Sexology
Chapter 17
Sexual disorders and sex therapy

Sexual disorders cause a great deal of psychological distress to the individuals troubled by them and to their partners.
Sexual disorder: a problem with sexual response that causes a person mental distress.
This is a continuum.

• Lifelong sexual disorder: a sexual disorder that has been present ever since the person began sexual functioning.
• Acquired sexual disorder: a sexual disorder that develops after a period of normal functioning

Kinds of sexual disorders

Desire disorders

Sexual desire: an interest in sexual activity, leading the individual to seek out sexual activity or to be pleasurably receptive to it.

Hypoactive sexual desire (HSD): a sexual disorder in which there is a lack of interest in sexual activity.
Found in both men and women.
Too little sexual desire is the most common sexual issue reported by women.
But, there are also many circumstances when it is normal for a person’s desire to be inhibited.
The problem is not the individual’s absolute level of sexual desire but a discrepancy between the partners’ levels.
Discrepancy of sexual desire: a sexual disorder in which the partners have considerably different levels of sexual desire.

Female sexual interest/arousal disorder: a diagnosis in the DSM-V that encompasses lack of interest in sexual activity and absent or reduced arousal during sexual interactions.
The diagnosis is limited to women.

Arousal disorders

Female sexual arousal disorder

Female sexual arousal disorder: a sexual disorder in which there is a lack of response to sexual stimulation, including lack of lubrication.
Involves both a subjective, psychological component and a physiological element.
Problems with lubrication become more frequent after menopause.

Erectile disorder

Erectile disorder: the inability to have or maintain an erection.
One result is that the man cannot engage in sexual intercourse.

• Lifelong erectile disorder
  Cases of erectile disorder in which the man has never had an erection sufficient to have intercourse
• Acquired erectile disorder
  Cases of erectile disorder in which the man at one time was able to have satisfactory erections but can no longer do so.

Psychological reactions to erectile disorder may be severe.

Orgasmic disorders

Premature ejaculation

Premature ejaculation (PE): a sexual disorder in which the man ejaculates too soon and thinks he cannot control when he ejaculates.

In practice it is difficult to specify when a man is a premature ejactulator.

• Ejaculation that always or almost always occurs prior to or within one minute of vaginal penetration
• The inability to delay ejaculation
• Distress about the problem

A common problem in the general male population.
The great majority probably never seek therapy for the problem, either because it goes away by itself or because they are too embarrassed.

Premature ejaculation may create a web of related psychological problems.
Rapid ejaculation can cause a man to become anxious about his sexual competence.
The partner may also become frustrated because she or he is not having a satisfying sexual experience either.
The condition may create friction in the relationship.

Delayed ejaculation

Delayed ejaculation: a sexual disorder in which the man cannot have an orgasm, even though he is highly aroused and has had a great deal of sexual stimulation.
The severity of the problem may range from only occasional problems with orgasming to a history of never having experienced an orgasm.
In the most common version, the man is incapable of orgasm during intercourse but may be able to orgasm as a result of hand or mouth stimulation.

These problems are rare.
It is a frustrating experience.

Female orgasmic disorder

Female orgasmic disorder: a sexual disorder in which the woman is unable to have an orgasm.
May be classified into lifelong and acquired.

Situational orgasmic disorder: a case of orgasmic disorder in which the woman is able to have an orgasm in some situations, but not in others.

Common among women.
Because the pattern of situational orgasmic disorder is common, some experts consider it to be well within the normal range of female sexual response.

Pain disorders

Painful intercourse

Dyspareunia: painful intercourse.
Genital pain experienced during intercourse.
Persisted dyspareunia is not very common.

Dyspareunia decreases one’s enjoyment of the sexual experience and may even lead one to abstain from sexual activity.

Painful intercourse may be related to a variety of physical factors.
It often triggers other serious problems with sexual functioning, which in turn can create relationship problems.

Genito-pelivic pain/penetration disorder: the term in DSM-V for pain during sex (dyspareunia) or vaginismus, which tend to go together.

Vaginismus

Vaginismus: a sexual disorder in which there is a spastic contraction of the muscles surrounding the entrance to the vagina, in some cases so severe that intercourse is impossible.

Vaginismus and dyspareunia are often associated.
If intercourse is painful, one result may be spams that close off the entrance to the vagina.

Not very common.
Women are more likely to seek treatment for it than for other disorders, because it can make intercourse impossible, creating enormous difficulties in a couple’s relationship.

What causes sexual disorders?

There are many causes of sexual disorders, varying form person to person and form one disorder to another.

• Physical factors
• Drugs
• Individual psychological factors
• Combined cognitive and physiological factors
• Interpersonal factors

Physical causes

Organic factors or sexual disorders: physical factors, such as disease or injury, that cause sexual disorders.

Erectile disorder

Diseases associated with the heart and the circulatory system are particularly likely to be associated with erectile disorder, since erection itself depends on the circulatory system.
Any kind of vascular pathology can produce erection problems.

Erectile disorder is associated with diabetes mellitus.
It may be one of the earlies signs of diabetes.
Also associated with sexual disorders in women.

Hypogonadism: an underfunctioning of the testes so that testosterone levels are low.
Associated with erectile disorder.
Hyperprolactinemia: excessive production of prolactin.
Also associated with erectile disorder.

Any disease or injury that damages the lower part of the spinal cord may cause erectile disorder.
That is the location of the erection reflex centre.

Erectile disorder may result from severe stress or fatigue.
And some kinds of prostate surgery may cause the condition.

With erectile disorders, the distinction between organic causes and psychological causes is an oversimplification.
Many sexual disorders result form a complex interplay of the two causes.

Premature ejaculation

More often caused by psychological than physical factors.
But in cases of acquired disorder, physical factors may be involved.

A local infection may be the cause.
Or degeneration in the related parts of the nervous system.

It may also be evolution of the fastest.

Delayed ejaculation

May be associated with a variety of medical or surgical conditions

• Multiple sclerosis
• Spinal cord injury
• Prostate surgery

Most commonly, it is associated with psychological factors.

Female orgasmic disorder

Causes

• Severe illness
• General ill health or extreme fatigue
• Injury to the spinal cord

Most cases are caused by psychological factors.

Painful intercourse or vaginismus

Dyspareunia in women is often caused by organic factors

• Disorders of the vaginal entrance
• Disorders of the vagina
• Pelvic disorders

Painful intercourse in men can also be caused by a variety of organic factors.

• For an uncricumcised man, poor hygiene
• An allergic reaction to spermicidal creams or latex
• Various prostate problems

Vaginismus is sometimes caused by painful intercourse

Drugs

Some drugs may have side effects that cause sexual disorders.

Alcohol

The effects of alcohol on sexual responding vary considerably.
Three categories

• Short-term pharmacological effects
• Expectancy effects
  Many people have the expectation that alcohol will loosen them up, making them more sociable and sexually uninhibited.
  These expectancy effects produce increased physiological arousal and subjective feelings of arousal
  • Expectancy effects interact with the pharmacological effects and work mainly at low doses
  • At high dosage levels, alcohol acts as a depressant and sexual arousal is suppressed
• Long-term effects of chronic alcohol abuse
  Alcoholics often have sexual disorders
  • Chronic alcoholism in men can cause disturbances in sex hormone production because of atrophy of the testes
  • Chronic alcohol abuse generally has negative effects on the person’s interpersonal relationships, which may contribute to sexual disorders

Illicit or recreational drugs

The effects of marijuana are limited.

• In women
  Low doses of cannabis are associated with increased sexual desire and sexual pleasure
  At higher doses, it creates sexual problems
• In men
  Moderate doses appear to increase sexual desire while at the same time creating erection problems

Cocaine

• Is said to
  Increase sexual desire
  Enhance sensuality
  Delay orgasm
• Chronic use is associated with
  Loss of sexual desire
  Orgasmic disorders
  Erectile disorders
• The most negative effects on sexual functioning occur among those who inject the drug

Stimulant drugs, amphetamines, are associated with increased sexual desire and arousal in some studies.

Crystal methamphetamine is of particular concern.
While high on it, people have a tendency to engage in risky sexual behaviours.
Can also lead to paranoia, hallucinations, and violent behaviour.

The opiates have strong suppression effects on sexual desire and response.
Long-term use of heroin, in particular, leads to decreased testosterone levels in males.

Prescription drugs

Some psychiatric drugs may affects sexual functioning.
In general, these drugs have their beneficial psychological effects because they alter neurotransmitter levels and the functioning of the central nervous system.
But these CNS alterations in turn affects sexual functioning.

Psychological causes

Immediate psychological causes

Prior learning: things that people have learned earlier that now affect their sexual response.
Immediate causes: various factors that occur in the act of lovemaking that inhibit sexual response.

Four factors have been identified as immediate psychological causes of sexual disorders

• Anxieties such as fear of failure
  Anxiety itself can block sexual response in some people
  Often anxiety can create a vicious cycle of self-fulfilling prophecy.
  The effects of anxiety are complicated and depend on the individual.
• Cognitive interference
  Negative thoughts that distract a person from focusing on the erotic experience.
  The problem is one of attention.
  Spectatoring: acting as an observer or judge of one’s own sexual performance; thought to contribute to sexual disorders.
• Failure of the partners to communicate
  Many people do not communicate their sexual desires.
• Failure to engage in effective, sexually stimulating behaviour
  Often a result of simple ignorance.

Prior learning

In some cases of sexual disorders, the person’s first sexual act was traumatic.
Seductive behaviour by parents and child sexual abuse are by parents or other adults are the more serious of the traumatic earlier experiences that lead to later sexual disorders.
In other cases, the person grew up in a very strict, religious family and was taught that sex is dirty and sinful.
Parents can punish children severely for sexual activity such as masturbation.
Parents who teach their children the double standard may contribute to sexual disorders, particularly in their daughters.

Emotional factors

Depression is associated with erectile disorder and other sexual disorders.

Emotions such as anger and sadness can interfere with sexual responding.
Anxiety can be a powerful impediment to sexual functioning in some people.
Disgust is the enemy of arousal.

Behavioural or lifestyle factors

Smoking, alcohol consumption, and obesity are all associated with higher rates of sexual disorders.

Sexual excitation-inhibition

People who are low on sexual excitation, or high on sexual inhibition, or both, are likely to develop sexual disorders.

Combined cognitive and psychological factors

We function well sexually when we are physiologically aroused and interpret that as sexual arousal.
People with sexual disorders tend to interpret that arousal as anxiety.
The physiological processes and cognitive interpretations form a feedback loop.

Interpersonal factors

Disturbances in a couple’s relationship are another leading cause of sexual disorders.

• Anger or resentment toward one’s partner does not create an optimal environment for sexual enjoyment
• Intimacy problems in a relationship can be a factor in sexual disorders
  Fear of intimacy causes a person to draw back from a sexual relationship before it becomes truly fulfilling

A new view of women’s sexual problems and their causes

Argues that the diagnostic categories have three flaws

• They treat male sexuality and female sexuality as totally equivalent, when they differ in some important ways
• They ignore the relational context of sexuality and desires for emotional intimacy
• They ignore differences among women and naturally occurring variations in women’s sexuality

Sexual problems due to sociocultural, political, or economic factors

Problems due

• Ignorance and anxiety due to inadequate sexuality education, lack of access to health services, or other social constraints
• Sexual avoidance or distress due to perceived inability to meet cultural norms regarding ideal sexuality
• Inhibitions due to conflict between the norms of one’s culture of origin and those of the dominant culture
• Lack of interest or fatigue due to family and work obligations

Sexual problems relating to partner and relationship

• Sexual inhibition or distress arising from betrayal or fear of the partner because of abuse
• Discrepancies in desire or preferences for sexual activities
• Ignorance or inhibition about sexual communications
• Loss of sexual interest as a result of conflicts
• Loss of arousal due to partner’s health or sexual problems

Sexual problems due to psychological factors

• Sexual aversion or inhibition of sexual pleasure due to past experiences of physical, sexual, or emotional abuse
• Personality problems with attachment or rejection, or depression or anxiety
• Sexual inhibition due to fear of sexual acts or their possible consequences

Sexual problems due to medical factors

• Any number of medical conditions that affect neurological, circulatory, endocrine, or other systems in the body
• Pregnancy or STIs
• Side effects of medications

Therapies for sexual disorders

Behaviour therapy

Behaviour therapy: a system of therapy based on learning theory, in which the focus is on the problem behaviour and how it can be modified or changed.
The basic assumption is that sex problems are the result of prior learning and that they are maintained by ongoing reinforcements and punishments.
These problem behaviours can be unlearned by new conditioning.

Sensate focus exercises: a part of the sex therapy developed by Masters and Johnson in which one partner caresses the other, the other communicates what is pleasurable, and there are no performance demands.
The couple chalk up a series of successes until eventually they are having intercourse and the disorder has disappeared.
The exercise fosters communication.

In addition, behaviour therapists supply simple education.

Cognitive-behavioural therapy

Cognitive-behavioural therapy: a form of therapy that combines behaviour therapy and restructuring of negative thought patterns.
Cognitive restructuring: the therapist essentially helps the client restructure his or her thought patterns, helping them to become more positive.

Couple therapy

Rests on the assumption that there is a reciprocal relationship between interpersonal conflict and sex problems.

• Sex problems can cause conflicts
• Conflicts can cause sex problems.

In couple therapy, the relationship itself is treated, with the goal of reducing antagonisms and tensions between partners.
As the relationship improves, the sex problem should be reduced.

Most sex therapists use combined or integrated techniques tailored to the specific disorder and situation of the couple.

Sex therapy online

Advantages

• More affordable
• Anonymity
• The advice columns can provide accurate, explicit, and non-judgmental information
• Interactions with a therapist online can break a wall of isolation surrounding a person with a sexual disorder
• Specialized messages boards and chat rooms can help create a sense of community
• People in countries in which sex therapy is unknown can obtain helpful information

Disadvantages

• Currently, there is no system for licensing online sex therapists
• Online sex therapists probably will not be able to give true intensive therapy of the kind on would get in multiple in-person sessions

Specific treatments for specific problems

The stop-start technique

Used in the treatment of premature ejaculation.

The woman uses her hand to stimulate the man to erection.
Then she stops the stimulation, gradually he loses his erection.
She resumes stimulation, he gets another erection.
She stops, and so on.

The man learns that he can have an erection and be highly aroused without having an orgasm.
Using this technique, the couple may extent their sex play to 15 to 20 minutes, and the man gains control over his orgasm.

Masturbation

The most effective form of therapy for women with primary orgasmic disorder is a program of directed masturbation.
Masturbation is the technique most likely to produce orgasm in women.

Masturbation is sometimes recommended as therapy for men as well.

Kegel exercises

Kegel exercises: a part of sex therapy for women with orgasmic disorder, in which the woman exercises the muscles surrounding the vagina.
The exercises are particularly helpful for women who have had this muscle stretched in childbirth and for those who simply have poor tone in the muscle.

The woman is instructed first to find her PC muscle by sitting on a toilet with her legs spread apart, beginning to urinate, and stopping the flow of urine voluntarily.
The muscle that stops the flow is the PC muscle.
After that the woman is told to contract the muscle 10 times during each of six sessions per day.
Gradually she can work up to more.

These exercises seem to enhance arousal and facilitate orgasm, perhaps by increasing women’s awareness of and comfort with their genitals.
They also permit the woman to stimulate her partner more because her vagina can grip his penis more tightly.

It is also sometimes used in treating men.

Bibliotherapy

Bibliotherapy: the use of a self-help book to treat a disorder.
It is effective for orgasmic disorders in women.
Also been shown to be effective for couples with a mixture of sexual disorders, both in men and in women.

Biomedical therapies

Drug treatments

Some are drugs that have direct sexual effects, whereas such as antidepressants work by improving the person’s mood.

Viagra: a drug used in the treatment of erectile disorder.
When the man is stimulated sexually after taking Viagra, the drug facilitates the physiological processes that produce erection.
It relaxes the smooth muscles in the corpora cavernosa, allowing blood to flow in and create an erection.
Men have generally been quite satisfied with Viagra.
Side effects are not common.

• Headache
• Flushing
• Vision disturbances

Viagra seems to be quite safe.

It is not helpful for sexual disorders other than erectile disorder.
Its recreational or high-performance use are causes for concern.

Al of the drugs are in the category of PDE-5 inhibitors.
They inhibit or block an enzyme, and by doing so, they relax smooth muscles in the arteries to the penis, thereby allowing more blood flow into it.
A particularly important success story is that these drugs are effective in treating erectile dysfunction that results from complete surgical removal of the prostate.

Often it is important to combine couple therapy with drug therapy.

Intracavernosal injection

Intracavernosal injection is a treatment for erectile disorders.
It involves injecting a drug intro the corpora cavernosa of the penis.
The drugs used dilate the blood vessels in the penis so that much more blood can accumulate there, producing an erection.
It is used mainly in cases in which the erection problem is organic and the man does not respond to Viagra or its successors.

Can be used in conjunction with cognitive-behavioural therapy in cases that have combined organic and psychological causes.

Both this and Viagra can have positive psychological effects, because it restores the man’s confidence in his ability to get erections and it reduces his performance anxiety since he is able to engage in intercourse.
There are also potential abuses.

Suction devices

Essentially, they pump you up.
A tube is placed over the penis and the mouth or pump produce suction.
Once a reasonably firm erection is present, the tube is removed and a rubber ring is placed around the base of the penis to maintain the engorgement with blood.

Surgical therapy: the inflatable penis

Penile prosthesis: a surgical treatment for erectile dysfunction, in which inflatable tubes are inserted into the penis.

A sac or bladder of water is implanted in the lower adbomen, connected to two inflatable tubes running the length of the corpora cavernosa, with a pump in the scrotum.
The man can literally pump or inflate his penis so that he has a full erection.

This is a radical treatment that should be reserved only for those cases that are not been cured by sex therapy or drug therapy.
The surgery itself destroys some portions of the penis, so natural erection will never again be possible.

In another version of a surgical approach, a semirigid, silicone-like rod is implanted into the penis.

Evaluation sex therapy

• Primary orgasmic dysfunction in women is successfully treated with directed masturbation.
  The treatment can be enhanced with sensate focus exercises.
• Treatments for acquired orgasmic dysfunction are somewhat less successful
• Vaginismus is successfully treated with progressive vaginal dilators.
• For premature ejaculation, drugs may be combined with CBT to improve effectiveness
• Hypoactive sexual desire disorder in women can be treated successfully with the kind of therapy by Masters and Johnson and with cognitive-behavioural therapy

Some practical information

Avoiding sexual disorders

Principles of good sexual mental health

• Communicate with your partner
• Don’t be a spectator
• Don’t set up goals of sexual performance
• Be choosy about the situations in which you have sex
• ‘Failures’ will occur