This interest would not stem from any epidemic of sex­ual dysfunction that is running rampant in the population. Rather, it would reflect the widespread preoccupation with sexual function­ing that pervades our culture—combined with misinformation. The topic of sex arouses both intense curiosity and intense anxiety.

How do I measure up? What am I missing out on? What can I do to make it better? Am I nor­mal? We are bombarded by pop opinions conveyed by tabloids, self-help books, talk shows, folk wisdom, and even pornography, all of which unfor­tunately far outweigh the availability of authoritative information.

What we do know is that “optimal” sexual functioning is in the eye of the beholder. What one person may consider to be healthy sexual activity, another may find insufficient, disturbed, or deviant. Even such a straightforward issue as the usual frequency of sexual activity is almost entirely subjective. A classic split-screen scene from the Woody Allen film Annie Hall illustrates how two partners in a relationship can view the same scenario in opposite ways: Man (on right) complaining to his therapist: “We hardly ever have sex—maybe three times a week!” Woman (on left) to her therapist: “We’re constantly having sex— I’d say three times a week!”  To further complicate matters, what is considered “normal” sexual activity is not only influenced by age, culture, and religious background but often changes over time.

The disorders of human sexuality are traditionally divided into three dif­ferent categories. Problems with one’s ability to function sexually, known as Sexual Dysfunc­tion, are among our patients’ most frequent concerns. The other two cate­gories of sexual problems are much less common. “Paraphilia” is the technical term for sexual perversion and describes people whose sexual lives, in fantasy or in action, are centered on deviant sexual stimuli or pref­erences (for example, sadism, fetishism, having sexual relations with chil­dren). Gender Identity Disorder describes people who feel that their sexual anatomy is at odds with their internalized sense of gender and are very dis­tressed by this mismatch.

To understand better how things can go wrong sexually, it may be helpful to examine the four phases of the “normal” sexual response cycle. The first phase is sexual desire, which includes thoughts and fantasies about sexual activity. The second phase is sexual excitement, which consists of the physical changes that occur when one is sexually aroused. For men, this involves erec­tion of the penis and for women vaginal lubrication and swelling of the gen­italia. The next phase is orgasm, the culmination in a pleasurable release of the sexual tension that has built up from the first two phases. Orgasm in men is reached with an ejaculation of semen, and in women with vaginal con­tractions.

The last phase of the sexual response cycle is resolution, which con­sists of a feeling of both physical and mental relaxation. During this phase, men have a refractory period lasting a variable amount of time during which they are not able to respond physically, either by erection or orgasm, to further stimulation. Women, on the other hand, do not have this refrac­tory period and may become aroused again during the resolution phase.

According to the diagnostic manual, you have Sexual Dysfunction if:

• – You have one (or more) of the following problems with sexual functioning: low sexual desire, aversion to sexual contact, difficulty becoming aroused, difficulty in achieving orgasm, premature ejac­ulation, or pain during intercourse.
• – The problem is not caused by a medical condition, a side effect of a medication you are taking, or drug or alcohol use.
• – You are distressed by this problem or it is causing significant prob­lems in your relationships with other people.