Sexual dysfunction is typically influenced by a variety of predisposing, precipitating, maintaining and contextual factors . There are no current data available to suggest that any one factor is more important than another. Predisposing factors include both constitutional (e.g. congenital illness, anatomical deformities) and prior life experiences, such as problematic attachments, neglectful or critical parents, restrictive upbringing, sexual and physical abuse and violence. Predisposing factors are often associated with a greater prevalence of sexual dysfunction and emotional difficulties in adult life. While some individuals appear less vulnerable and more resilient in the face of stressors, others are more susceptible.
Precipitating factors are those that initiate or trigger sexual problems. For any one individual it is impossible to predict which factors, under what circumstances, will impair sexual desire or performance. Nonetheless, an individual's vulnerability to a particular set of circumstances can precipitate sexual dysfunction. For instance, traumatic events such as the discovery of a spouse's infidelity may cause one man to lose his sexual desire while another man's desire may increase. While initially a precipitating event may be problematic and distressing, it need not necessarily lead to a diagnosable dysfunction in the long term. Over time however, repetition of such events, especially those that damage self-confidence and self-esteem result in sexual dysfunction, even in reasonably resilient individuals. Examples of such precipitating events include con-flictual separation or divorce, a sudden brush with death through an accident or disease process, or unsatisfying sexual experiences.
Finally, maintaining factors such as relationship conflict, performance anxiety, guilt, inadequate sexual information or stimulation, psychiatric disorders, loss of sexual chemistry, fear of intimacy, impaired self-image or self-esteem, restricted fore-play, poor communication and lack of privacy, may prolong and exacerbate problems, irrespective of the original predisposing or precipitating conditions. Maintaining factors also include contextual factors that can interfere or interrupt sexual activity, such as environmental constraints or anger/resentment towards a partner. Each of these four factors adversely contributes to, or diminishes, both the individual's and the couples' ability to sustain an active and satisfying sexual life. Often there is not a clear distinction between predisposing and precipitating and precipitating and maintaining factors. For instance, anxiety can increase an individual's vulnerability to sexual dysfunction as a common predisposing factor; it can also serve as a maintaining factor leading to sexual avoidance or arousal inhibition.
• Recommendation 1. Clinical assessment should aim to identify the predisposing, precipitating, maintaining and contextual factors related to the individual's sexual dysfunction.
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