Sexual desire and erectile dysfunction in men and women

Sexual arousal is not just a localized reaction of the genitals, but a complex response of the entire body. It involves changes in blood flow, nervous system function, hormonal shifts, and emotional state, as well as the context of the relationship and a sense of safety. In men, the key physical manifestation of arousal is an erection, while in women, it is increased blood flow to the clitoris and vagina, hydration of the mucous membranes, increased sensitivity, and an internal feeling of being "involved" in the process. [1]

Modern classifications identify specific disorders associated specifically with the arousal phase. In men, the International Classification of Diseases, 11th revision, describes male erectile dysfunction as a persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse. In women, a disorder of sexual interest and arousal is defined as a decreased interest in sex and impaired subjective and physical arousal, with the individual suffering from these changes. [2]

It's important to note that there are no uniform "norms" for the frequency or intensity of arousal. For some people, it's natural to experience sexual desire and arousal several times a week, while for others, it's less often, but without internal discomfort. A disorder is considered only when problems with arousal last for at least six months, recur in most situations, and cause significant distress to the person or complicate relationships. [3]

Erectile dysfunction and decreased sexual arousal in women are not a "quirk" or an inevitable sign of aging. These conditions are often associated with cardiovascular and endocrine diseases, medication side effects, chronic stress, depression, and relationship problems. For a doctor, this is a signal to carefully assess overall health, not just a "local" problem. For the person themselves, this is a reason to stop blaming themselves and view the situation as a medical issue that can be addressed. [4]

The modern approach to such disorders is based on the biopsychosocial model. This means that the doctor considers three layers simultaneously: biological (vascular, hormonal, and nervous system conditions), psychological (stress, depression, anxiety, sexual attitudes), and social (relationship quality, everyday stress, and cultural expectations). Only in this context can one understand why a particular person has difficulty with arousal and what steps can truly help. [5]

Table 1. Normal sexual arousal in men and women

Component	Men	Women
Main physical feature	Enlargement and hardening of the penis due to blood flow	Filling of the clitoris and surrounding tissues with blood, lubrication of the vagina
The role of blood vessels	Critical to achieving and maintaining an erection	Important for enhancing sensitivity and lubrication
The role of hormones	Testosterone, nitric oxide, vascular endothelial function	Estrogens, testosterone, local mediators
Mental component	Visual and fantasy stimuli, stress level	Emotional closeness, sense of security, context
Risk factor control	Prevention of cardiovascular diseases	Prevention of hormonal and gynecological disorders [6]

Erectile dysfunction in men: essence, scale, risk

Erectile dysfunction is defined as the persistent or recurring inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. The term "impotence" is considered outdated and stigmatizing, and modern guidelines use the term "erectile dysfunction." It typically refers to a problem that persists for at least 6 months and is present in most sexual encounters, rather than occasional "failures." [7]

This is one of the most common sexual disorders in middle-aged and older men. According to epidemiological studies, moderate to severe erectile dysfunction occurs in 5-20% of men, and the incidence increases with age and the number of comorbidities. After age 40, the proportion of men with severe symptoms increases with each decade of life. However, milder disorders are significantly more common, but do not always lead to medical attention. [8]

Erectile dysfunction is closely linked to cardiovascular risk factors. Penile vessels have a small diameter, so early signs of atherosclerosis, hypertension, diabetes, and metabolic syndrome often manifest as erectile dysfunction long before the development of overt angina or stroke. Guidelines on male sexual health emphasize that erectile dysfunction should be considered as a possible marker of underlying cardiovascular disease. [9]

In addition to physical causes, erectile dysfunction is often accompanied by significant psycho-emotional consequences. A man may experience shame, anxiety, low self-esteem, feelings of inadequacy, and fear of losing his partner. This increases tension during sexual intercourse and, in turn, worsens erectile function, creating a vicious cycle that is difficult to break without professional help. [10]

It's important to remember that the absence of a partner or an active sex life does not protect against cardiovascular disease, which is why men with erectile dysfunction should be examined. Even if a man doesn't plan on regular sexual intercourse, persistent erectile dysfunction alone is a reason to check his cardiovascular risk, blood sugar levels, lipid profile, and hormonal status. [11]

Table 2. Prevalence of erectile dysfunction by age (approximate data)

Age	Approximate proportion of men with moderate to severe erectile dysfunction
Up to 40 years old	About 5%
40-49 years old	5-10%
50-59 years old	10-20%
60-69 years old	20-40%
Over 70 years old	40% or more [12]

Causes of erectile dysfunction

Based on the mechanism of occurrence, erectile dysfunction is classified as vascular, neurogenic, hormonal, anatomical, psychogenic, and mixed. In practice, most men experience a combination of factors, and a strict distinction between "organic" and "psychogenic" forms is often lacking. For example, diabetes damages blood vessels and nerves, while at the same time, a person begins to worry about failure, and the psychological component further exacerbates the problem. [13]

Vascular causes are associated with atherosclerosis, hypertension, vascular endothelial dysfunction, and smoking. Stenosis of the arteries supplying the penis reduces blood flow, and venous insufficiency interferes with blood retention in the corpora cavernosa. Erectile dysfunction is often the first noticeable manifestation of systemic atherosclerosis, especially in men with excess weight, hypertension, and lipid metabolism disorders. [14]

Neurogenic forms are associated with damage to the spinal cord, peripheral nerves, and the consequences of pelvic and prostate surgery. Damage to nerve fibers disrupts the transmission of signals from the brain to the corpora cavernosa and from the sensory organs to the excitation centers. These situations include spinal injuries, severe forms of diabetic neuropathy, the consequences of radical prostatectomy, and certain bowel and bladder procedures. [15]

Hormonal factors include testosterone deficiency, severe hypothyroidism, hyperprolactinemia, and other endocrine disorders. Severe testosterone deficiency reduces sexual desire, mood, muscle mass, and energy levels, which indirectly impacts erectile function. However, a moderate decrease in testosterone in older men is not always the sole cause of erectile dysfunction, and hormone replacement does not solve all problems. [16]

Medications and mental disorders play a special role. Selective serotonin reuptake inhibitors, some antipsychotics, antihypertensive drugs, as well as alcohol and other substance abuse, can reduce erectile function. Depression and anxiety disorders themselves impair sexual arousal and increase anxiety about failure. Therefore, the contribution of medications and mental state must be assessed in each case. [17]

Table 3. Main groups of causes of erectile dysfunction

Group	Examples	Brief mechanism
Vascular	Atherosclerosis, hypertension, metabolic syndrome, smoking	Violation of blood flow and retention in the cavernous bodies
Neurogenic	Spinal cord injuries, diabetic neuropathy, prostate surgery	Disruption of nerve impulse conduction
Hormonal	Testosterone deficiency, hyperprolactinemia, severe thyroid disease	Decreased libido and changes in vascular response
Medicinal and toxic	Antidepressants, antipsychotics, antihypertensives, alcohol	Direct influence on blood vessels and the nervous system, changes in the balance of mediators
Psychological and mixed	Depression, anxiety, conflicts in couples, chronic stress	Inhibition of excitation, increased anxiety in anticipation of failure [18]

Diagnosis of erectile dysfunction

Diagnosis begins with a detailed interview. The specialist will determine when erectile dysfunction first began, whether there were previously consistent periods of normal sexual function, whether the problem occurs in all situations or only with a specific partner, and whether spontaneous morning erections persist. These details help differentiate primary from secondary erectile dysfunction, as well as suspect a predominantly psychogenic or organic nature of the disorder. [19]

Standardized questionnaires, such as the Abbreviated International Erectile Dysfunction Scale, are widely used to quantify the severity of symptoms. At the same time, the physician collects information about comorbidities, physical activity levels, unhealthy habits, medication use, and overall quality of life. Already at this stage, clear risk factors such as hypertension, diabetes, obesity, smoking, or chronic stress are often identified. [20]

A physical examination includes cardiovascular assessment, blood pressure measurement, body mass index determination, examination of the genitals and prostate, and a neurological assessment of pelvic sensation and reflexes. It is important to note signs of endocrine disorders, such as decreased hair growth, changes in fat distribution, and decreased testicular volume. [21]

Laboratory testing typically includes a complete blood count, fasting glucose or glycated hemoglobin, lipid profile, morning total testosterone, and, if necessary, prolactin and thyroid hormone levels. The goal is to identify diabetes, dyslipidemia, testosterone deficiency, and other conditions that are directly related to erectile dysfunction and cardiovascular risk. [22]

In complex or unclear cases, instrumental methods may be used: Doppler ultrasonography of the penile vessels after a pharmacological test, nocturnal erection recording, and specific tests for venous insufficiency. These methods are used in planning invasive treatment, as well as in situations where it is necessary to clearly distinguish between the vascular and psychogenic nature of the disorder. [23]

Table 4. Main stages of examination for erectile dysfunction

Stage	Task	Examples of actions
Survey	Understand the nature and duration of the problem	History of symptoms, relationship to situation and partner
Risk factor assessment	Identify somatic and behavioral causes	Questions about illnesses, smoking, activity, medications
Physical examination	Assess blood vessels, hormonal signs, and neurological status	Blood pressure measurement, examination, neurological tests
Laboratory tests	Detect diabetes, dyslipidemia, hormonal disorders	Glucose, lipids, testosterone, and prolactin if necessary
Additional methods	Clarify the mechanism of the violation	Dopplerography, nocturnal erection tests when indicated [24]

Treatment of erectile dysfunction

Current guidelines emphasize that treatment should begin with risk factor and lifestyle modification. Regular aerobic physical activity, weight loss in obese individuals, smoking cessation, moderate alcohol consumption, and blood pressure and sugar control can improve erectile function while simultaneously reducing cardiovascular risk. These measures are considered a basic component of therapy for all patients. [25]

First-line pharmacotherapy includes phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, vardenafil, and avanafil. These drugs enhance the action of nitric oxide in the corpora cavernosa and improve blood flow during sexual stimulation. They are effective in a significant proportion of men and, when properly dosed and administered, are safe for most patients, with the exception of men taking nitrates, for whom this combination is strictly contraindicated. [26]

If pills are ineffective or impossible to use, other methods are used. Vacuum erectile devices create negative pressure around the penis and mechanically ensure blood flow, while a special ring helps retain it. Intracavernous injections of prostaglandin E1 or combination medications can induce an erection through direct vasodilatory action. These approaches require training and adherence to safety precautions, but produce good results in cases of severe vascular disorders. [27]

Surgical treatment, primarily the installation of penile prostheses, is used for severe forms of erectile dysfunction when all conservative methods have proven ineffective or contraindicated. Modern prostheses can restore sexual intercourse and ensure high satisfaction with proper selection and patient preparation. It is important to consider the risks of surgery, the need for sterility, and potential mechanical complications. [28]

Psychotherapy and couples work play a significant role in almost every case. A specialist can help reduce anxiety about failure, adjust inflated expectations, discuss intimacy scenarios, and reduce the pressure to achieve an "obligatory" erection. Involving your partner helps eliminate mutual accusations and foster a more supportive interaction style, which in itself has a positive effect on arousal. [29]

Table 5. Main methods of treating erectile dysfunction

Method	Examples	When it is especially useful
Lifestyle correction	Physical activity, weight loss, smoking cessation	Any patient with cardiovascular risk factors
Oral medications	Phosphodiesterase type 5 inhibitors	Mild to moderate erectile dysfunction, preserved vascular reserve
Vacuum devices	Mechanical creation of an erection	In case of contraindications to tablets or severe vascular disorders
Intracavernous injections	Prostaglandin E1 preparations and combinations	If tablets are ineffective, after prostate surgery
Surgical treatment	Penile prostheses	Severe organic erectile dysfunction with failure of conservative treatment [30]

Sexual arousal deficiency in women: nature and prevalence

In women, arousal disorders are typically described as disorder of sexual interest and arousal. Diagnostic criteria include a decrease or absence of sexual thoughts and fantasies, decreased initiative, poor response to caresses, decreased lubrication and physical sensations during stimulation, and a lack of pleasure from sexual activity. A prerequisite is significant personal distress due to these symptoms, lasting at least 6 months. [31]

Research shows that difficulties with desire and arousal are the most common types of sexual dysfunction in women. In various studies, up to 30-50% of women report a decrease in interest in sex, and clinically significant distress is found in approximately 8-15%. Prevalence depends on age, hormonal status, the presence of chronic diseases, and the quality of relationships, as well as how openly women are willing to discuss intimate matters. [32]

Modern classifications group female sexual disorders differently. The Diagnostic and Statistical Manual of Psychological Disorders, 5th Edition, groups decreased interest and arousal difficulties into one category, while professional societies on women's sexual health sometimes suggest considering them separately. However, all approaches emphasize that the key criterion is not comparison with an abstract "norm," but subjective suffering and impact on life. [33]

A lack of sexual arousal isn't simply a matter of "frigidity" or the idea that a woman "doesn't like sex." It's often a combination of factors: fatigue, an overload of responsibilities, chronic stress, hormonal changes, painful intercourse, negative experiences, and relationship dissatisfaction. Under these conditions, the body simply can't activate arousal mode, even if the woman knows she wants to maintain intimacy. [34]

It's important to consider the cultural context. In many societies, female sexuality is still surrounded by shame, double standards, and a lack of information. This leads to women seeking help late, unaware that decreased arousal is related to, for example, menopause or medication, and perceiving it as a personal failure or "the price of aging." Educational programs and access to evidence-based information can significantly reduce such "hidden" suffering. [35]

Table 6. Criteria for sexual interest and arousal disorder in women (summary)

Component	The essence of the criterion
Decreased thoughts and fantasies	Rare or absent sexual thoughts for a long period of time
Decrease in initiative	The woman hardly initiates contact and responds weakly to her partner's initiative.
Physical arousal disorder	Insufficient hydration, poor feeling of fullness and sensitivity
Decreased pleasure	Pleasure from intimacy has decreased or disappeared compared to previous levels
Duration and suffering	Symptoms last for at least 6 months and cause significant personal distress [36]

Causes of sexual arousal deficiency in women

Biological factors include hormonal changes, vascular and neurological disorders, and gynecological conditions. Decreased estrogen levels during perimenopause and menopause lead to thinning and dryness of the vaginal mucosa, reduced blood flow and sensitivity, which causes discomfort and pain during intercourse. Under these conditions, the body "learns" to associate sexual stimulation with unpleasant sensations, and arousal naturally decreases. [37]

Medications play a significant role. Selective serotonin reuptake inhibitor (SSRI) antidepressants, some antipsychotics, anticonvulsants, antihypertensives, and hormonal contraceptives can reduce interest in sex, impair libido, and subjective arousal. The impact of medications used to treat depression on the ability to experience pleasure in general, which also impacts sexual function, is discussed separately. [38]

Gynecological conditions and chronic pelvic pain are often key obstacles. Endometriosis, vulvodynia, chronic inflammatory processes, pelvic organ prolapse, and the consequences of surgery can all cause pain during intercourse. In response to pain, the pelvic floor muscles tense, a protective avoidance of penetration occurs, and over time, not only desire but also the ability to achieve arousal decreases. [39]

Psychological factors include depression, anxiety disorders, chronic stress, sexual abuse, and negative body image. Depression reduces the ability to experience joy, disrupts sleep, lowers energy, and sexual arousal is one of the first to suffer. Anxiety and constant tension make it difficult to relax and focus on bodily sensations, and traumatic experiences can cause fear and avoidance of any sexual contact. [40]

Interpersonal and social factors are no less significant. Unfair distribution of household and emotional burdens, conflicts, mistrust, criticism, and pressure within a couple lead to a woman simply lacking the resources for arousal. For many women, sexual desire is closely linked to a sense of care and respect from their partner. If, instead, demands and blackmail are present, decreased arousal becomes a logical defensive reaction rather than a "breakdown." [41]

Table 7. Main factors of sexual arousal deficiency in women

Group of reasons	Examples	Main effect
Hormonal	Perimenopause, menopause, ovarian dysfunction	Dryness, decreased sensitivity, discomfort
Medicinal	Antidepressants, antipsychotics, hormonal contraceptives	Decreased desire and arousal
Gynecological	Endometriosis, vulvodynia, chronic inflammation	Pain, protective muscle tension
Psychological	Depression, anxiety, post-traumatic stress disorder	Anhedonia, fear, avoidance
Interpersonal	Conflicts, overload, lack of support	Distancing from a partner, decreased interest in intimacy [42]

Diagnosis of sexual arousal deficiency in women

The assessment begins with a thorough conversation, where the woman can detail how her interest in sex has changed over time, what physical and emotional sensations accompany attempts at intimacy, and whether there is pain, dryness, fear, or shame. It is important to understand whether there have been periods of normal sexual activity, the duration of current difficulties, and the extent to which they interfere with her personal and family life. The specialist will always clarify whether the woman herself considers the situation to be a problem. [43]

For a quantitative assessment, female sexual function questionnaires are used to help structure complaints and monitor progress during treatment. The doctor collects information about the patient's menstrual and reproductive history, previous gynecological surgeries and illnesses, childbirth, lactation, and medications that affect hormonal balance and the nervous system. Even at this stage, clear links between the start of medication and decreased arousal are often identified. [44]

A physical examination and gynecological examination allow for an assessment of the condition of the external and internal genitalia, the presence of atrophic changes, inflammation, painful areas, scarring, and prolapse of the pelvic organs. If necessary, smears are taken, an ultrasound of the pelvic organs is performed, and other tests are performed to confirm the diagnosis. [45]

Laboratory tests may include assessment of estrogen levels, follicle-stimulating hormone, prolactin, thyroid hormones, and other parameters depending on the clinical situation. The goal is to detect endocrine disorders that contribute to arousal problems, as well as to assess the overall metabolic profile and cardiovascular risk factors. [46]

A mandatory part of the diagnosis is a mental health assessment. Screening for depression, anxiety, and post-traumatic stress disorders is performed, and the presence of traumatic sexual experiences is also clarified. The specialist considers whether decreased arousal is a primary symptom or a consequence of long-term depression, chronic stress, or violence. This determines the treatment priorities and the need for psychotherapy. [47]

Table 8. Main stages of examination for sexual arousal deficiency in women

Stage	Tasks	Comments
Detailed survey	Identify the nature, duration and subjective significance of the problem	It is important to create a safe, non-judgmental atmosphere
Evaluation of reproductive and drug history	Find links to childbirth, menopause, medications	The influence of contraception or antidepressants is often detected.
Gynecological examination	Detect atrophy, inflammation, pain, scarring	If necessary, it can be expanded using instrumental methods
Laboratory diagnostics	Assess hormonal and metabolic levels	Endocrine factors of disorders are identified
Psychological assessment	Identify depression, anxiety, traumatic experiences	Determines the need for psychotherapy and support [48]

Treatment of sexual arousal deficiency in women

Therapy is always comprehensive. The first step is eliminating or reducing the physical causes. For vaginal atrophy associated with menopause, topical estrogenic agents or other modern approaches to treating genitourinary syndrome of menopause are used. This helps reduce dryness, itching, and pain during intercourse, thereby creating the conditions for restoring arousal. For pain disorders such as vulvodynia or chronic pelvic pain, multicomponent programs involving a gynecologist, physiotherapist, and psychotherapist are used. [49]

An important part of treatment is a review of medication therapy. If possible, replacing medications that negatively impact sexual function with those with a lower risk of such side effects is discussed. This is especially true for antidepressants and antipsychotics. The decision is always made in consultation with the treating physician, taking into account the patient's mental state and the risk of relapse. [50]

Psychotherapy and sex therapy focus on addressing attitudes, anxiety, shame, and traumatic experiences, as well as developing skills for consciously perceiving one's own body and pleasure. Cognitive-behavioral techniques help change negative beliefs about sex and oneself, and sensory focus exercises teach focusing on pleasurable sensations without the pressure of an "obligatory" orgasm. If a traumatic history is present, trauma-focused approaches are used. [51]

Medications aimed specifically at improving sexual desire and arousal are studied and used with caution. In a number of countries, flibanserin and bremelanotide, which act on central mechanisms regulating desire and arousal, are approved for the treatment of hypoactive sexual desire disorder in women. Their efficacy is moderate, and their use is associated with a risk of side effects and strict indications, so the decision to prescribe them is made by a physician after a detailed assessment and informed consent. [52]

A separate issue is the use of androgen medications in women with a significant decrease in desire and arousal. International guidelines permit the use of low doses of testosterone in selected postmenopausal patients in the absence of contraindications and under careful monitoring. However, in most countries, there are no official guidelines for women, and therapy is administered "off-label." In any case, the decision regarding such therapy should be made by a specialist with experience in female sexual medicine. [53]

Table 9. Main directions of treatment of sexual arousal deficiency in women

Direction	Examples	Main objectives
Treatment of painful and atrophic conditions	Local estrogens, genitourinary syndrome therapy, pelvic floor physiotherapy	Eliminate pain and discomfort during sexual intercourse
Correction of drug therapy	Revision of antidepressant, antipsychotic, and contraceptive regimens	Reduce the drug's effect on arousal
Psychotherapy and sex therapy	Cognitive behavioral therapy, trauma-focused therapy, sensory focus exercises	Reduce anxiety and shame, strengthen connection with the body and pleasure
Specialized drugs	Flibanserin, bremelanotide for strict indications	Moderate increase in desire and arousal in some patients
Androgen therapy (for strict indications)	Low-dose testosterone in selected postmenopausal women	Correction of hormonal deficiency and improvement of sexual function [54]

General principles of prevention and working with couples

For both sexes, the key to preventing arousal disorders is caring for cardiovascular and endocrine health. Controlling blood pressure and blood sugar, managing body weight, engaging in regular physical activity, quitting smoking, and drinking alcohol in moderation reduce the risk of atherosclerosis, diabetes, and associated erectile dysfunction and sexual dysfunction. In fact, recommendations for cardiovascular health largely also apply to intimate health. [55]

Mental health is equally important. Seeking help for depression and anxiety disorders promptly, managing stress, and learning relaxation and self-support techniques reduce the likelihood that sexual arousal will fade due to chronic tension. Research shows that high levels of overall well-being are associated with better sexual function in both men and women. [56]

Relationships require as much preventative care as blood pressure. Open communication about sexual preferences, fantasies, fears, and boundaries helps avoid the accumulation of resentments and false expectations. It's important to agree on a time for intimacy, share household and emotional responsibilities, and respect each other's right to fatigue and low spirits. This style of interaction reduces the risk that decreased arousal will lead to mutual recriminations. [57]

A practical step when persistent problems arise is to consult a doctor immediately. Men with erectile dysfunction should discuss the situation with a general practitioner or urologist, while women with arousal deficits should consult a gynecologist or a women's sexual health specialist. If there is significant suffering, depression, anxiety, or a traumatic experience, it is advisable to involve a psychologist or psychotherapist familiar with sexual disorders. [58]

An important conclusion for both genders: sexual arousal disorders are not a death sentence or a "punishment for age." In the vast majority of cases, specific biological, psychological, and interpersonal factors can be identified and a treatment plan can be proposed. The sooner a person stops blaming themselves and seeks support, the greater the chance of maintaining or resuming a satisfying sex life without sacrificing safety and respect for their own boundaries. [59]

Table 10. Practical steps for couples with sexual arousal disorders

Step	The essence	Why is this necessary?
Joint discussion of the problem	Calmly describe what has changed, without making accusations	Reduce stress and eliminate guilt
Health assessment	Undergo a basic examination with a specialist doctor together	Identify reversible medical causes
Lifestyle revision	Introduce regular activity, normalize sleep, reduce alcohol and smoking	Improve vascular and hormonal health
Contacting a sexual health specialist	Get a personalized therapy plan and recommendations for nearby	Avoid ineffective or dangerous DIY solutions
Support, not pressure	Agree that the goal is overall well-being, not sexual activity at any cost	Maintaining trust and emotional intimacy in a couple [60]