Sunday, November 2, 2008

Sexual Disorders & Dysfunction

Although the majority of sexual dysfunction probably has a physical basis it is fitting to mention some sexual disorders here because dysfunctions, whether mainly due to physical or psychological causes, can result in distress. For example,
the individual with a sexual disorder may suffer related anxiety and sexual frustration which in turn leads to insomnia, and that insomnia may be the presenting complaint to the GP. The individual's close relationships may suffer and tension may build up in the family as a whole.

According to DSM-IV (the American Psychiatric Association's classification system) there are a dozen or so sexual disorders. All have to cause marked distress or interpersonal difficulty to rate as disorders. A brief overview follows:

1. Hypoactive sexual disorder
A persistently reduced sexual drive or libido, not attributable to depression where there is reduced desire, sexual activity and reduced sexual fantasy.

2. Sexual aversion disorder
An avoidance of or aversion to genital sexual contact

3. Female sexual arousal disorder
A failure of arousal and lubrication/swelling response.

4. Male erectile disorder
Inability to gain an erection or inability to maintain an erection once it has occurred.

5. Female orgasmic disorder
A lengthy delay or absence of orgasm following a satisfactory excitatory phase. The GP must take into account the patient's age, previous sexual experience and adequacy of sexual stimulation.

6. Male orgasmic disorder
A lengthy delay or absence of orgasm following normal excitation, erection and adequate stimulation.

7. Premature ejaculation
Ejaculation occurring with only minimal stimulation, either before penetration or soon afterwards, in either case ceratinly before the patient wishes it. Again the GP must take into account the patient's age, previous sexual experience, extent of sexual stimulation and 'novelty' of the sexual partner.

8. Dyspareunia (not due to general medical condition)
Recurrent pain associated with intercourse, but in women not due to vaginismus, poor lubrication, and in women and men not due to drugs or other physical causes

9. Vaginismus
An involuntary or persistent spasm of the muscles of the outer third of the vagina, again not attributable to physiological effects of physical causes. Vaginismus may be
either lifelong or recent; generalised to all sexual encounters or specific to certain partners or situations.

10. Secondary sexual dysfunction
Dysfunction secondary to illness eg hypothyrodism, mental disorder eg depression, or drugs eg fluoextine.

11. Paraphilias
Exhibitionism (exposure of genitals to strangers). Fetishism (finding nonliving objects erotic eg women's underwear). Paedophilia. Frotteurism (fantasies, urges or behviour centred around rubbing self against non-consenting other). Sexual masochism and sadism. Transvestic festishism (cross-dressing for erotic pleasure). Voyeurism (fantasies, urges or behviour centred around watching non-consenting others undressing, or having sex).

12. Gender identity disorder
Strong and persistent identification of the self with another gender. Persistent dissatisfaction with own sex. Desire to participate in stereotyped games and pastimes of opposite sex. Preference for cross-dressing. May insist that they are
wrong sex. May occur in children, adolescents and adults, (Green, 1985). Not concurrent with physical intersex condition.

Table One: Physical Causes of Male Erectile Disorder

Illness and disease

* Alcoholism (neuropathy)
* Diabetes mellitus
* Arterial disease eg Leriche syndrome
* Renal failure
* Carcinomatosis
* Neurosyphilis
* Hypothalamo-pituitary dysfunction
* Liver failure
* Multiple sclerosis
* and many others


* Beta-blockers
* Thiazide diuretics
* Tricyclic antidepressants
* Phenothiazines
* Spironolactone
* Cimetidine
* Cannabis
* Anti-epileptics

Table Two: Physical causes of dyspareunia that would need to be excluded


* Failure of vaginal lubrication
* Failure of vasocongestion
* Failure of uterine elevation and vaginal ballooning during
* Oestrogen deficiency leading to atrophic vaginitis
* Radiotherapy for malignancy
* Vaginal infection e.g. Trichomonas or herpes
* Vaginal irritation e.g. sensitivity to creams or deodorants
* Abnormal tone of pelvic floor muscles
* Scarring after episiotomy or surgery
* Bartholin's gland cysts/abscess
* Rigid hymen, small introitus


* Painful retraction of the foreskin
* Herpetic and other infections
* Asymmetrical erection due to fibrosis or Peyronie's disease
* Hypersensitivity of the glans penis

How common are sexual disorders?

The majority of adults can recall times in their lives when they were troubled with low desire or problems with orgasms. Arousal difficulties increase with age. Sexual dysfunction may arise in the most well-adjusted and satisfied of couples. In 100 educated young couples Frank et al (1978) found that 50% of men had difficulties with erection, ejaculation or orgasm sometimes and 75% of women had problems with arousal or orgasm sometimes.

Table Three: Estimated lifetime prevalence of sexual problems in young adults (at some time).


* Reduced libido 40%
* Arousal difficulties 60%
* Reach orgasm too soon 10%
* Unable to have orgasm 35%
* Dyspareunia 15%


* Reduced libido 30%
* Arousal difficulties 50%
* Reach orgasm too soon 15%
* Unable to have orgasm 2%
* Dyspareunia 5%
(Source: Haas & Haas, (1993) Understanding Human

What can be done?

Given that these disorders are relatively common and that they can cause such distress it is a matter of concern that patients often feel they cannot talk to their doctors about such matters.

Treatments break down into two main kinds: behavioural psychotherapy and physical. The former is largely derived from the pioneering work of people like Masters &
Johnson. Masters & Johnson type therapy addresses the sexual problem itself directly using the couple as a co-operative unit in the here-and-now rather than delving into an individual's unconscious for details of their past life. Masters & Johnson sessions may involve a male and female co- therapists who
sit with the couple and discuss the couple's sexual education and involve a medical examination by separate medical staff. If the problem is thought to be primarily medical then physicians usually take over the treatment. Within further sessions the couple is given guidance, instruction, and 'homework' - sexually orientated activities which the couple practice in their own bedroom alone.

Masters & Johnson Techniques:

Giving and Receiving Partners take turns in giving and then receiving touch and massage, i.e. giving pleasure, without at first touching breast or genital areas. This giving and receiving exercise is called sensate focus.

The early prohibitions on touching and orgasm hopefully reduce the couple's anxiety level and re-educate them that mutual pleasure can be derived from simple touching. Some authors have written about how it is possible to prescribe sensate focus without prohibiting sexual intercourse,(Lipsius, 1987). In the sensate focus process
each partner may use the hand over technique where the others' hand is guided. The receiver puts his/her hand over the giver's to show where touch should be and what that touch should be like. This further improves communication and teaches the couple what they can achieve rather than what they can't achieve. Masturbation, either alone or together may form part of the programme as may also the squeeze
technique which is sometimes used to prevent premature ejaculation - in this the partner places their thumb just below the coroanl cleft of the glans and places her other fingers opposite. Gentle, firm pressure for about five seconds usually stops the ejaculatory urge. After a rest of a few minutes sexual activity can begin again. The squeeze technique can be repeated several times during lovemaking.

Accurate information, to dispel false ideas, can often be enough to resolve problems. Indeed such a simple, straightforward strategy will obviate the need for specialist input in many cases. Jack Anon's PLISSIT approach is a pragmatic example (1976). Anon, acknowledging that all couples are different and require tailored solutions described a four stage model. Some couples/individuals are seeking Permission from their doctor/therapist i.e. reassurance about their activities. Others will respond to Limited Information or Specific Suggestions and a few may
require Intensive Therapy. This four level approach advances with the patient(s) as necessary.

Low sexual interest has ben found to respond to the encouragement of sexual fantasy. Orgasm and arousal difficulties often respond to the sensate focus approach described above. Dyspareunia and vaginismus may also respond to senate focus, although is some cases of generalised vaginismus treatment may involve teaching the woman to insert her own fingers into her vagina, and after practice, when the
woman is comfortable she may use the hand- over technique to introduce her partner's fingers into her vagina, whilst relaxing. Ultimately progression to penile insertion is encouraged.

Physical treatments are much more in vogue than they were. Useful though they were seemed in the seventies and eighties, Masters & Johnson type therapy has been re-eavluated. Like many treatments and drugs the initial enthusiasm has
been tempered with time. Initially a success rate of 80% was quoted for their techniques, but further evaluation suggest that in the medium term such techniques bring benefit to about 50% of patients. The current opinion suggests that a
high proportion of sexuxal dysfunction is attributable to psychophysical causes rather than purely psychological ones. In other words a man may complain that he is impotent, but there are several aspects to his problem - there is the tension caused in his relationship with his partner because they can't have a certain kind of sex - there is anxiety about performing which reduces his ability to begin to have an erection and there is an underlying transient or permanent physiological difficulty with erection. Once the latter is treated and the man is able to see that he can have
intercourse again after all some of the secondary anxieties (which were also affecting performance) begin to be dispelled as well.

Possible physical treatments:
o Premature ejaculation fluoxetine / clomipramine
o Erectile difficulties intrapenile injections of papaverine
and prostaglandin, inflatable prosthetic penile implants, suction
devices, cockrings

Audit Points

As a doctor, estimate how often people come to see you with their sexual problems? Do you think that the majority of people who come tosee you about their sexual difficulties can talk to you? What can you do to make it easier for people to
talk to you about these issues? What local resources are there to help doctors treat sexual disorders? If the resources seem scarce or have exceedingly long waiting times is there anything that can be done about this?

Self- Assessment MCQs

1. In terms of sexual function:

A women taking benzodiazepines may experience delayed orgasm
B men taking fluoxetine may experience delayed ejaculation
C sexual interest can be reduced by benperidol
D chlorpromazine may cause galactorrhoea in women
E libido can be reduced by digoxin therapy

2. Useful treatments for:

A erectile dysfunction include intrapenile injections of dobutamine
B premature ejaculation include the squeeze technique
C homosexuality include electric shock therapy
D vaginismus include the 'stop-start' technique
E premature ejaculation include fluoxetine


1. All true.
2. A=F, B=T, C=F, D=F, E=T.

Useful Addresses

Institute of Psychosexual Medicine, 11, Chandos Street,
Cavendish Square, London, W1M 9DE. Tel: 0171-580-0631

Relate, Herbert Gray College, Little Church, Rugby, CV21
13AP. (Look in UK telephone directory for local address/telephone

References and further reading.

American Psychiatric Association, (1994). Diagnostic and
Statistical Manual of Mental Disorders. Fourth Edition (DSM-IV).

Bancroft, J. (1989) Human sexuality and its problems. 2nd
Edition. Edinburgh, Churchill Livingstone.

Covington, S. (1991) Awakening your sexuality. San Francisco,
Harper SanFrancisco.

Cranston-Cuebas, M A, Barlow, D H. (1990) Cognitive and
affective contributions to sexual functioning. Annual Review of Sex
Research. 1,119-162.

Fisher, R, & Brown S. (1988) Getting Together. Boston,

Frank, E, Anderson, C & Rubinstein D. (1978) Frequency of
sexual dysfunction in 'normal' couples. The New England Journal of
Medicine, 299, 111-115.

Green, R. (1985) Gender identity in childhood and later
sexual orientation: follow-up of 78 males. American Journal of
Psychiatry. 142, 339-341.

Haas, K & Haas, A, (1993) Understanding Human Sexuality,
St. Louis, Mosby.

Kinsey A C, Pomeroy W B, Martin C E (1948) Sexual behaviour
in the human male. Philadelphia, Saunders.

Kinsey A C, Pomeroy W B, Martin C E, Gebhard P H. (1953)
Sexual behaviour in the human female, Philadelphia, Saunders.

Lipsius, S H. (1987) Prescribing sensate focus without
proscribing intercourse. J-Sex-Marital-Ther. 13(2): 106-16

Masters W H, Johnson V E. (1970) Human sexual inadequacy.
London, Churchill.

Mathers, N, et al. (1994) Assessment of training in
psychosexual medicine. BMJ, 308, 969- 972.

Pollack-MH; Reiter-S; Hammerness-P (1992) Genitourinary and
sexual adverse effects of psychotropic medication.
Int-J-Psychiatry-Med. 1992; 22(4): 305-27

Walbroehl-GS (1987) Sexuality in the handicapped.
Am-Fam-Physician. 36(1): 129-33

Wyatt-GE; Peters-SD; Guthrie-D (1988) Kinsey revisited, Part
Comparisons of the sexual socialization and sexual behavior
of white women over 33 years. Arch-Sex-Behav.17(3): 201-39

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