioning, there is a growing consensus about psychological treatment relating to psychosexual health in young patients (Hughes, Houk, Ahmed, & Lee, 2006). The approach is one of full disclosure (with the permission of parents where necessary) and openness regarding sexual functioning. Talk-based therapy is often used to address psychological sequelae of these dysfunctions (e.g., Hughes et al., 2012).

Interestingly, in this context, sexual activity is generally seen as a healthy and natural part of early adult life. The goal of the health care provider is to promote healthy sexual functioning. In the absence of structural abnormality, frank discussion regarding sexual functioning, treatment options, and general sexual health apply.

Although there are as yet no reports of outcomes specific to psychological therapeutic approaches in counseling adolescents and young adults with possible sexual dysfunction secondary to DSD, one successful approach has incorporated cognitive theory.

According to cognitive theory, general positive beliefs about the self are central to healthy psychological functioning and should be considered in parallel with treatments aimed at specific sexual problems. Open communication with ones partner(s) may be difficult or impossible for a young person experiencing dysfunction. Improving the self-and body image by restructuring beliefs and underlying assumptions may be valuable here. In many cases, sex therapy requires that both partners participate and work together toward solving sexual functioning problems. Although such an approach requires trust and a degree of stability in the relationship, we recommend incorporating partners wherever possible.

Some useful resources include books such as Sex, Therapy, and Kids: Addressing Their Concerns through Talk and Play, by Sharon Lamb (Norton, 2006); Its Perfectly Normal: Changing Bodies, Growing Up, Sex, and Sexual Health, by Robie H. Harris and Michael Emberley (Candlewick, 2009); and Nurturing Queer Youth: Family Therapy Transformed, by Linda Stone Fish and Rebecca G. Harvey (Norton, 2005). Excellent Web resources include those of the College of Sexual and Relationship Therapists, the Sex Information and Education Council of Canada, the Sex Information and Education Council of the United States, American Association of Sexuality Educators, Counselors and Therapists, sexualityandU.ca, and Advocates for Youth.

**CASE DISCUSSIONS**

We reiterate here that there is no systematic report of sexual dysfunction or its treatment in adults younger than 17 years old. We present two cases and outcomes here, but these are only examples and not evidence of treatment success. Larger samples and 468

systematic implementation of treatment protocols are needed to establish guidelines beyond our recommendations.

**Case 1**

Here we present a case of a 17-year-old female, JL, who presented upon referral from her general practitioner and at her mothers insistence. The primary complaint was that, for about 8 weeks, JL had been exhibiting symptoms of what her mother feared might be depression. JL had withdrawn from most activities with her family, spent much of her free time by herself in her bedroom, had fallen behind in her homework, and showed no outward signs of distress at her failing grades. Most notably, however, was that she had cut off contact with her boyfriend, who also expressed concern to her family. In JLs first meeting with the psychologist, she calmly and quietly confirmed what her mother had reported. In this case, a standard psychological assessment was administered, confirming clinical depression. However, upon hearing the results of the assessment, JL

broke down in tears and revealed that, contrary to her presentation heretofore, she was keenly aware of the factors contributing to her withdrawal and low mood.

In the prior 4–5 months, JL had become sexually active with the boyfriend who she had been dating for 2 years. She made it clear that she had consented and that the two loved each other. The problem was that JL was left with severe abrasions after each episode. The psychologist quickly assessed that the abrasions were likely due to lack of lubrication and began a line of questioning about JLs sexual response from the desire to arousal to orgasm. Not surprisingly, JL reported that most encounters began quickly and passionately, but without sufficient arousal (or time for arousal) to allow for lubrication.

JL was unaware of the relationship between arousal and lubrication, nor did she report experiencing orgasm during intercourse. In any case, the abrasions became infected, and intercourse became incredibly painful for JL. Not wanting to disappoint her boyfriend, she gave excuses for withdrawal from him that led to feelings of sadness and despair. JLs mood lifted very quickly upon realization that there was nothing mysteriously wrong with her, as she had tested negative for STIs.

This case illustrates several points critical to the conceptualization of sexual dysfunction in adolescents and young adults. First, JL would not meet the standard criterion that suggests that the "dysfunction" should be noted in comparison with previous satisfactory functioning. JL had only been sexually active for a very short time.

Second, JL, as with many young women, may not have been exposed to features of healthy sexual functioning. In fact, she was unaware of the necessity for lubrication to facilitate coitus. She was also seemingly unaware that her own sexual response was critical to her sexual satisfaction. She seemed to be under the impression that women should "have sex" with their partners because that is what the partner desires. Finally, this case illustrates the fragility of the sexual response in the context of depressed mood, or, in this case, apparent clinical depression. In many cases, the clinician has trouble discerning which factors lead to the other, that is, whether low arousal contributes to relationship difficulties and/or depression or whether depression completely unrelated 469

to relationships can decrease desire and arousal. In this case, confusion, pain, and fear of disappointing her partner clearly led to the depressed mood. Once this cascade of events was set in motion, it likely turned into a cycle difficult to break.

JL was a bright and insightful young woman. She was visibly affected by the short course of sexual education that she received in the therapists office. She took advice with respect to taking some control of the sexual encounters. She, surprisingly, was also open to having a discussion with her boyfriend explaining what she had kept secret for several months. At follow-up, JL reported that she had taken some time for the abrasions to heal, although she very quickly became romantically engaged with her boyfriend again. The reunion had a very positive effect on her mood and self-esteem.

Once she and her partner resumed sexual relations, she felt more in control and better understood her own sexuality. Her report suggested that she now had what appeared to be a healthy sexual relationship. One final point should be noted: Without the education JL received from the psychologist, she may well have gone on to have further difficulty in other areas of her life in addition to romantic/sexual relationships. This, again, illustrates the importance of education for a healthy beginning to sexual life.

**Case 2**

Our second case is that of a 16-year-old male, TM, who presented to a community mental health clinic with complaints of erectile dysfunction. This young man presented of his own accord without hesitation regarding his inability to maintain an erection during heterosexual encounters. He reported that he had never suffered from a psychological disorder, nor was there any such history in his family. TM reported that he came from an intact family including three children, two boys and one girl. TM was the oldest. There was no history of sexual abuse, and his parents appeared to him to have a loving relationship. TMs family was of middle income, which afforded him the ability to focus on his studies and social affairs. He planned at the time to go to a university to study art history. TM presented with no obvious personality or psychological dysfunction. He was engaged and measured with regard to the frank discussion about his sexual problem.

When asked to describe the problem specifically, TM said that on several occasions he had been unable to maintain an erection to the point of climax and had had to end the encounters with attractive young women prematurely. He found this embarrassing, although he had been able to attribute the dysfunction to alcohol consumption, allowing him to save face. It became clear that he had a tight circle of friends and that these episodes occurred with girls in his social network. He had asked for help, as he felt he could no longer engage sexually in his network without solving this problem first.

Although he recognized, from popular culture, that young males need to find their way about sexual relations, he believed that the problems he was experiencing reflected something more than inexperience. At the completion of the general assessment, TM

was offered a referral to a sex therapy center. TM expressed that the couple-oriented nature of sex therapy did not appeal to him, as he had no regular partner and no one 470

with whom he might comfortably implement treatment strategies. It was at this point that TM offered his impression that there was a psychological conflict at the root of his problem and suggested that he would like to further explore his sense of self as a sexual person.

It later came to light that TM had concerns regarding his sexual orientation but had yet to explore them for fear of a homosexual orientation. He was not bigoted toward homosexuality, nor did he maintain beliefs about the superiority of heterosexuals. He said that the thought of letting his parents down when it came to having a family of his own someday had caused him some concern. It also came to light that TM perceived that his male friends were engaging completely successfully in sexual relations. This apparently had become a topic of discussion among the young men on a regular basis. It was also the case that the sought-after girls were in the same network and that gossip traveled quickly. TM had put immense pressure on himself to perform before he had even begun his sexual life in full.

Although there was no clear evidence of anxiety disorder, this preoccupation had become a type of obsession for TM. The therapist proposed a combination of schema therapy and cognitive-behavioral therapy. The aim was for TM to first explore his relationship with his parents and his sense of self in that context. Next steps involved assessing TMs beliefs about himself in his cohort as a successful male. Both therapist and patient agreed that to relieve the pressure might alleviate the problem. Twelve sessions were proposed.

Given TMs general intelligence and insight, the case took clear form and resolved.

He reevaluated his parents expectations, which were clearly that he grow into a happy, healthy adult. He also had the insight that his male companions were likely presenting as socially desirable in competing for females. The greatest relief came with the insight that he could explore his sexual orientation if he wanted to, albeit in a context outside his social set. TMs dysfunction abated in the sense that he no longer felt pressured to perform nor distressed about the prospects of maintaining an erection during intercourse with women. He carried on with his goals toward becoming an art historian.

In this case, we were able to watch this young mans sexuality as it first developed. This likely provided a strong foundation for a healthy sex life, although no follow-up has been completed. Although in this case the therapist was confronted with the inability to apply traditional couple or sex therapy, we can see that the application of schema and cognitive theories was successful, at least in the short term. TM was never diagnosed with ED, which, in our view, was to his benefit.

**CONCLUSIONS**

Our current understanding of sexual problems in adolescents and young adults is based on a small, but growing, body of research and to some extent extrapolation from the adult literature on dysfunctions. Many sexual problems among young people likely reflect a steep learning curve emanating from a dearth of information about how sex 471

works; however, rates of sexual problems appear high and no gender differences in rates are noted. Our strongest recommendation is to provide extensive, comprehensive, and explicit information about healthy, pleasurable sexual functioning, with an emphasis on effective and clear partner communication and negotiation, as well as strategies for seeking treatment. Connecting with health care providers, who are likely to learn first of any problems that emerge, and encouraging frank discussions about sexual matters among youth in ones practice are also recommended. Until intervention research has advanced, clinicians must adapt standard approaches for adults to the unique contexts of young peoples lives. We also strongly suggest that clinicians treating young people connect to organizations aimed at improving the sexual lives of youth for resources, support, and continued education.

**REFERENCES**

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Brown, R. T., & Brown, J. D. (2006). Adolescent sexuality. Primary Care: Clinics in Office Practice, 33, 373–390.

Centers for Disease Control and Prevention. (2013). Vaccines for college students and young adults (19 to 26 years old). Available at www.cdc.gov/vaccines/adults/rec-vac/college.html.

Derogatis, L. R., Rosen, R., Leiblum, S., Burnett, A., & Heiman, J. (2002). The Female Sexual Distress Scale (FSDS): Initial validation of a standardized scale for assessment of sexually related personal distress in women. Journal of Sex and Marital Therapy, 28, 317–330.

Dworkin, S. L., & OSullivan, L. (2005). Actual versus desired initiation patterns among a sample of college men: Tapping disjunctures within traditional male sexual scripts. Journal of Sex Research, 42, 150–158.

Elmerstig, E., Mijma, B., & Berterö, C. (2008). Why do young women continue to have sexual intercourse despite pain? Journal of Adolescent Health, 43, 357–363.

Fisher, W.A., Boroditsky, R., & Morris, B. (2004). The 2002 Canadian Contraception Study: Part B. Journal of Obstetrics and Gynaecology of Canada, 26(6), 580–590.

Galinsky, A. M., & Sonenstein, F. L. (2011). The association between developmental assets and sexual enjoyment among emerging adults. Journal of Adolescent Health, 48, 610–615.

Graham, C. A., Sanders, S. A., Milhausen, R. R., & McBride, K. R. (2004). Turning on and turning off: A focus group study of the factors that affect womens sexual arousal. Archives of Sexual Behavior, 33, 527–538.

Greydanus, D. E., & Matytsina, L. (2010). Female sexual dysfunction and adolescents. Current Opinion in Obstetrics and Gynecology, 22, 375–380.

Hughes, I. A., Davies, J. D., Bunch, T. I., Pasterski, V., Mastroyannopoulou, K., & Mac-Dougall, J. (2012). Androgen insensitivity syndrome. Lancet, 380, 1419–1428.

Hughes, I. A., Houk, C., Ahmed, S. F., & Lee, P. A. (2006). Consensus statement on the management of intersex disorders. Journal of Pediatric Urology, 2, 148–162.

Landry, T., & Bergeron, S. (2011). Biopsychosocial factors associated with dyspareunia in a community sample of adolescent girls. Archives of Sexual Behavior, 40, 877–889.

Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors.

Journal of the American Medical Association, 281, 537–544.

McKee, M. D., Rubin, S., Campos, G., & OSullivan, L. F. (2011). Challenges of providing confidential care to adolescents in urban primary care: Clinicians perspectives. Annals of Family Medicine, 9, 37–43.

Mercer, C. H., Fenton, K. A., Johnson, A. M., Wellings, K., Macdowall, W., McManus, S., et al. (2003). Sexual function problems and help seeking behavior in Britain: National Probability Sample Survey. British Medical Journal, 327, 426–427.

OSullivan, L. F., Brotto, L., Byers, E. S., Majerovich, J. A., & Wuest, J. (in press). Problems in sexual functioning among adolescents and young adults. Journal of Sexual Medicine.

OSullivan, L. F., & Majerovich, J. (2008). Difficulties with sexual functioning in a sample of male and female late adolescent and young adult university students. Canadian Journal of Human Sexuality, 17, 109–121.

472

Pasterski, V., Prentice, P., & Hughes, I. A. (2010). Impact of the consensus statement and the new DSD

classification system. Best Practices and Research Clinical Endocrinology and Metabolism, 24, 187–195.

Peters, R. J., Johnson, R. J., Kelder, S., Meschack, A. F., & Jefferson, T. (2007). Beliefs and social norms about sildenafil citrate (Viagra) misuse and perceived consequences among Houstonian teenage males. American Journal of Mens Health, 1, 208–212.

Reynolds, C. F., Frank, E., Thase, M. E., Houck, P. R., Jennings, J. R., & Howell, J. R. (1988). Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis of a Brief Sexual Function Questionnaire for men. Psychiatry Research, 24, 231–250.

Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., et al. (2000). The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex and Marital Therapy, 26, 191–208.

Rosen, R., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997). The International Index of Erectile Function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology, 49, 822–830.

Rust, J., & Golombok, S. (1985). The Golombok–Rust Inventory of Sexual Satisfaction (GRISS). British Journal of Clinical Psychology, 24, 63–64.

Simon, W., & Gagnon, J. (1986). Sexual scripts. Archives of Sexual Behavior, 15, 97–120.

Symonds, T., Perelman, M. A., Althof, S., Giuliano, F., Martin, M., May, K., et al. (2007). Development and validation of a premature ejaculation diagnostic tool. European Urology, 52, 565–573.

Taylor, J. R., Rosen, R. C., & Leiblum, S. R. (1994). Self-report assessment of female sexual dysfunction: Psychometric properties of the brief index of sexual functioning for women. Archives of Sexual Behavior, 23, 627–643.

Tolman, D. L. (2001). Female adolescent sexuality: An argument for developmental perspective on the New View of womens sexual problems. Women and Therapy, 24, 195–209.

United Nations Population Information Network. (2007). HIV prevalence (females 15–24). Available at http://data.un.org/data.aspx?q=15-24&d=unaids&f=inid %3a346.

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**CHAPTER 24**

Sexuality and Aging

Marc E. Agronin

**"S** exuality continues to play a vital role in the lives of aging individuals," writes Agronin. He details the physiological, psychological, and relational changes that affect the sexuality of older adults. Throughout the chapter the message is clear. Although aging is associated with declines in frequency and function, sexual satisfaction often remains high. Agronin suggests multiple roles for the sex therapist, including reassurance, education, counseling and therapy. It is important for the sex therapist to be able to function in a multidisciplinary setting and adapt interventions to the physical and social realities associated with aging. In addition, Agronin discusses special issues related to aging, including how to deal with sexuality in long-term-care settings and how to cope with the complex interpersonal and ethical issues related to sexuality and dementia. He also points out that aging individuals may be less aware of the dangers of sexually transmitted infection but are still at risk. Agronin is optimistic about the possibility that sexuality can continue to contribute to quality of life throughout the lifespan, noting that it is the ability to adapt to physical, social, and interpersonal changes that is the key to sexual longevity.

**Marc E. Agronin, MD,** is a board-certified adult and geriatric psychiatrist who has served since 1999 as Medical Director for Mental Health and Clinical Research at the Miami Jewish Health Systems. He is also Affiliate Associate Professor of Psychiatry and Neurology at the University of Miami Miller School of Medicine. In 2008, Dr. Agronin was named the "Clinician of the Year" by the American Association for Geriatric Psychiatry, and in 2011, he was elected as a Distinguished Fellow of the American Psychiatric Association. Dr. Agronin is a nationally recognized expert in psychiatric illnesses in the elderly and has authored several books, including How We Age: A Doctors Journey into the Heart of Growing Old (2011), Alzheimers Disease and Other Dementias: A Practical Guide, 3rd edition (2014), and Therapy with Older Clients: Key Strategies for Success (2010) and is the coeditor of the textbook Principles and Practice of Geriatric Psychiatry, 2nd edition (2011). He has published widely on sexuality and aging, including a chapter coauthored with the noted TV and radio personality Dr. Ruth Westheimer.

The impact of aging on sexual function has historically been regarded as an inevitable process of decline that robbed individuals of any possible or enjoyable sexuality in late life. Both the science and the attitudes toward sex and sexual disorders in late life have evolved considerably, however, pushed along by the sexual and feminist revolutions in the 1960s and 1970s, the fact of longer and healthier lifespans for most elders, and the development and popularization of medications to treat erectile dysfunction (ED), the most common age-related sexual dysfunction. With the advent of 77 million members of the baby-boom generation beginning to turn 65, we can expect to see sexuality playing an increasingly active and vital role in the lives of most elders.

**AGE-RELATED CHANGES IN SEXUAL RESPONSE**

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Normal aging is associated with a general decline in physiological sexual response and more variable declines in sexual activity. For women, the experience of sexuality in late life is fundamentally shaped by the physiological and psychological changes that occur with menopause. For men, no comparable midlife change in physiological function occurs. With aging, however, many men can experience important changes in bodily function that are linked to declines in testosterone production.

Menopause leads to important changes in female genital anatomy and function, including atrophy of urogenital tissue; decreased uterine and vaginal size; and decreases in vaginal lubrication, vasocongestion, and the erotic sensitivity of nipple, clitoral, and vulvar tissue during sexual activity (Wilson, 2003a). Accompanying changes in sexual function include declines in libido, sexual responsiveness, and the frequency of sexual activity (Hayes & Dennerstein, 2005; Dennerstein, Guthrie, Hayes, DeRogatis, & Lehert, 2008). During menopause up to 85% of women also experience symptoms such as hot flashes, head and neck aches, transient disruptions in mood (e.g., anxiety, irritability, and depression), sleep disturbances, and excess fatigue. Although these changes are primarily attributed to the loss of estrogen production, the role of age-related disruption in hypothalamic function has also been investigated for many menopausal symptoms, particularly hot flashes. Declines in testosterone production in premenopausal women may also lead to changes that affect sexual function, including loss of libido; decreased clitoral, vulvar, and nipple sensitivity; and fatigue (Morley, 2003).

As men age, there are gradual declines in sexual function that have variable impacts on sexual activity. There are no predictable changes in sexual desire, although it remains relatively stable in most men. Erections are less reliable and durable and require more stimulation to achieve and sustain. Ejaculation during orgasm involves decreased amounts of seminal fluid, and the refractory period between orgasms can increase by hours to days. By middle age, testosterone levels begin to decrease by 1–2% per year, meaning that anywhere from 35 to 70% of men over the age of 70 suffer from hypogonadism, defined by a testosterone level less than 200 ng/dL (Morley, 2003; Harman, Metter, Tobin, Pearson, & Blackman, 2001). Terms such as andropause, male climacteric, partial androgen deficiency of the aging male, and late-onset hypogonadism have all been coined to refer to a symptom complex that results from age-related declines in testosterone levels (Pines, 2011). Clinical symptoms include decreased libido and sexual function; depression; decreased lean body mass, body hair, muscle power, and bone density; and increased visceral fat distribution. Some researchers also believe that andropause brings an increased risk for osteoporosis, bone fractures, obesity, insulin resistance, and cardiovascular disease (Shabsigh, 2003; Sternbach, 2003). Some individuals will react negatively to these age-related changes, viewing them as harbingers of physical decline or sexual dysfunction. For men, declines in erectile function can symbolize a threat to their sense of masculinity and lead to excessive worry, anger, or even depression. Some women grieve the loss of potential motherhood at menopause, particularly if they never had children. Negative reactions may reinforce stereotypes about late-life sexuality being inappropriate or dangerous and may lead to less frequent and less enjoyable sexual relations (Agronin, 2005). On the other hand, aging can bring increased emotional maturity and a heightened capacity for intimacy 475

that can enhance sexual relationships. Older couples may also have greater privacy and more time for intimacy. Individuals who understand that certain changes in sexual function are normal are less fearful and better able to adapt. For example, instead of dreading the effects of menopause, a woman may welcome the freedom from worry about contraception and unwanted pregnancy. Instead of focusing solely on sexual intercourse as the end-all and be-all of sexuality, a man may be able to shift his focus to the pleasurable sensual intimacy of sexual foreplay. Couples who communicate well can adjust sexual practices in order to maintain or even improve on previous levels of enjoyment (Agronin, 2005).

**PREVALENCE OF SEXUALITY IN LATER LIFE**

For both men and women, the impact of age-related changes in sexual function has a variable effect on sexual attitudes and behaviors. In general, there is a decline in the frequency of sexual activity after the age of 65, but not as much as might be imagined (National Council on Aging, 1998; Jacoby, 1999; American Association for Retired Persons [AARP], 2005; Fisher, 2010; Lindau et al., 2007). For example, a study of late-life sexuality by Lindau and colleagues (2007) involved a representative probability sample of 3,005 individuals ages 57–85 (1,550 men and 1,455 women) who agreed to comprehensive interviews by trained individuals. The definition of being sexually active was not limited to intercourse or orgasm but included any mutual sexual activity. The percentages of individuals who had been sexually active within the previous 12 months were quite high but declined with age, from 83.7% of men and 61.6% of women ages 57–

64 to 67% of men and 39.5% of women ages 65–74 to 38.5% of men and 16.7% of women ages 75–85. Of those individuals in the oldest age group who were sexually active with partners, 54% of them were sexually active at least 2–3 times per month, while 23% were sexually active at least once a week.

In the Lindau (2007) and other studies, older men were found to be more sexually active than older women, although sexual satisfaction was relatively high in both sexes.

The major predictors of sexual activity have included previous level of sexual activity, an individuals physical and psychological health, and the availability, interest level, and health of a partner (Lindau et al., 2007; Schick et al., 2010). Physical health appears to be the most influential factor for older men, while the quality of the relationship is most important for older women (Lindau et al., 2007; Schick et al., 2010).

**HOMOSEXUALITY**

There are an estimated 1–3 million gay and lesbian individuals over the age of 60 in the United States, and this number is expected to double in the next 30 years. In a 2009

survey conducted by the AARP, 5% of the roughly 2,000 respondents described 476

themselves as having same-sex partners (8% of men, 2% of women), with 3% identifying as gay, less than 0.5% as lesbian, and 1% as bisexual (Fisher, 2010). Gay and lesbian individuals and couples face similar issues as heterosexuals in terms of age-associated changes in sexual function and sexual relationships. Several studies indicate that older gay and lesbian individuals feel high levels of satisfaction with both their identities and lifestyles, and high levels of sexual satisfaction. For example, in one study of over 100

older gay men, 86% of respondents 60 years and older were sexually active, with two-thirds of them reporting sexual activity at least once a month (Adelman, 1991).

**SEXUALITY IN LONG-TERM-CARE SETTINGS**

Compared with elderly individuals living in the community, nursing home residents are significantly less likely to be sexually active (Hajjar & Kamel, 2003a; Spector & Fremeth, 1996). In one study of 250 nursing home residents, less than 10% reported being sexually active in the preceding month, although nearly 20% reported a desire for sexual activity but were limited by the lack of a partner or privacy (White, 1982). Barriers to sexuality in long-term care include loss of interest, poor health, sexual dysfunction, lack of partners, lack of privacy, and the negative attitudes of staff (Hajjar & Kamel, 2003a; Richardson & Lazur, 1995). Older gay and lesbian individuals in long-term care face additional challenges, as they fear being rejected and neglected (Stein, Beckerman, & Sherman, 2010). In addition, one small study suggested that staff members tend to have more negative views of same-sex intimacy (Hinrich & Vacha-Haase, 2010). Long-term-care facilities have the responsibility, however, to educate both staff and residents about the residents rights to privacy and to engage in intimate relationships. There are many accommodations that can be provided in a facility to appropriate individuals, such as beauty services, private rooms for conjugal visits, and medical and mental health consultation for sexual dysfunction (Schick et al., 2010).

**SEXUALLY TRANSMITTED DISEASES**

Sexually transmitted diseases (STDs) are at epidemic levels in the United States, affecting over 65 million people, many with incurable viral infections (Wilson, 2003b).

The Centers for Disease Control and Prevention (CDC) and other research groups indicate that individuals 65 and older account for less than 2% of reported STDs, including chlamydia, gonorrhea, syphilis, and HIV (Centers for Disease Control and Prevention, 2009; Xu, Schillinger, Aubin, St. Louis, & Markowitz, 2001). The differences in STD rates between young and old might be largely attributed to the fact that older individuals have fewer sexual encounters with fewer partners.

Despite low prevalence rates, older people remain at risk for acquiring STDs, especially as they are increasingly sexually active. There are numerous reasons for this, 477

including the fact that many older people never received the sex education provided to todays younger population. In addition, the knowledge that STDs are most prevalent in younger people may lead to a false sense of safety among older couples, causing them to neglect safe-sex practices. Older couples may also be less apt to use barrier contraceptives that protect against some STDs because they do not have to worry about unwanted pregnancy. In fact, a large study that looked at nearly 6,000 individuals ages 14–94 found that 91% of older men and a majority of older women did not use a condom when having sex with a date or acquaintance, and some didnt even use one when they knew their partner had an STD (AARP, 2005). Given these lapses in safe-sex measures, education about sexuality, STDs, and safe-sex practices remains critical throughout the entire adult life cycle.

**SEXUAL DYSFUNCTION**

ED is the most common form of sexual dysfunction in older men, affecting 20–40% of men in their 60s and 50–70% of men in their 70s and 80s (Lewis et al., 2004; Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994; Laumann & Waite, 2008). In older women, the most common forms of sexual dysfunction include hypoactive sexual desire, inhibited orgasm, and dyspareunia (Bitzer, Platano, Tschudin, & Alder, 2008; Lindau et al., 2007). The percentage of women with low sexual desire jumps from 10%

of women under 50 to nearly 50% of women in their late 60s and 70s (Lewis et al., 2004).

One study found that 43% of women ages 57–85 years reported low desire, 39% had difficulty with lubrication, and 34% had anorgasmia (Lindau et al., 2007).

The causes of sexual dysfunction in late life are typically multifactorial, involving the physical effects of medical illness and/or medications, comorbid psychiatric illness, and underlying maladaptive attitudes and/or dysfunctional relationships. Any medical illness that impairs the blood supply or nervous innervation of genital tissue can potentially serve as a primary cause of sexual dysfunction. Secondary sexual dysfunction may result from fatigue, pain, physical disability, or some other effect of a medical illness. For example, a man with chronic obstructive pulmonary disease may become short of breath during sexual activity, causing him to become less aroused, with resultant ED. Another example would be a woman with a history of cervical cancer who has pain during sex and subsequent loss of libido due to scarring and contractures of her vaginal tissue from surgery and radiation.

There are numerous medical conditions commonly associated with sexual

dysfunction in late life, including cardiac and pulmonary disease, vascular damage due to atherosclerosis or diabetes mellitus, endocrine disorders that affect estrogen or testosterone levels, urological or gynecological conditions that require surgical or chemotherapeutic intervention that alters or damages urogenital tissues, and neurological disorders such as peripheral neuropathy, multiple sclerosis, and Parkinsons disease that can diminish nervous innervation of genital tissue and lead to diminished physical mobility that in turn impairs sexual activity. Orthopedic problems 478

and joint disease can also cause pain and physical disability that can similarly affect sexual activity.

Medications often play a role in precipitating sexual dysfunction, and they can affect both sexes at any point in the sexual response cycle (Crenshaw & Goldberg, 1996; Goodwin & Agronin, 1997; Thomas, 2003). Some of the most common culprits include antihypertensives (e.g., ß-blockers, diuretics), antiandrogens, and many psychotropic medications, particularly antidepressants (Thomas, 2003; Montejo, Llorca, & Izquierdo, 2001; Ferguson, 2001). One prospective study found that nearly 60% of individuals on selective serotonin reuptake inhibitors (SSRIs) or venlafaxine suffered from various forms of sexual dysfunction, such as low desire, ED, and delayed orgasm, with higher rates in men (Montejo et al., 2001). By contrast, up to 25% of those on mirtazapine and only 8% on nefazodone reported such forms of sexual dysfunction. Bupropion has also been associated with lower rates of sexual dysfunction, in the 5–15% range (Kavoussi, Segraves, Hughes, Ascher, & Johnston, 1997).