Sexuality and Sexual Medicine

Sexual medicine is the clinical assessment and management of sexual health concerns across the lifespan. Sexual difficulty is extremely common in all age groups. It is frequently underreported, because patients are reluctant to raise it and clinicians are uncomfortable or lack confidence in initiating the enquiry.

The framework covers sexual dysfunction in both men and women. It also covers the impact of chronic illness, medication and ageing on sexual function. Proactive, non-judgmental enquiry addresses an underaddressed but significant aspect of health and quality of life.

Proactive, routine, sensitive assessment is therefore an essential component of holistic clinical care, not a topic to be addressed only if the patient raises it.

Classification and general principles

• Sexual dysfunction encompasses disorders of:
  • desire (reduced or absent interest in sexual activity)
  • arousal (difficulty achieving or maintaining physiological arousal, including erectile dysfunction in men, and difficulty with lubrication or subjective arousal in women)
  • orgasm (delayed, absent or, less commonly, premature orgasm)
  • pain associated with sexual activity (dyspareunia)
• These categories frequently overlap and coexist in the same individual.
• A biopsychosocial assessment is essential. Psychological, relational and social factors often contribute substantially alongside any identifiable biological or medical cause.
• Chronic illness (including diabetes, cardiovascular disease and various neurological conditions) and numerous medications (particularly antidepressants, antihypertensives and antipsychotics, among many others) are common, frequently underrecognised contributors to sexual dysfunction.
• Enquire about sexual function when initiating or reviewing any medication with recognised potential for this adverse effect. This is frequently omitted.
• Sexual health and function matter across the full lifespan. In older adults, ongoing sexual interest and activity vary between individuals but remain common and important to many.
• Clinician assumptions that older adults have no sexual interest or activity are a frequently unrecognised barrier to assessment and support.

• The presenting concern varies with the type of sexual dysfunction.
• Erectile dysfunction in men presents as consistent or recurrent difficulty achieving or maintaining an erection sufficient for satisfactory sexual activity.
• Female sexual dysfunction presents with variable combinations of reduced desire, difficulty with arousal or lubrication, difficulty achieving orgasm and, in a substantial proportion, pain with sexual activity.
• A careful, full history is the essential foundation of assessment. Explore the nature and onset of the concern. Onset may be gradual or sudden, which has differing diagnostic implications, particularly in erectile dysfunction.
• Explore situational variation: whether the difficulty occurs in all sexual situations or only with a particular partner or context. This helps distinguish a primarily psychological from a primarily organic cause.
• Take a relevant medical, psychiatric, medication and relationship history.
• Erectile dysfunction of gradual, progressive onset, particularly with cardiovascular risk factors, may be an early marker of occult cardiovascular disease. The pathophysiology is shared, and the smaller calibre penile vasculature tends to show clinically significant compromise before larger vessel disease becomes symptomatic elsewhere.
• Any man with new, unexplained erectile dysfunction needs full cardiovascular risk assessment, particularly when no other cause is clear.
• Explore sensitively any significant relationship distress and psychological difficulty. Depression and anxiety are both a potential cause and a consequence of sexual difficulty, creating a frequently self-perpetuating cycle.
• In a proportion of individuals there is a relevant history of sexual trauma, which should also be explored sensitively.

• Clinical history, conducted with sensitivity and without judgment, is the essential foundation of assessment. A structured approach to sexual history taking supports comfortable, open discussion of this frequently sensitive topic.
• Direct physical examination and laboratory investigation according to the presenting concern and clinical context.
• Assess hormonal function: testosterone in men with reduced libido or erectile dysfunction, with broader endocrine screening where clinically indicated.
• Carry out full cardiovascular risk assessment in men presenting with erectile dysfunction.
• Review medication, considering any drug with recognised potential to contribute to sexual dysfunction. Explore alcohol and substance use.
• Where significant psychological or relational factors appear predominant, referral for specialist psychosexual counselling or couples therapy may be the most appropriate diagnostic and therapeutic pathway. Avoid extensive medical investigation to exclude an organic cause that clinical assessment suggests is unlikely to be the primary factor.

• Erectile dysfunction: first line pharmacological treatment is a phosphodiesterase type 5 inhibitor (sildenafil, tadalafil or vardenafil). These agents enhance the normal physiological erectile response to sexual stimulation. They require stimulation to be effective and do not produce a spontaneous erection independent of it.
• They are contraindicated with nitrate medication, because of the risk of significant, potentially severe hypotension. Ask directly about nitrates before prescribing.
• Where a phosphodiesterase type 5 inhibitor is inadequate or contraindicated, options include intracavernosal injection therapy, a vacuum erection device or, for refractory cases, a surgically implanted penile prosthesis.
• Add testosterone replacement where confirmed, clinically significant hypogonadism is a relevant contributing factor.
• Female sexual dysfunction: direct management by the type of dysfunction and the contributing factors identified.
• In postmenopausal women, topical oestrogen or, more broadly, management of genitourinary syndrome of menopause addresses arousal and pain related difficulty associated with vulvovaginal atrophy.
• For reduced desire, consider contributing psychological, relational and medication-related factors. For appropriately selected patients, consider specific pharmacological treatment where available and clinically indicated.
• Addressing any identified underlying medical condition or contributing medication is a foundational component of management across the sexual dysfunction spectrum. Where clinically appropriate and feasible given the indication for the original medication, consider an alternative with a more favourable sexual function adverse effect profile.
• Specialist psychosexual counselling or therapy is a valuable, often underutilised resource. Use it as a standalone approach where psychological or relational factors predominate, or as an adjunct to medical treatment where several factors contribute.
• It addresses the psychological, relational and communication dimensions of sexual difficulty that medical or pharmacological treatment alone frequently does not.
• Ongoing clinical engagement underpins effective management. Make regular, proactive, sensitive enquiry about sexual function and satisfaction a routine, integrated part of health assessment, not a topic addressed only when the patient raises it.