The Anxiety by Level of Interference in Sexual Dysfunctions (ALI‑SD) framework
As clinicians we often observe that patients who present with sexual dysfunction commonly exhibit multiple concurrent forms of anxiety. Sexual performance anxiety, sexual phobia, sexual distress, attachment insecurity, and somatic symptom disorder are only some of the anxieties patients may present. For example, an individual with erectile dysfunction may experience anxiety specifically during partnered intercourse (sexual performance anxiety), while also displaying features of an anxious attachment style. Would the treatment for this patient’s performance anxiety differ from the approach for someone who has performance anxiety but a secure attachment style? Similarly, a woman with painful intercourse may have an intense fear of penetration (sexual phobia), persistent rumination and shame about being “broken” (sexual distress), and repeated medical consultations driven by conviction of an undetected physical cause (somatic symptom disorder). Would treatment of the phobia be the same if sexual distress and somatic preoccupation were absent? Is the management of one anxiety type influenced by the co‑occurrence of other types? How does treating one anxiety type affect the course of the others? How should clinicians prioritize treatment goals? These are frequent clinical questions; yet, research has most often examined anxiety types in isolation.
The Anxiety by Level of Interference in Sexual Dysfunction (ALI‑SD) conceptual framework organizes sex‑related anxiety according to the degree to which it interferes with the patient’s life.
The framework distinguishes three levels at which anxiety may interfere.
Level I — Anxiety interferes with a specific sexual situation
Definition: Anxiety tied to discrete sexual situations, triggered by identifiable stimuli; intensity is typically acute and perceived as threatening in those specific contexts.
Examples: sexual performance anxiety (e.g., anxiety that arises only when approaching partnered sexual activity); sexual phobia (e.g., fear of penetration).
Clinical note: Resolution often follows removal or modification of the eliciting situation or by situation‑focused interventions.
Level II — Anxiety interferes with one’s sexual life
Definition: Anxiety that disrupts broader aspects of sexual expression and interpersonal sexual life, extending beyond single events to affect multiple sexual contexts and relationships.
Examples: sexual distress linked to dysfunction; attachment insecurity manifesting in sexual behaviour (for example, pursuing sex to alleviate fear of abandonment rather than for sexual pleasure).
Clinical note: At this level, anxiety affects overall sexual expression and frequently involves relational patterns that maintain the problem.
Level III — Anxiety interferes with one’s life
Definition: Anxiety triggered by a sexual problem that extends beyond sexual scenarios and disrupts daily functioning across multiple life domains.
Examples: sex‑related somatic symptom disorder; obsessive sexual worries that interfere with sleep, work, or other functions.
Clinical note: Interference at this level is broad and may require interdisciplinary psychiatric and medical management.
Operational use of the framework
Clinicians should routinely screen for cues indicative of multiple anxiety types and assess their impact on the three levels: (a) specific sexual situations, (b) the patient’s overall sexual life, and (c) broader life functioning. The framework guides systematic intake, case formulation, and selection of level‑appropriate interventions.
Managing multiple types of anxiety
When multiple anxiety types are present, clinicians must determine priorities collaboratively with the patient. Considerations include the pervasiveness of each problem element, the expected effects of treating each element on other elements, the availability of treatment resources, and patient preference. Practical recommendations include:
- Work collaboratively to prioritize treatment targets rather than apply a single standardized approach. Gather comprehensive intake information and agree with the patient on priorities.
- Consider sequencing and combined approaches. When Level III psychiatric or somatic preoccupation is prominent, psychiatric stabilization and treatments for somatic symptom presentations may be required prior to or concurrently with sex‑therapy interventions. When Level I performance anxiety coexists with Level II attachment insecurity, combine situational behavioural techniques with relational or attachment‑focused work.
- Recognize that unresolved anxiety at broader levels may undermine focused interventions; interactions among levels should inform the treatment plan and ongoing reassessment.
Future research could investigate:
- Whether different sexual anxieties are distinct or overlapping constructs and the extent to which they share common risk and maintenance factors (for example, anxiety sensitivity and intolerance of uncertainty).
- The optimal sequencing and integration of treatments when multiple anxiety types co‑
- The need for prospective and interventional studies (including randomized trials) to determine causal sequencing among anxiety types and to test whether targeting one anxiety domain produces spillover benefits to others.
Recognition of multiple sexual anxieties and their differing clinical implications is necessary for tailored assessment and treatment. The ALI‑SD framework provides a structured method to map anxiety according to the level of interference—specific sexual situations, one’s sexual life, or broader life functioning—facilitating targeted intervention and collaborative prioritization.
This blog post is based on the work of Evie Kirana, Marieke Dewitte, Jaques van Lankveld and David Rowland. It is published as an ESSM statement position paper:
Kirana PS, van Lankveld JJDM, Dewitte M, Rowland DL. Different faces of anxiety in sexual dysfunction: key features, effective interventions, and critical implications for health care professionals-ESSM position statements. Sex Med. 2025 Dec 8;13(6):qfaf097. doi: 10.1093/sexmed/qfaf097. PMID: 41367643; PMCID: PMC12684971.
