Raiyyan Tahsan

Raiyyan Tahsan
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TC(946).(20).Sexology Case No 99. Relationship-related Sexual Dysfunction

Relationship-related Sexual Dysfunction — বাংলা ক্লিনিক্যাল নোট

Relationship-related sexual dysfunction বলতে বোঝায়—সম্পর্কের দ্বন্দ্ব, emotional distance, poor communication, trust issue, performance anxiety, sexual dissatisfaction, coercion/violence, mismatched desire বা chronic conflict–এর কারণে desire, arousal/erection/lubrication, ejaculation, orgasm বা sexual pain–এ clinically significant সমস্যা হওয়া। WHO sexual health-কে physical, emotional, mental ও social well-being–এর অংশ হিসেবে দেখে, এবং relationship, pleasure, dysfunction, STI, violence—সবই sexual health-এর অন্তর্ভুক্ত।

Clinical warning: এগুলো self-medication করার বিষয় না। PDE5 inhibitor, SSRI, dapoxetine, testosterone বা estrogen therapy—সবই physician/urologist/gynecologist/psychiatrist assessment অনুযায়ী দিতে হবে।

1. Definition

Relationship-related sexual dysfunction হলো এমন sexual dysfunction যেখানে সমস্যা প্রধানত relationship context–এ দেখা যায়—যেমন partner-এর সাথে erection/ejaculation/orgasm/sexual desire সমস্যা, কিন্তু masturbation বা অন্য context-এ তুলনামূলক ভালো function থাকতে পারে।

ICD-11 sexual dysfunction-কে sexual response/pleasure-এর clinically significant disturbance হিসেবে classifies করে; ED, early ejaculation, desire/arousal disorder, orgasm disorder এবং sexual pain disorder—সবই আলাদা clinical entity হিসেবে বিবেচ্য।

2. Etiology / Pathophysiology — কারণ ও মেকানিজম

A. Relationship-related cause

  • Poor communication: partner কী পছন্দ/অপছন্দ করে তা না জানা।
  • Unresolved conflict: ঝগড়া, resentment, emotional hurt।
  • Lack of trust / infidelity history: betrayal বা সন্দেহ libido কমিয়ে দেয়।
  • Performance pressure: “আমি পারব তো?” anxiety → sympathetic overactivity → ED/PE।
  • Mismatched libido: একজন বেশি চায়, অন্যজন কম চায়।
  • Emotional distance: affection/foreplay কমে গেলে arousal কমে।
  • Coercion or intimate partner violence: fear, pain, avoidance, trauma response তৈরি করে।
  • Fertility pressure: সন্তান নেওয়ার চাপ sexual pleasure কে performance task বানায়।

Relationship stress ও sexual dysfunction-এর মধ্যে strong association আছে, বিশেষ করে female sexual dysfunction ও male partner-এর sexual dysfunction–related relationship stress–এ association বেশি দেখা যায়।

B. Psychological cause

  • Depression, anxiety, panic disorder
  • Body-image concern
  • Past sexual trauma
  • Porn comparison/performance expectation
  • Religious/cultural guilt or shame
  • Low self-esteem

C. Organic / medical cause

  • Diabetes mellitus, hypertension, dyslipidemia, obesity
  • Cardiovascular disease
  • Hypogonadism / low testosterone
  • Hyperprolactinemia
  • Thyroid disease
  • Menopause-related vaginal dryness / genitourinary syndrome of menopause
  • Prostatitis, LUTS, STI, pelvic inflammatory disease
  • Endometriosis, vaginismus, vulvodynia
  • Drugs: SSRI, antipsychotic, finasteride, spironolactone, some antihypertensives, opioids, alcohol

EAU guideline অনুযায়ী ED common worldwide, CVD-এর risk factor share করে, lifestyle modification EF improve করতে পারে, এবং ED অনেক সময় underlying disease-এর symptom—তাই শুধু erection medicine দিলেই পূর্ণ evaluation শেষ হয় না।

3. Clinical Features / Symptoms — উপসর্গ

Male symptoms

  • Sexual desire কমে যাওয়া
  • Partner-এর সাথে erection না হওয়া বা maintain করতে না পারা
  • Morning erection ঠিক আছে কিন্তু partner situation-এ ED
  • Premature ejaculation
  • Delayed ejaculation বা ejaculation না হওয়া
  • Orgasmic dissatisfaction
  • Performance anxiety
  • Avoidance: intimacy এড়িয়ে চলা
  • Shame, frustration, anger

Female symptoms

  • Sexual interest/desire কমে যাওয়া
  • Arousal কম, lubrication কম
  • Painful intercourse / dyspareunia
  • Vaginismus বা penetration fear
  • Orgasm difficulty
  • Partner-এর প্রতি resentment বা emotional withdrawal
  • Sex-এর সময় fear, disgust, sadness বা anxiety

Couple-level symptoms

  • Frequent conflict after sex
  • Blaming: “তোমার জন্য হচ্ছে”
  • Intimacy কমে যাওয়া
  • Infidelity suspicion
  • Fertility-related stress
  • Relationship breakup risk

4. Clinical Diagnosis — কীভাবে diagnose করবেন

A. History taking — specific

  1. Problem type: desire, arousal/ED, ejaculation, orgasm, pain—কোন phase?
  2. Onset: lifelong নাকি acquired?
  3. Situation: সব partner/context-এ নাকি শুধু current relationship-এ?
  4. Duration: সাধারণত clinically significant distress সহ ≥6 months হলে sexual dysfunction diagnosis শক্ত হয়।
  5. Relationship history: conflict, trust issue, emotional closeness, communication, coercion/violence আছে কিনা।
  6. Sexual history: masturbation, morning erection, foreplay, frequency, satisfaction।
  7. Medical history: DM, HTN, CVD, thyroid, menopause, pelvic pain, STI।
  8. Drug history: antidepressant, antipsychotic, antihypertensive, finasteride, alcohol, recreational drug।
  9. Mental health: PHQ-9, GAD-7, trauma history, suicidal ideation।
  10. Safety: sexual coercion, intimate partner violence থাকলে couple therapy নয়—first priority safety.

B. Validated tools

  • Male ED: IIEF-5 / SHIM, Erectile Hardness Score
  • Premature ejaculation: PEDT, self-estimated IELT, perceived control, distress
  • Female sexual dysfunction: FSFI, FSDS-R, HSDD screener
  • Mental health: PHQ-9, GAD-7
  • Relationship: couple satisfaction/communication assessment

EAU guideline ED work-up–এ medical/psychosexual history, IIEF/SHIM, focused physical exam, BP/BMI, glucose/HbA1c, lipid profile ও morning testosterone recommend করে। PE diagnosis-এ history, self-estimated IELT, perceived control, distress, interpersonal difficulty এবং physical examination গুরুত্বপূর্ণ; routine lab test দরকার নেই যদি history/exam-এ indication না থাকে।

5. Investigations — specific list

Basic investigation

  • Fasting blood glucose / HbA1c
  • Fasting lipid profile
  • BP, BMI, waist circumference
  • CBC if fatigue/anemia suspected
  • TSH if low libido, fatigue, menstrual change, anxiety symptom
  • Serum prolactin if low libido, ED, galactorrhea, amenorrhea
  • Morning total testosterone, ideally 07:00–10:00 AM; low হলে repeat + LH/FSH
  • LFT/RFT before long-term psychotropic/hormonal medicine if indicated
  • Urine R/E, urine culture if urinary symptom
  • STI tests: VDRL/RPR, HIV, HBsAg, anti-HCV, NAAT for gonorrhea/chlamydia if risk/discharge/pain
  • Pregnancy test before hormonal therapy where relevant

EAU 2026 guideline male hypogonadism evaluation-এ morning fasting total testosterone measure করতে বলে।

Advanced investigation — only if indicated

  • Penile Doppler ultrasound: suspected vasculogenic ED, trauma, severe ED
  • Nocturnal penile tumescence: psychogenic vs organic ED differentiation
  • Pelvic exam/speculum exam: dyspareunia, discharge, bleeding
  • Pelvic ultrasound: pelvic pain, fibroid/endometriosis suspicion
  • Pap smear/HPV screening as age/risk-based
  • Cardiology evaluation: ED + chest pain/exertional dyspnea/high CVD risk

6. Differential Diagnosis

  • Primary erectile dysfunction due to diabetes/CVD
  • Premature ejaculation independent of relationship conflict
  • Major depressive disorder / anxiety disorder
  • SSRI-induced sexual dysfunction
  • Hypogonadism
  • Hyperprolactinemia
  • Hypothyroidism / hyperthyroidism
  • STI, prostatitis, PID
  • Menopause-related GSM
  • Vaginismus, vulvodynia, endometriosis
  • Substance/alcohol-related sexual dysfunction
  • Sexual trauma/PTSD
  • Intimate partner violence/coercion

7. Complications

  • Marital/relationship breakdown
  • Low self-esteem, shame, depression, anxiety
  • Infertility-related distress
  • Avoidance of intimacy
  • Extramarital conflict/suspicion
  • Unsafe self-medication with sildenafil/tadalafil/dapoxetine
  • Dangerous interaction: PDE5 inhibitor + nitrate → severe hypotension
  • Partner dissatisfaction and sexual distress

8. Management / Treatment — Guideline-based

A. First-line: Non-pharmacological management

Relationship-related sexual dysfunction-এর core treatment medicine না—psychosexual/couple intervention।

  • Psychoeducation: sexual response cycle, arousal, desire, orgasm নিয়ে clear explanation
  • Couple communication training: blame-free conversation
  • Sensate focus exercise: intercourse goal বাদ দিয়ে touch/intimacy rebuild
  • Scheduled intimacy time: pressure-free closeness
  • Performance anxiety CBT
  • Mindfulness-based sex therapy
  • Conflict resolution therapy
  • Treat depression/anxiety/trauma
  • Pain থাকলে penetration বন্ধ রেখে cause treat
  • Diabetes, HTN, obesity, smoking, alcohol control
  • Porn/performance comparison কমানো
  • Coercion/violence থাকলে safety plan + legal/psychological support

ISSWSH female sexual concern process of care guideline screening, education, basic management and referral approach দেয়। PE management-এ EAU patient education, treatment option discussion, ED থাকলে ED first/concomitantly treat, pharmacotherapy + behavioural therapy combination উল্লেখ করে।

9. Pharmacological Management — Bangladesh brand সহ

1. Sildenafil

  • Generic name: Sildenafil citrate
  • Therapeutic category: Drug for erectile dysfunction
  • Pharmacological class: PDE5 inhibitor
  • কেন used হয়: Relationship/performance anxiety-এর সাথে ED থাকলে erection achieve/maintain করতে। Sexual stimulation ছাড়া কাজ করে না।
  • Dose: 25–50 mg orally, intercourse-এর প্রায় 1 hour আগে; maximum 100 mg/day। Elderly, hepatic/renal impairment, CYP3A4 inhibitor থাকলে lower starting dose।
  • Duration: SOS use; 4–8 weeks পরে response, side effect ও relationship factor reassess।
  • Common side effects: headache, flushing, dyspepsia, nasal congestion, dizziness, visual tinting।
  • Important interaction/contraindication: nitrate/nitroglycerin/isosorbide/poppers-এর সাথে contraindicated; alpha-blocker, antihypertensive, ritonavir/strong CYP3A4 inhibitor-এ caution। DailyMed sildenafil label nitrate co-administration contraindicated বলে।
  • Bangladesh available brands: Vigorex 25/50 mg, Silagra 50/100 mg, Viamax 25/50/100 mg, Performax 50/100 mg, Panagra 50/100 mg, Viax 50/100 mg, Niagra 50/100 mg—availability pharmacy অনুযায়ী verify করতে হবে।

2. Tadalafil

  • Generic name: Tadalafil
  • Therapeutic category: Drug for erectile dysfunction; also BPH
  • Pharmacological class: PDE5 inhibitor
  • কেন used হয়: ED + performance anxiety, ED + BPH/LUTS থাকলে ভালো option; effect up to 36 hours।
  • Dose: On-demand 10 mg before sex; response অনুযায়ী 5–20 mg; maximum once daily। Daily regimen: 2.5–5 mg once daily। DailyMed tadalafil label ED starting dose 10 mg as needed এবং dose 20 mg পর্যন্ত increase বা 5 mg পর্যন্ত decrease করার কথা বলে।
  • Duration: SOS বা daily; 4–12 weeks পরে reassess।
  • Common side effects: headache, dyspepsia, back pain, myalgia, flushing, nasal congestion।
  • Interaction/contraindication: nitrate contraindicated; riociguat contraindicated; alpha-blocker/antihypertensive/alcohol/CYP3A4 inhibitor caution।
  • Bangladesh available brands: Adafil 10/20 mg, Ciaton 5/10/20 mg, Intimate 2.5/5/10/20 mg, Tada 5/10/20 mg, Tadafil 5/10 mg, Tadalis 10 mg, Tealis 5/10/20 mg, Nirvana 5/10/20 mg।

3. Dapoxetine

  • Generic name: Dapoxetine hydrochloride
  • Therapeutic category: PE medicine / sexual dysfunction medicine
  • Pharmacological class: Short-acting SSRI
  • কেন used হয়: Premature ejaculation—বিশেষ করে poor ejaculatory control, distress, interpersonal difficulty থাকলে।
  • Dose: 30 mg orally, sex-এর 1–3 hours আগে; inadequate response + tolerable side effects হলে 60 mg; maximum once/24 hours। MedEx dapoxetine monograph একই dose schedule দেয়।
  • Duration: 4 weeks বা কমপক্ষে 6 doses পরে response reassess; long-term need হলে specialist review।
  • Common side effects: nausea, dizziness, headache, dry mouth, diarrhea, insomnia।
  • Important interaction/contraindication: MAOI, thioridazine, SSRI/SNRI/TCA, serotonergic herbal/drug, alcohol, significant cardiac disease, moderate/severe hepatic impairment; PDE5 inhibitor ও alpha-blocker-এর সাথে orthostatic hypotension caution।
  • Bangladesh available brands: Susten 30 mg, Dumax 30/60 mg, Daxetin 30/60 mg, Maturex 30/60 mg, Dapoxen 60 mg, Prolong 30/60 mg, Dapotin 30 mg।

4. Lidocaine + Prilocaine cream

  • Generic name: Lidocaine 2.5% + Prilocaine 2.5%
  • Therapeutic category: Topical anesthetic; PE adjunct
  • Pharmacological class: Amide local anesthetic combination
  • কেন used হয়: Glans sensitivity কমিয়ে PE delay করতে; on-demand use।
  • Dose: Thin layer glans/penile tip-এ 10–20 minutes আগে; intercourse-এর আগে ধুয়ে ফেলতে হবে অথবা condom use করতে হবে, না হলে partner numbness হতে পারে।
  • Duration: SOS; 4–8 weeks পরে reassess।
  • Side effects: local burning, numbness, irritation, reduced pleasure; excessive use-এ systemic toxicity/methemoglobinemia rare।
  • Interaction/caution: large area, broken skin, G6PD deficiency, methemoglobinemia risk drug, severe liver disease—caution। Lidocaine/prilocaine cream genital mucous membrane–এ absorbed হতে পারে এবং excessive use-এ methemoglobinemia reported।
  • Bangladesh available brands: Emprila 2.5%+2.5%, Skisia 2.5%+2.5%。

5. Sertraline — off-label for PE / anxiety-depression

  • Generic name: Sertraline hydrochloride
  • Therapeutic category: Antidepressant; off-label PE management
  • Pharmacological class: SSRI
  • কেন used হয়: PE with anxiety, depression, performance anxiety বা chronic PE; ejaculation latency বাড়াতে পারে।
  • Dose: PE off-label: 25–50 mg daily; titrate 50–100 mg/day. Depression/anxiety: usually 50 mg/day, therapeutic range 50–200 mg/day।
  • Duration: PE trial 6–12 weeks; depression/anxiety হলে 6–12 months বা psychiatrist plan অনুযায়ী।
  • Side effects: nausea, insomnia/somnolence, sweating, diarrhea, delayed ejaculation, low libido, anorgasmia।
  • Interaction: MAOI/linezolid/tramadol/St John’s wort → serotonin syndrome risk; NSAID/warfarin → bleeding risk; other serotonergic drug caution।
  • Bangladesh available brands: Chear 25/50/100 mg, Repose 25/50/100 mg, Serolux 25/50/100 mg, Seronex 25/50/100 mg, Setra 25/50/100 mg, Sertal 25/50/100 mg।

6. Paroxetine — off-label PE / anxiety

  • Generic name: Paroxetine hydrochloride
  • Therapeutic category: Antidepressant; off-label PE
  • Pharmacological class: SSRI
  • কেন used হয়: PE delay effect তুলনামূলক বেশি; anxiety/depression থাকলে useful, কিন্তু sexual side effect বেশি।
  • Dose: 10–20 mg daily; PE-তে 20 mg/day commonly used; titrate cautiously।
  • Duration: 6–12 weeks trial; abrupt stop নয়, taper করতে হয়।
  • Side effects: low libido, ED, delayed orgasm, weight gain, sedation, sweating, withdrawal symptom।
  • Interaction: MAOI/serotonergic drugs, tramadol, linezolid, NSAID/warfarin; CYP2D6 inhibition—tamoxifen interaction clinically important।
  • Bangladesh available brands: Oxat 10/20 mg, Melev 20 mg, Panirid 20 mg, Parotin 10/20 mg।

7. Clomipramine — off-label PE

  • Generic name: Clomipramine hydrochloride
  • Therapeutic category: Antidepressant; off-label PE
  • Pharmacological class: Tricyclic antidepressant, serotonin reuptake inhibition prominent
  • কেন used হয়: PE delay; SSRI intolerant বা selected case-এ।
  • Dose: 15–25 mg on-demand 3–6 hours before intercourse অথবা 25 mg nightly; titration specialist-directed। EAU guideline clomipramine 15 mg on-demand trial data উল্লেখ করে এবং paroxetine/sertraline/fluoxetine/clomipramine dose ranges আলোচনা করেছে।
  • Duration: 4–8 weeks trial; cardiac risk থাকলে ECG consideration।
  • Side effects: dry mouth, constipation, urinary retention, sedation, orthostatic hypotension, QT prolongation, seizure risk, sexual dysfunction।
  • Interaction/contraindication: MAOI-এর সাথে contraindicated; acute MI recovery period contraindicated; other serotonergic drug/QT-prolonging drug caution।
  • Bangladesh available brands: Anafranil 25 mg, Clofranil 25 mg, Clopramin 25 mg, Timex 25 mg।

8. Testosterone therapy — only confirmed hypogonadism

  • Generic name: Testosterone gel / Testosterone undecanoate
  • Therapeutic category: Hormone replacement therapy
  • Pharmacological class: Androgen
  • কেন used হয়: Low libido/ED তখনই যখন symptoms + repeated low morning testosterone confirmed। Relationship conflict-এর জন্য testosterone দেওয়া যাবে না।
  • Dose:
    • Testosterone gel 1.62%: specialist-directed daily topical dosing
    • Testosterone undecanoate oral: preparation-specific dosing, meal with fat needed; endocrine/urology follow-up essential
  • Duration: 3–6 months trial with monitoring; then continue only if objective benefit + safe labs।
  • Monitoring: testosterone level, CBC/hematocrit, PSA/prostate risk, LFT, lipid, sleep apnea symptom, fertility plan।
  • Side effects: acne, oily skin, erythrocytosis, edema, gynecomastia, infertility/spermatogenesis suppression, prostate symptom worsening, mood change।
  • Contraindication/caution: prostate/breast cancer, high hematocrit, severe untreated sleep apnea, severe LUTS, uncontrolled heart failure, men wishing fertility। EAU guideline testosterone therapy male infertility বা fatherhood planning-এর ক্ষেত্রে ব্যবহার না করতে বলে।
  • Bangladesh available brands: AndroGel 16.2 mg/gm topical gel, Andriol TestoCaps 40 mg, Androcap 40 mg/112.5 mg।

9. Estriol vaginal cream — female dyspareunia/GSM

  • Generic name: Estriol vaginal cream
  • Therapeutic category: Drug for menopausal symptoms; female sex hormone; HRT
  • Pharmacological class: Estrogen
  • কেন used হয়: Postmenopausal vaginal dryness, thin vaginal epithelium, painful intercourse/GSM। Relationship issue থাকলেও pain থাকলে pain আগে treat করতে হবে।
  • Dose: Each applicator dose 0.5 mg estriol; initially daily for 3 weeks, পরে twice weekly maintenance—physician advice অনুযায়ী।
  • Duration: lowest effective dose; periodic gyne review।
  • Side effects: vaginal irritation/itching, discharge, breast tenderness, nausea, fluid retention, spotting/bleeding।
  • Contraindication/caution: unexplained vaginal bleeding, breast/ovarian/vaginal cancer suspicion/history, thromboembolism, stroke/MI, liver disease, pregnancy।
  • Bangladesh available brands: Femastin 0.1%, Gynest 0.1%, Ovestin 0.1%, SRT 0.1%。

10. Bangladesh doctors commonly prescription approach — practical list

A. ED predominant

  • Sildenafil 50 mg SOS বা Tadalafil 10 mg SOS
  • Why: erection initiation/maintenance improve
  • Must check: nitrate, cardiac risk, BP, diabetes, lipid, testosterone

B. PE predominant

  • Dapoxetine 30 mg SOS
  • Alternative/adjunct: Lidocaine-prilocaine cream
  • Chronic PE/anxiety: Sertraline / Paroxetine / Clomipramine off-label
  • Why: ejaculation latency বাড়ায়, control improve করে

C. Low libido predominant

  • Relationship therapy + depression/anxiety/medical cause treatment
  • Male: low testosterone confirmed না হলে testosterone নয়
  • Female: HSDD হলে gyne/sexual medicine specialist; menopause/GSM হলে vaginal estrogen

D. Painful intercourse

  • Lubricant + cause treatment
  • Postmenopausal GSM: estriol vaginal cream
  • Infection/pelvic pain/vaginismus থাকলে specific treatment + pelvic floor therapy

E. Performance anxiety

  • CBT/sex therapy first
  • Depression/anxiety diagnosis থাকলে SSRI/SNRI/bupropion/buspirone psychiatrist-directed; তবে SSRI নিজেই sexual dysfunction বাড়াতে পারে

11. Prevention — কীভাবে প্রতিরোধ করবেন

  • সপ্তাহে অন্তত ১ দিন blame-free relationship talk
  • Sex নিয়ে expectation আগে discuss করা
  • Foreplay ও non-penetrative intimacy maintain
  • Consent, comfort, pain—এই তিনটি আগে নিশ্চিত করা
  • Diabetes, BP, lipid, weight control
  • Smoking, alcohol, recreational drug বন্ধ
  • Regular exercise + sleep
  • Depression/anxiety early treatment
  • Porn/performance comparison কমানো
  • STI prevention: condom, testing, faithful relationship
  • Menopause/pelvic pain হলে early gyne consult
  • Partner violence থাকলে sexual therapy নয়—first safety

Overview / Summary

Relationship-related sexual dysfunction সাধারণত psychological + relational + biological factor মিলে হয়। Core treatment হলো couple communication, psychosexual therapy, CBT, medical comorbidity correction। Medicine শুধু specific diagnosis অনুযায়ী—ED হলে PDE5 inhibitor, PE হলে dapoxetine/topical anesthetic/selected SSRI, hypogonadism হলে testosterone, postmenopausal dyspareunia হলে vaginal estrogen।

Actionable Plan / Steps

  1. Problem phase identify করুন: desire, erection/arousal, ejaculation, orgasm, pain।
  2. Relationship factor assess করুন: conflict, trust, coercion, communication।
  3. Basic tests করুন: HbA1c, lipid, BP/BMI, TSH, prolactin, morning testosterone, STI test if indicated।
  4. Red flag exclude করুন: chest pain, nitrate use, genital ulcer/discharge, severe depression/suicide risk, violence।
  5. First-line: couple counselling + CBT/sensate focus + lifestyle correction।
  6. Drug choose করুন only diagnosis অনুযায়ী; PDE5 inhibitor/dapoxetine/SSRI/testosterone/estrogen self-start করা যাবে না।
  7. 4–8 weeks পরে response, side effect ও relationship improvement reassess করুন।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. Sections: Endocrinology, male reproductive endocrinology, erectile dysfunction, depression/anxiety-related sexual symptoms.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Sections: Endocrinology, psychiatry, sexual health, cardiovascular risk and diabetes-related ED.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Chapters: Male genital system, female genital tract, endocrine pathology.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Chapters: Reproductive physiology, hypothalamic-pituitary-gonadal axis, autonomic physiology.

Guidelines / Consensus

  1. WHO Sexual Health topic and working definition of sexual health.
  2. European Association of Urology. Sexual and Reproductive Health Guidelines, 2026 limited update.
  3. AUA Erectile Dysfunction Guideline, 2018. DOI: 10.1016/j.juro.2018.05.004.
  4. ISSWSH Process of Care for Identification of Sexual Concerns and Problems in Women, 2019. DOI: 10.1016/j.mayocp.2019.01.009.
  5. ISSWSH Testosterone for HSDD in Women Guideline, 2021. DOI: 10.1016/j.jsxm.2020.10.009.
  6. ISSWSH Process of Care for HSDD in Women, 2018. DOI: 10.1016/j.mayocp.2017.11.002.

Peer-reviewed DOI

  1. Reed GM et al. Disorders related to sexuality and gender identity in ICD-11. World Psychiatry. 2016;15(3):205–221. DOI: 10.1002/wps.20354.
  2. McCabe MP. Sexual dysfunction and relationship stress. Current Opinion in Psychology. 2017.
  3. Parish SJ et al. ISSWSH testosterone guideline. Journal of Sexual Medicine. 2021;18(5):849–867. DOI: 10.1016/j.jsxm.2020.10.009.
  4. Burnett AL et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633–641. DOI: 10.1016/j.juro.2018.05.004.

Md.Rafiqul Islam Lipu,Date:-01-06-2026 Monday, Time:-06-48-37 Pm

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