• Little or no desire for sexual relations
• Different levels of desire for sex between partners
• Disgust or distress with having sex or even thinking about it
• Failure to become aroused before sex and/or the inability to stay aroused until the sex act is completed
• Impotence in males. This means not being able to sustain an adequate erection.
• Premature ejaculation in the male. Ejaculation comes too early. Some experts define "too early" as 2-4 minutes. The concern, though, is not the exact amount of time, but that ejaculation comes with a minimum amount of stimulation sooner than the person wants it to come.
• Delay in or absence of orgasm in either the female or male
• Pain during intercourse
• Painful, sustained erection

• Psychological factors. Examples are:
  • Sexual trauma from things such as rape, incest, past sexual embarrassments or failures
  • Worry or anxiety about sexual performance
  • Guilt or inner conflicts about sex such as when a person's sexual needs, wishes, or thoughts go against family, religious, or cultural teachings
  • Depression
  • Relationship problems and/or lack of communication of wants and needs between sex partners
• Physical conditions that affect a person's sexual response. Examples include disorders that involve:
  • The heart and blood vessels. Less blood can flow to the genitals. Even the arteries and veins in the penis can be involved.
  • The nervous system, with a condition like multiple sclerosis
  • The body's glands such as with diabetes and/or any condition that alters the making or release of sex hormones
  • The use of any substance that alters the sexual response. These include some medications, drugs, alcohol and/or smoking. For example, some antidepressants may lead to impotence or failure to achieve orgasm.
  • Surgery. For example, prostate surgery can result in impotence.
  • Injuries such as ones that cause damage to nerves used in the sexual response or that result in scar tissue that interferes with sensations felt during sex

• Hormonal studies
• Ones that check for neurological problems
• Ones that measure the flow of blood and the conditions of the veins and arteries in the penis
• Blood and urine tests to detect diabetes, urinary tract infections, etc.
• X-rays and/or ultrasound, if needed, which can help detect endometriosis, vaginal scar tissue, ovarian tumors, etc., in women.

• A special vacuum that is placed over the penis to remove air. This causes an erection.
• Self-injections of a prescription medicine
• Penile implant surgery

• Individual counseling
• Counseling with both partners
• Sex therapy
• Behavior therapy

Does it hurt to have sex and are any of these problems present? The urge to go to the bathroom very badly or passing urine a lot more often than usual Burning or stinging feeling when passing urine The feeling that the bladder is still full after voiding Bad-smelling urine Bloody or cloudy urine Pain in the abdomen or over the bladder Stomachaches or feeling like throwing up
Do you have signs of "Anxiety"?	Or
Do any of the following cause a great deal of distress? Little or no desire for sex Disgust with having sex or even thinking about it Failure to get aroused before sex and/or the inability to stay aroused until the sex act is completed Delay or absence of orgasm
For Men Only: Does impotence occur with any of the following? Prostate surgery Medication for: High blood pressure Allergies (antihistamines) Depression Anxiety Muscle relaxation Any other prescriptions or over-the-counter medicine Drugs such as cocaine Excessive use of alcohol
Does impotence occur with one or more of these problems? An urge to urinate right away or the need to urinate often, especially at night Not being able to empty the bladder completely A feeling of hesitancy or delay or straining to urinate A weak or interrupted urinary stream Flowchart continued in next column
Does impotence occur with diabetes or the following signs of diabetes? Constant or frequent urination Extreme thirst Unusual hunger Weight loss or gain Fatigue Slow healing of cuts or wounds, especially on the feet Irritability
Are any of these problems present? Pain in the penis during intercourse Sustained erection that is painful Sores and/or painful blisters on the genital area and/or anus A discharge of pus from the penis Pain and swelling in the scrotum
Do one or both of the following cause a great deal of distress? Not being able to sustain an adequate erection Ejaculation that comes too soon
For Women Only: Is intercourse very painful with or without any of the following? Heavy, painful periods A yellowish-green vaginal discharge Chronic pain in the abdomen or a dull and constant ache on either or both sides of your pelvis Abnormal bleeding from the vagina Itching and burning around the vagina A large, painless, ulcerlike sore (chancre) or painful blisters in the genital area, anus, or mouth
Has sex been painful and given less pleasure since having an intrauterine contraceptive device (IUD) inserted?
Is there a great deal of distress due to an ongoing problem of not being able to allow anything to penetrate the vagina?	Or

Self-Care Tips
Stay healthy:

• Eat well.
• Exercise regularly.
• Get enough sleep.
• Don't ignore signs of illnesses.
• Follow your doctor's advice for a chronic illness, if you have one, to help prevent possible problems with sexual satisfaction.
• Practice safe sex to prevent sexually transmitted diseases.
• Limit alcohol. A little alcohol can act as an aphrodisiac. Too much, however, can lead to unsafe sex, violent behavior, etc.
• Don't smoke.

• Make a point to spend at least 15 minutes of uninterrupted time with your partner each day. If you can't meet face to face, call each other on the telephone.
• Remember to express your affection for each other every day.
• Plan to spend part of a day alone together at least once a week. Make a date to take a walk in the park, go out for dinner, or share other activities you both enjoy.
• Schedule a weekend away together every 2 months or so.
• Go to bed together at the same time. Tell yourself that what you haven't accomplished by 11 p.m. can wait until the next day.
• Relax by giving each other a massage or taking a shower together.
• Keep the television set out of the bedroom. Watching TV can be sexual suicide.

For Premature Ejaculation

• The squeeze technique. If a man feels he's about to ejaculate prematurely, he firmly pinches the penis directly below the head using the thumb and first two fingers of one hand and squeezes for 3 to 4 seconds. (This technique was developed by William H. Masters, M.D. and Virginia E. Johnson, founders of the Reproductive Biology Research Foundation).
• The start/stop method. The couple should abstain from intercourse for 2 weeks, but focus on touching. The man concentrates on the sensations in his penis as his partner touches his genitals and brings him to an erection. The man asks his partner to stop just before ejaculation. After a few minutes, his partner continues to arouse him, then stops again. This sequence is repeated twice more with ejaculation occurring the fourth time. Then each time the couple has sex, foreplay is prolonged.

• For the first week, limit lovemaking to cuddling, kissing, and nuzzling. Don't touch the genitals or breasts.
• During the second week, the man should gently touch his partner's vaginal area during lovemaking, but stop before she reaches orgasm to increase vaginal lubrication.
• During the third week, repeat the first 2 phases, then proceed with intercourse. If the vagina isn't adequately lubricated, apply a water-soluble lubricant such as K-Y Jelly to the penis to facilitate penetration. (Penetration may also be easier if the woman is on top.)

• The woman should gently place the tip of her partner's little finger against her vagina and gently push his finger into her vagina. If this feels uncomfortable, she should stop and wait a few minutes.
• The couple should continue this exercise until the man can insert 2 fingers in his partner's vagina without causing pain or discomfort. (It may take several attempts over a period of weeks for this technique to work.)