"I can't seem to keep it up like I used to. The drugs my doctor prescribed don't seem to help much. My partner and I have not even tried in months because I am afraid I will fail, and she no longer approaches me because she is afraid to upset me."

• Diminished sexual desire or drive
• Aversion to sexual activity
• Difficulty attaining or maintaining arousal (including erection or lubrication)
• Delayed or absent orgasm
• Premature ejaculation
• Pain during sexual activity

Cognitive-behavioral Model of Sexual Dysfunction
The interaction of cognition (thoughts), behavior, biology, and interpersonal relationships is central to understanding and treating sexual dysfunction. Negative thoughts that adversely affect sexual function often involve worry about performance. Worry pulls attention away from erotic cues, reducing sexual response and pleasure. Maladaptive underlying attitudes about sex (e.g., "I should be able to reach orgasm during every sexual encounter", "my partner's sexual arousal is a good indicator of how much he loves me or how attractive he finds me") cause and perpetuate negative thoughts. The negative thoughts shape emotional reactions to sex, and sexual activity becomes paired with negative emotions, such as fear and despair. The behavioral response to these thoughts and emotions often involve avoidance of sexual activity, which can be misinterpreted by the individual's partner as an indicator that he or she is not attractive, causing further distress.

Medical problems can also influence sexual response. Conditions that affect the vascular, neurological, or endocrine systems, including hypertension, spinal cord injury, diabetes, and hormonal insufficiency, are associated with the greatest risk. Prescription drugs can also interfere with sexual response. Attitudes and beliefs about the effects of these physical factors can also have an impact on sexual response and satisfaction.

Relationship problems may also play a role in causing or maintaining sexual dysfunction. Anger, resentment, and lack of emotional intimacy are generally incompatible with a healthy sexual relationship.

Cognitive-behavior Therapy for Sexual Dysfunction
Cognitive-behavioral sex therapy consists of several components intended to change maladaptive sexual thoughts and behaviors. Treatment is conducted in individual or couple format. Treatment plans are individually constructed to meet the specific needs of the patient. Interventions include:

• psychoeducation focusing on commonly-held myths and misinformation about sex
• cognitive restructuring to modify negative thoughts about sex
• scheduling and planning intimate time
• exposure-based treatments in which the patient or couple carries out a series of specific, home-based behavioral homework assignments designed to reduce anxiety during sex and increase focus on pleasurable aspects of intimacy
• sexual communication training
• discussion of expanding sexual repertoire to minimize boredom and maximize interest
• lifestyle interventions such as developing better exercise and sleep behaviors to set the stage for improved general physical function and well-being

In some cases, referrals to other clinicians are made for assessment and treatment of other problems that can interfere with normal sexual response and with sex therapy. These referrals may involve:

• individual therapy to address problems such as depression or anxiety
• medical evaluation to assess or treat contributing problems