Psychiatric Medicine II
The Sexual Disorders
Meg Kaplan, Ph.D.
I. Introduction
Human sexuality is important to the well-being and health of
individuals of all ages. The World Health Organization has defined sexual
health as “the integration of the somatic, emotional, intellectual and social
aspects of the sexual being.”
Individuals also of all ages have sexuality concerns and questions; it is
often their physicians to whom they turn for answers.
As individuals, we all hold our own set of personal values, attitudes,
and beliefs regarding “appropriate” sexual behavior. The physician should be
aware of these values, and how they may affect patient care. There is
enormous cross-cultural diversity; it is important to respect differences in
sexual norms and mores across cultures, religious and ethnic groups, and life
stages.
Ideology also affects how sexual issues and problems are approached.
Biological, socio-cultural, political, religious beliefs and therapeutic
perspectives all interact with each other. At different stages of a person’s life,
one or more of these may assume greater importance.
Because sexuality is a major part of life, when there is a problem, there is
usually great concern. However, patients are generally uncomfortable in
bringing up their sexual issues. Therefore, part of the physician’s role is to
inquire about sexual functioning and satisfaction. The ease with which the
physician models comfort in discussing sexual issues will help give the patient
permission to feel more relaxed. Assurances of confidentiality and normalizing
any patient anxiety can help set a more relaxed tone.
Part of the physician’s role is to assist her/his patient in adapting to and
coping with life experiences that have impacted on sexuality. For example, it is
important to inquire as to sexual functioning satisfaction when seeing a patient
for a physical exam or if the patient has medical illness which might affect
sexual functioning (e.g., diabetes or has undergone a medical procedure which
may impact on a person’s body image (such as mastectomy). This can be
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accomplished by the physician being: 1) informed; 2) asking questions about
sexual functioning in a non-judgmental, accepting manner, 3) listening to the
patient; and 4) making recommendations and referrals when appropriate.
The physician might ask: “Are you having any sexual difficulties or
concerns?” or have there been any major changes in your sexual functioning or
satisfaction?”
If the patients answers “yes” then it is appropriate to take a more
detailed history to determine if a referral is needed.
II. The Sexual Dysfunctions
Definitions of sexual function and dysfunction are influenced by current
values, social belief and knowledge. For example, in the 18th century,
masturbation was condemned. Currently it is considered “normal” and even
prescribed as part of sexual therapy.
The current medical classification scheme for sexual dysfunctions (DSM
IV) divides women’s and men’s sexual problems into 4 categories; sexual desire
disorders, sexual arousal disorders, orgasmic disorders and sexual pain
disorders. Masters and Johnson first developed this classification in the 1960’s
who described a normative sexual response pattern, which proceeds
sequentially from sexual drive through stages of desire, arousal and orgasm.
However, the above approach to diagnosis tends to focus on physiological or
behavioral dysfunctions. That is, individuals may be “dysfunctional”, but they
are not necessarily dissatisfied! Sexual health involves more than just intact
physiology and functioning. Relational aspects of sexuality often affect sexual
satisfaction i.e., desire for intimacy, and subjective feelings about a partner.
Therefore, sexologists have begun to develop a more integrated approach that
builds in attention to psychosocial factors and recognizes the complexity of the
relationship between desire, arousal and orgasm.
Sexual problems may be characterized as:
1. Primary (lifelong) or secondary (acquired)
2. Generalized (occurring with all partners and in all sexual situations) or
situational (occurring only with certain partners or in certain situations)
Etiology
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A. Multiple factors in client history. Sexual problems result from multiple
factors:
1. Predisposing factors (such as diabetes or childhood sexual trauma)
2. Precipitating or triggering factors (such as loss of job or love)
3. Maintaining factors (such as heavy drinking or domestic strife)
4. Lack of information or misinformation (myths)
5. Guilt and anxiety
B. Causes of sexual problems may be determined to be:
1. Medical of biological (hormone change)
2. Psychological (depression or anxiety)
3. Related to social context (communication failure in a marriage)
Assessment of sexual problems includes:
A. Detailed Sexual History
B. Sexual Inventories
C. Psychophysiologic Assessment
NPT − NOCTURNAL PENILE TUMESCENCE
UROLOGICAL OR GYNECOLOGICAL EVALUATION
Differential Diagnosis:
Patients presenting with a sexual dysfunction should be medically
evaluated by a gynecologist or urologist to rule out treatable organic etiologies.
There may be local diseases of the genitals, endocrine disorders, vascular
illness, neurological diseases, or systematic illness. The patient should always
be asked about medications including over the counter medicines as well as
illegal drugs.
Annon (1974) provides an overview of a model for treating sexual
dysfunctions. This model is labeled the PLISSIT model:
P= PERMISSION
LI= LIMITED INFORMATION
SS= SPECIFIC SUGGESTIONS
IT= INTENSIVE THERAPY
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P = Some patients who enter counseling are seeking permission to engage or
not engage in sexual behavior. Examples would be self exploration,
masturbation or permission in terms of acceptable behavior.
LT = Is useful in helping some individuals resolve their sexual problems, such
as the importance of foreplay for vaginal lubrication in women.
SS = Other individuals are in need of specific suggestions, such as the use of
specific lubricants or homework activities to enhance physical control or
sensation.
IT = Finally, some patients are in need of intensive therapy to help them deal
with their sexual problems.
Types of sexual dysfunctions
Women’s commonly reported sexual problems are:
- Anorgasmia – the inability to experience orgasm
- Vulvadynia – a general painful vulvar condition that interferes with
sexual satisfaction, which has multiples causes.
- Lack of desire - The relational context of sexuality is extremely
important for women. In a recent survey by Ellison and Ulbergeid (2000), the
top 3 items women associated with satisfying sex in an ongoing relationship
were “feeling close to my partner before sex, emotional closeness after sexual
activity, and feeling loved.” In general, women need to feel good about
themselves to feel satisfied sexually, and associate sexual satisfaction in an
ongoing relationship with closeness, love, acceptance and safety.
Men’s commonly reported sexual problems are:
- erectile dysfunction
- premature ejaculation
- lack of desire
Treatment
A strength of sex therapy has been its ability to treat specific sexual
problems quickly and effectively, as compared to traditional psychotherapy.
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In general, sex therapy treats the specific symptoms and mechanical
problems very effectively. Critics have claimed that sex therapy is too genital
and goal oriented. In addition, currently, an emphasis is on medical and
pharmacological interventions.
TREATMENT STRATEGIES FOR SEXUAL PROBLEMS
THE PRESCRIPTION OF BEHAVIORAL TASKS
Insight has traditionally been viewed as the most powerful agent of
change in psychotherapy. Insight is useful, but not sufficient in overcoming
specific sexual problems. The judicious integration of carefully selected
behavioral tasks augments and facilitates treatment.
Behavioral tasks are employed to (1) overcome performance anxiety. (2)
aid with diagnostic assessment and clarification of underlying dynamics, (3)
alter the previous destructive sexual system, (4) confront resistances in each
partner, (5) alleviate couple’s anxiety about physical intimacy, (6) dispel myths
and educate patients regarding sexual function and anatomy, (7) counteract
negative body image concerns, and (9) heighten sensuality.
Techniques that have been successfully used in treating sexual dysfunction
are:
Systematic Desensitization: A procedure to eliminate maladaptive anxiety.
Sensate focus: Behavioral exercises are frequently employed to help patients
achieve the three requirements necessary for a good sexual life-willingness,
relaxation, and sensuality. Masters and Johnson developed these structured
exercises to heighten sensuality and arousal, while minimizing performance
demands.
Behavioral Rehearsal: A special form of the role-playing, which enables the
client to practice certain situational behaviors with the clinician before
engaging in such behaviors in an actual situation.
Guided Imaging: A covert procedure designed to increase the probability of
the occurrence of a certain behavior that the client wishes to engage in, but is
anxious about doing so.
Restructuring Belief Systems / Cognitive-Behavioral Therapy
Medical Interventions Used
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- Drug therapy
- Mechanical devices
- Other surgical interventions
In addition to the previous mentioned treatment, for many individuals
or couples more intensive therapy is required to help them understand why
they continue to have sexual problems. These include:
- Increasing self awareness
- Enhancing sexual experiences through improved communication
and skills
- Reducing anxiety
- Expanding sexual scripts or repertoires
- Encouraging erotic responses
B. PARAPHILIAS
Historically, paraphilias were termed perversions. Paraphiliac disorders
are characterized by repetitive or preferred sexual fantasies or acts that
involved non-human objects or nonconsenting partners. In order to make the
diagnosis of a paraphilia, the fantasies must have existed for at least six-
months, and the person should have either acted on the fantasies or suffered
serious distress because of them. There are numerous categories of paraphilias,
including:
Exhibitionism: Involves exposing the genital to an unsuspecting stranger.
Exhibitionists may expose their genitals to children, adolescents or adults, and
in some cases may masturbate while exposing their genitals.
Frotteurism: A frotteur is an individual who achieves sexual gratification by
rubbing up against a nonconsenting person. The behavior usually occurs in
crowded places, such as elevators, bus, or subways.
Fetishism: The sexual attraction is to inanimate objects and these often include
woman’s clothing, such as shoes, stockings or undergarments. Or, person can
be attracted to a specific body part. Usually, the person with a fetish fondles
the article to which he or she is attracted, to achieve sexual gratification.
Pedophilia: The sexual arousal to prepubescent children. Some pedophiles are
exclusively attracted to girls or boys while other pedophiles, termed bisexual
pedophiles, do not discriminate in their attraction, and might sexually molest
both male and female children.
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Sexual Sadism: A sexual sadist is an individual who is sexually aroused by
inflicting pain or suffering on another person. There can be an escalation in the
severely of the maltreatment of the victim over time.
EPIDEMIOLOGY
The majority of individuals who experience paraphilias are male in
gender. About 50% of the people with paraphilias experience the development
of the paraphilic disorder in adolescence. Furthermore, it is not unusual for the
person to develop two or more paraphilias. The majority of people may have
both a paraphilic and non paraphilic, (nonsexually deviant) arousal pattern at
the same time. An individual who has paraphilia is rarely distressed by the
paraphilia and when this person presents for an evaluation or treatment, it is
usually because of sexual partner or criminal justice system has recommended
or mandated that an evaluation and /or treatment be given. This is
particularly true of individuals who are pedophiles or ephebophiles (engage in
sexual activity with those of pubertal age). The reason for this is that the
individual with a paraphilia, in the majority of cases, finds the fantasies and
behavior exciting and rewarding, and does not want to give up what he or she
finds to be sexually exciting.
Historically, it was believed that an individual would have only one
type of paraphilia. However, recent studies have indicated that it is not
uncommon for individuals to have more than one form of paraphilia. Also, in
some cases, there can be an escalation. For example, some exhibitionists also
molest children or rape adult women.
Information on what percentage of male and female paraphilias in the
United States is lacking. These data are difficult to obtain because not all
people who have paraphilias are forthcoming in discussing their sexual
atypical interests.
In making the diagnosis of paraphilia, it is important for the clinician to
remember that not all forms of inappropriate sexual behavior are the result of a
paraphilic interest patter. For example, a patient with a psychosis may, as part
of his delusional system, engage in sexual activity that he might not ordinarily
engage in. On occasion, individuals who are diagnosed as manic may become
hypersexual and engage in forms of paraphilic behavior. Once the mania is
treated pharmacologically, the inappropriate behavior may cease.
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Clinical Course and Prognosis
Various forms of treatment have been defined in the psychological and
psychiatric literature for the treatment of individuals with paraphilias. These
treatments can be grouped into biological treatment, psychodynamic
treatment, and a variety of behavioral therapies.
Recent treatment methodologies that have shown the greatest promise are:
1. Cognitive Behavioral Therapy
Comprehensive Cognitive-behavioral Therapy Program for sex
offenders generally includes components in the following areas: (a) behavior
therapy to reduce inappropriate sexual arousal and to enhance or maintain
appropriate sexual arousal, (b) training to develop or to enhance prosocial
skills, (c) modification of distorted cognitions and development of victim
empathy, and (d) relapse and development to enhance maintenance of
treatment gains.
2. Behavior Therapy
The primary goal of behavior therapy is to teach patients techniques that
they can employ to decrease and/or to control their deviant sexual urges and
behaviors. A number of behavior therapies have been developed or adapted
for use with sexual offenders, including electrical aversion, olfactory aversion,
covert sensitization, various masturbatory reconditioning techniques, modified
aversive behavioral rehearsal, and imaginal desensitization training.
3. Medication Therapy
Anti-androgenic medication has been utilized with paraphilias. Their
mechanism of action is, to decrease testosterone, upon which sexually
motivated behavior depends, and thus libido or the sexual drive. This
consequently diminishes the individual’s pattern of compulsive paraphilic
behavior. Once the medication is discontinued, sexual drive returns.
Consequently, it is important that the patient also receive other forms of
therapy that will help redirect their sexual interests.
The main anti-androgens currently in use are the gonadotropin releasing
hormone analogues that are also used for a broad range of other illnesses,
including prostatic cancer, endometriosis and premature onset of puberty.
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The serotonin re-uptake inhibitors are a class of antidepressants that
have also been used with success to treat hypersexual states.
Paraphilic behavior is frequently accompanied by antecedent anxiety,
depressive symptoms or obsessive-compulsive disorder.
In addition, paraphiliacs have been treated with antipsychotics,
antianxiety agents, lithium, and antidepressants, but placebo-controlled studies
demonstrating efficacy are lacking.
Clinical research studies have demonstrated that treatment interventions
utilizing a multicomponent approach have relatively high success rates in
treating individuals who have paraphilias. Not only are such treatments
effective in teaching individuals who have paraphilic behavior and thereby
reducing future victimization, but also they are also cost-effective. For every
individual who is successful treated, there are tens if not hundreds of people
who needs to focus on early identification of individuals at risk of developing
paraphilias as well as developing new forms of interventions, because there is
no intervention that is effective in 100% of the cases.
REFERENCES
BOOKS FOR PROFFESIONALS
Wincze, J. and Carey M. Sexual Dysfunction: A Guide for Assessment
and Treatment. New York, Guilford Press, 1991.
Annon, J.: The Behavioral Treatment of Sexual Problems. Honolulu,
Hawaii: Kapiolani Health Service, 1974.
Leiblum, Sandro & Rosen, Raymond, eds. Principles and Practice of Sex
Therapy: Update for the 1990s. New York: Guilford Press, 1989.
Leiblum, Sandra & Rosen, Raymond, eds. Sexual Desire Disorders. New
York: Guilford Press, 1988.
Lipiccolo, J. & Lopiccolo, L. (eds.) Handbook of Sex Therapy. New
York: Plenum Press, 1978.
Abel, G.G., Osborn, C., Anthony, D., Gardos, P. (1992) Current treatment
of paraphiliacs. Annual Review of Sex Research. Vol. 111, 255-290.
Psychiatric Medicine II—Sexual Disorders—Meg Kaplan, Ph.D. Page 10
Fall 2005
Marshall, W.L., Laws, D.R., H.E., Eds. (1990). Handbook of Sexual
Assault: Issues, Theories and Treatment. Plenum Press, New York.
BOOKS FOR PATIENTS
Barbach, Lonnie. For Yourself: The Fulfillment of Female Sexuality.
Garden City, New York: Doubleday, 1975.
Heiman, Julia & LoPiccolo, Joseph. Becoming Orgasmic: A Sexual
Growth Program for Women. Englewood Cliffs, New Jersey: Prentice-Hall,
1988.
Zibergeld, Bernard. Male Sexuality: A Guide to Sexual Fulfillment.
Boston: Little Brown & Co., 1978
Kaplan, Helen Singer. PE: How To Overcome Premature Ejaculation.
New York: Brunner/Mazel, 1989
Barbach, Lonnie Garfield. For Each Other: Sharing Sexual Intimacy.
Anchor Press/Doubleday, 1982
Comfort, A. (Ed.) The New Joy of Sex. New York: Crown Publishers,
1991
Snarch, D. Passionate Marriage: Love, Sex and Intimacy in Emotionally
Committed Relationships. Henry Halt and Co. 1998
Kaschak, E., Tiefer, L. (Eds.) A New View of Women’s Sexual Problems.
New York: Haworth Press, 2001
