• Background factors: anxiety or ignorance about sex, past experience of sexual abuse, general disharmony between the couple concerned, a constitutional discrepancy in sex drive between the two partners, or a lack of physical attraction between them.

• Ageing: sexual drive and performance in both sexes decrease with age, although the decline is more marked in males. For example, the prevalence of erectile dysfunction in men is about 2 per cent at age 40, and 25-30 per cent at age 65.

• Psychiatric illness: most psychiatric illnesses, especially depressive illness and anxiety states, reduce sexual drive, performance, and pleasure. The exception is mania, in which sexual interest and activity increase.

• Organic brain disease: the dementias, and lesions of the frontal lobe may produce sexual disinhibition.

• Genital and pelvic pathology: for example, congenital abnormality, infection, and injury to the genitalia or spinal cord.

• Endocrine and metabolic disorders: for example, diabetes, sex hormone deficiency, hyperprolactinaemia, hypertension, arteriosclerosis, and renal failure.

• Drugs: psychotropic drugs, especially antidepressants and neuroleptics, may affect sexual function and so may many of the drugs used in general medicine, such as antihypertensives and diuretics. The most common culprits are SSRIs, which frequently reduce libido and/or produce anorgasmia in both sexes.

• Alcohol: impaired sexual function may result from intoxication, peripheral neuropathy, disturbed sex hormone metabolism due to cirrhosis of the liver, marital conflict, or treatment with disulfiram.

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