- ‘Sexual dysfunction’ includes loss of sexual desire, painful sex, and problems with erection or orgasm.
- Stress, health problems and heavy drinking can contribute to sexual dysfunction.
- Psychological factors may be particularly relevant for people living with HIV.
- Help is available from doctors and psychologists.
A healthy sex life, intimacy and physical pleasure are important parts of your overall health. This should not change because of your HIV diagnosis. However, some people living with HIV find it difficult to enjoy a healthy sex life. Although sexual problems (often called sexual dysfunction) can be a problem for anyone at different times in their lives, studies show that people with HIV are particularly prone to them.
Four types of sexual problems are commonly reported. There may be:
- Problems with sexual desire: usually a loss of interest in sex.
- Problems with arousal: difficulties getting or keeping an erection or becoming relaxed and lubricated.
- Orgasm problems: not having an orgasm at all, taking a long time to have one, or rapid (premature) ejaculation.
- Pain during sex, which may cause avoidance.
Sexual difficulties may have a physical cause, but they may also be caused or aggravated by psychological, emotional and relationship factors. Often there is not a single cause for sexual difficulties, but rather a combination of factors may be involved.
Poor physical health, imbalanced hormone levels, heart and circulatory problems, smoking, being overweight, pregnancy, older age, and physical disability can all affect sexual desire and performance. Having an STI can cause pain and discomfort during sex.
Some medications can contribute to sexual dysfunction. These include some drugs taken to treat depression and other mental health conditions, drugs to treat high blood pressure, some forms of contraception, and opioid painkillers. Recreational drugs and alcohol can also contribute to sexual problems.
These may be particularly relevant for people living with HIV. There are specific psychological stressors linked to having HIV, such as the fear of transmitting it to others, the stigma surrounding the virus, concerns about discussing your status with others, and body image changes. These can potentially affect your feelings about sex.
Similarly, the way you feel about your body and sexuality, low self-confidence and poor self-image can all contribute to sexual difficulties.
Anxiety, depression, mood problems and the medications used to treat them can contribute to sexual difficulties (such as inability to reach orgasm).
Issues such as difficulty speaking about HIV with your partners, concerns about prevention and safety, trust issues, infidelity, and decreased intimacy can contribute towards sexual problems.
Whatever the problem, it is important to first talk to your HIV doctor or GP. They can rule out any other underlying health condition as the cause, and you can discuss what options there may be for treating problems.
It is important to seek out help that not only attends to the physical causes of sexual difficulties, but also considers psychological causes and consequences.
If you find that your sexual problems are present all the time and in all situations (for example, both with any sexual partner and when trying to masturbate alone) then it’s likely that physical factors, the effects of recreational drugs or alcohol, or taking certain medications could be responsible.
If, on the other hand, you find that your problems only emerge in certain circumstances, for example with a particular partner, or when you’re having sex in particular situations, then psychological or relationship factors are likely to be more important.
Where psychological causes contribute significantly to sexual problems, psychosexual or talking therapies, which allow you to talk through issues, can often help. These include counselling, cognitive behavioural therapy and psychotherapy.
Even if the primary cause of sexual problems is physical, talking therapies can reduce the associated psychological component. They may also help with HIV-related stigma, reducing anxiety related to sexual problems and fear of HIV transmission. Talking therapies are available through your HIV clinic or GP.
Specific sexual problems or situations
It is normal for vaginal lubrication to vary depending on your health, age, and where you are in the menstrual cycle. Using lubrication can help alleviate discomfort associated with vaginal dryness.
If you are taking testosterone and experiencing vaginal (or front hole) dryness or atrophy, lubrication can help, as will the application of topical oestrogen creams (which do not affect your testosterone levels).
Menopause is when you stop having periods and are no longer able to get pregnant naturally. It is a natural part of ageing that usually happens between the ages of 45 and 55. People with HIV may experience menopause a little earlier than those who are HIV negative.
Oestrogen and testosterone levels fall significantly during and after menopause and can cause a reduction in sexual desire. During and after menopause, the vagina becomes less flexible or elastic and the tissue becomes thinner. There is also reduced blood flow to the pelvic region. This can also lead to increased vaginal dryness and pain or discomfort during sex.
To relieve vaginal dryness and loss of libido, oestrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This releases a small amount of oestrogen (the equivalent of one hormone tablet a year) which raises local hormone levels but does not affect the whole body. Using a vaginal lubricant can also help with dryness.
Pain during receptive vaginal sex (or front hole sex)
If you are experiencing pain during sex, it is important to have a physical examination done by a clinician who has experience with sexual problems.
Discomfort or pain can occur for many reasons. Having an STI or other infection such as thrush (a yeast infection) or bacterial vaginosis can all cause discomfort or pain during sex. Injuries to the vagina or vulva, which can happen during childbirth or sexual assault, may cause pain or discomfort during sex.
"Sexual difficulties may have a physical cause, but they may also be caused or aggravated by psychological, emotional and relationship factors."
Pre-menstrual syndrome (PMS) is a collection of symptoms that many people experience a week or two before their period. You may experience changes in libido or increased discomfort during sex at this time. As noted above, physical changes to the body during menopause can cause discomfort, which may be treated by using lubrication or oestrogen supplements.
Some common disorders can lead to pain during sex. For example, polycystic ovary syndrome (PCOS) is a common disorder that can affect the menstrual cycle, hormones, and cause cysts to form on the ovaries. Endometriosis is a common and painful condition where the tissue that normally lines the uterus grows outside the uterus on the ovaries, fallopian tubes, or intestines.
Experiencing pain during sex can lead to increased anxiety or fear about having sex, because of the anticipation of discomfort. This fear or anxiety can lead to decreased arousal, performance anxiety, and vaginal dryness. Feeling or anticipating pain during sex can also lead to involuntary tightening of the vaginal muscles, known as vaginismus.
During and after pregnancy
Many people find that their sexuality is affected during pregnancy, after pregnancy in the postpartum period, or when breastfeeding (also known as chest-feeding). Sexual problems during this time can be caused by physical and hormonal changes after childbirth, concerns about body image, and psychological causes.
People who are having difficulties conceiving may experience sexual difficulties. This can be due to feelings and concerns about infertility, methods used to treat infertility (e.g. timed intercourse), medications used to treat infertility, and the psychological impact of infertility.
Problems with ejaculation
Some people report problems with ejaculation: either they ejaculate too quickly, or ejaculation is delayed or absent. Some things that can help with ejaculating too quickly include behavioural techniques, such as masturbating before sex or stopping sex right before orgasm. Using condoms or an anaesthetic cream or spray can also reduce sensitivity and help prevent premature ejaculation.
Many people with HIV have low testosterone levels (hypogonadism). This can be difficult to diagnose because some symptoms (such as loss of vitality, low sexual desire, low bone mineral density and loss of muscle mass) are less specific and can occur in HIV-positive people who have normal testosterone levels. Low testosterone is sometimes the cause of erectile dysfunction.
If you have low testosterone, testosterone replacement treatment may help with sexual problems, such as restoring sexual desire, improving erection quality and enhancing the effectiveness of erectile dysfunction medications. Erectile dysfunction medications may be helpful but not as effective if underlying hypogonadism is not treated.
Pressure to use condoms
Pressure to use condoms can have an impact upon sexual performance. Some people find that their penis is less sensitive to touch when using condoms, which may contribute to erectile dysfunction. Research has shown that men who experience sexual dysfunction may be less likely to use condoms, possibly for this reason. In this instance, knowledge about being undetectable, and therefore not being able to pass the virus on to others even when not using condoms, often comes as quite a relief. It is important for partners to discuss their feelings regarding condom use in order to ensure that sex is pleasurable, but also that both partners feel safe.
Erectile dysfunction (or impotence) is when you cannot get or keep an erection that enables you to have sex. Many people struggle with erectile dysfunction, especially as they get older. It is also more common in people with HIV than in the general population, although it has been difficult to estimate how many are affected. Research suggests that around 40 to 60% of men with HIV may experience some degree of erectile dysfunction.
There may be physical or psychological causes, or more frequently a combination of the two. Erectile dysfunction is often associated with conditions that affect blood flow in the penis, including diabetes, high cholesterol, high blood pressure, cigarette smoking, obesity and heart disease. Other factors commonly linked to erectile dysfunction include older age, low testosterone levels, alcohol or drug use, anxiety and depression.
Medications such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Spedra or Stendra) are used to treat erectile dysfunction. They work by increasing blood flow to the penis, making it more sensitive to touch. They do not primarily increase sexual desire and only work when you are sexually stimulated. These medications are usually the first-line medical treatment for erectile dysfunction and are effective for about 70% of people.
The medications vary in dosage, how quickly they start to work, how long they work for, and their side effects. Possible side effects include facial flushing, nasal congestion, headaches and indigestion.
There can be drug-drug interactions with other medications you take, potentially including anti-HIV drugs. When taken with ritonavir or cobicistat (boosting agents included in some HIV treatment regimens), levels of the erectile dysfunction medication may be increased, potentially leading to serious side effects. On the other hand, when taken with anti-HIV drugs that are non-nucleoside reverse transcriptase inhibitors (NNRTIs), levels of the erectile dysfunction drug may be lowered.
These drugs should also be taken with care if you are using ketoconazole, itraconazole or erythromycin (drugs used to treat some infections). In these instances, doses of sildenafil and other medications need to be modified or they may need to be avoided altogether.
The recreational drug ‘poppers’ should not be used with any erectile dysfunction medications as this could result in a potentially fatal drop in blood pressure.