What sexual disorders are there? - Chapter 17

Sexual disorders cause a big deal of psychological distress. A sexual disorder is described as a problem with responses in sexuality that cause mental distress. Another term is sexual dysfunction. Defining a sexual disorder is not straightforward because the disorders are spread over a continuum. There is a distinction between a lifelong sexual disorder that was present from the moment sexual development began and an acquired sexual disorder, which developed after some time of normal sexual functioning.

What are sexual desire disorders?

There are two types of disorders concerning sexual desire: hypoactive -and discrepancy of sexual desire.

• Hypoactive sexual desire (HSD) is when an individual is not interested in sexual activity. It is a deficiency in sexual desire or libido, which refers to the interest in sexual activity. It is found in both men and women. The responsive desire is the pattern of the start of feeling sexual desire.
• Discrepancy of sexual desire is when hypoactive sexual desire is caused by the discrepancy between partners levels of sexual desire.

In the DSM the distinction between male hypoactive sexual desire disorder and female sexual interest/arousal disorder is now made to split the disorder. There might be a third category needed to represent other genders.

What are arousal disorders?

There are two types of disorders with sexual arousal, they include the female sexual arousal disorder and the male erectile disorder.

• Female sexual arousal disorder is the lack of response to sexual stimulation. It has several components including a psychological, a subjective and a physiological one. It can be expressed by the lack of feeling sexually aroused despite of adequate stimulation or the absence of enough lubrication in the vagina. These problems occur more during menopause.
• Erectile disorder is described as the inability to maintain or get an erection. Another term is impotence or erectile dysfunction. The result is that a man cannot have intercourse. A lifelong erectile disorder is when a man has never been able to have an erection hard enough for intercourse, whereas an acquired erectile disorder occurred after some successful erections. Responses to this disorder are severe and it can cause depression.

What are orgasmic disorders?

Orgasmic disorders include male orgasmic disorder, premature ejaculation and female orgasmic disorder.

• Premature ejaculation (PE) is when a man ejaculates too soon, this may even be before the intercourse has started. The man might be unable to delay the orgasm long enough for the partner’s preference. The precise criteria for early ejaculation are unclear, but experts defined it as the occurrence of an orgasm when the intercourse lasted less than one minute. Kaplan (1974) believes that it is the lack of control over the orgasm that defines the disorder. The best definition might be self-definition when a man thinks he ejaculates too early and is worried about it.
• Delayed ejaculation or male orgasmic disorder is when a man is unable to have an orgasm despite of erection and stimulation. It is a frustrating experience to have a long-lasting erection without an orgasm. Some women might experience the inability of the man as a personal rejection.
• Female orgasmic disorder is the inability for a woman to have an orgasm. The term frigidity is a name for disorders ranging from total lack or sexual arousal to arousal without an orgasm. Therapists reject this term because it is an incorrect description of the disorder. A common pattern for women is the situational orgasmic disorder where a woman sometimes has an orgasm and sometimes, she does not. There should be room for the self-definition of these disorders. The request for therapy should come with the own dissatisfaction of the woman.

What are sexual pain disorders?

Examples of disorders causing pain during sex are vaginismus and painful intercourse.

• Painful intercourse or dyspareunia is a disorder where genital pain is experienced during intercourse. It can be experienced by males and females. Occasional dyspareunia is common among women, but persistent dyspareunia is not. It decreases the enjoyment of sex and may lead to abstinence of sexual activity.
• Vaginismus is a spastic contraction in the vagina. It can be so severe that the vagina is closed, and intercourse becomes impossible. If intercourse is possible, this is often painful. In the DSM, dyspareunia and vaginismus are merged into genito-pelvic pain or penetration disorder.

What are the physical causes of sexual disorders?

The physical factors causing a sexual disorder are also referred to as organic factors and include disease, drugs or injuries.

• Erectile disorder can be caused by any heart, vascular and circulatory problem because erection depends on this system. Damage to the arteries and veins stops the blood flow to the penis. It is associated with diabetes. Another cause of ED is hypogonadism, low testosterone levels in the testes. Erectile disorder can also be caused by fatigue, stress or psychological issues. The distinction between psychological and organic causes is very important for treatment.
• Premature ejaculation is more often caused by psychological, than physiological problems. Often it is an acquired disorder for which the organic cause could be an infection in the prostate.
• Delayed ejaculation is associated with medical surgical conditions such as a spinal cord injury. However, more often psychological factors are causing this dysfunction.
• Female orgasmic disorder can be caused by injury, illness or extreme fatigue.
• Painful intercourse and vaginismus can be caused by disorders of the vaginal entrance, disorders of the vagina or pelvic disorders. In a man, the cause could be poor hygiene when he is uncircumcised.

What are the effects of drugs on the development of sexual disorders?

The side affects of many drugs can cause sexual disorders. It was found that medicine for high blood pressure caused a decrease in sexual desire and an increase in erectile problems.

• The effects of alcohol fall into three categories. The first is short-term pharmacological effects, second are expectancy effects and third are long-term effects of alcohol abuse. Alcohol abuse often causes a variety of sexual disorders such as loss of desire and erectile disorder. This might be caused by reduced hormones in the testes or the dysfunctional relationships people with chronic alcohol abuse have.
• Illicit or recreational drugs have different effects, depending on the drug and dosage. Marijuana is an aphrodisiac according to users but can lead to risky sexual behaviour. Chronic users report a decrease in sexual desire. Cocaine is said to increase sexual desire and prolong the orgasm; however, it is also associated with a loss of desire and orgasmic and erectile disorders. Amphetamines can cause an increased sexual arousal and desire. Crystal methamphetamine users have the tendency to engage in highly risky sexual behaviour, such as unprotected sex with multiple partners. Opiates have a suppressing effect on sexual response and desire.
• The psychiatric prescription drugs affect sexual activity and functioning because they influence neurotransmitters. For instance, medication for schizophrenia may cause delayed or dry ejaculation in men.

What are the psychological causes of sexual disorders?

There are different types of psychological causes including emotional factors, prior learning, problems with sexual inhibition/excitation or immediate causes.

• Immediate psychological causes are the things that happen during lovemaking that can inhibit the sexual response. Immediate psychological causes are anxiety, fear of failure, failure of communication, failure to engage in effective -and stimulating behaviour and cognitive interference.
• Prior learning refers to the learned experiences in earlier sexual encounters, it might be a traumatic experience that can lead to a sexual disorder, for example a history of sexual abuse.
• Emotional factors can contribute to the development of sexual disorders. Depression or emotions such as sadness and anger can interfere with pleasantness of sexual activity.
• Behavioural or lifestyle factors are the consumption of drugs, alcohol or obesity. These behaviours lead to organic causes of sexual disorders but can be modified trough psychological interference.
• Sexual excitation/inhibition means that people who score low on sexual excitation and high on sexual inhibition are more likely to develop a sexual disorder.

What are combined physiological and cognitive causes for sexual disorders?

The two-component theory of love describes that love depends on the fulfilment of two conditions: the physical arousal itself and the cognitive label: “love” attached to it. Palace (1995) argues that sexual functioning is good when people are sexually aroused and have the label of “sexual arousal” attached to it. People with sexual disorders tend to misinterpret arousal as anxiety. Research proved that the combination of cognitive and physiological factors can help treatment for sexual disorders.

What is the role of interpersonal factors in sexual disorders?

Another main cause of developing a sexual disorder is the status of the relationship. Anger resentment towards the partner is a far less than optimal environment for pleasurable sexual behaviour. The big problems with relationships and sex are intimacy or conflict over power. Problems with intimacy often reflect psychological and relationship problems. Some people fear intimacy which might be the result of disappointing previous intimate relationships.

What are newly discovered causes of women’s sexual problems?

In 2001, a new view of the nature of sexual problems in women was formulated (Tiefer, 2001). It is argued that the current listings in the DSM have three flaws in the definition of their categories:

1. Male sexuality and female sexuality are considered equivalent even though they differ in many ways.
2. The relational aspect of sexuality and desire is ignored.
3. The naturally occurring variation between women and women’s sexuality are ignored.

Based on these criticisms, the experts described new categories to describe sexual disorders for women.

1. Sexual problems because of sociocultural, economic or political factors is a category that describes ignorance and anxiety as a result of bad sexual education, no access to health services or social inhibitions. It also includes distress or avoidance of sex because someone thinks he is not able to meet the cultural requirements. Lastly, this category includes people who have a lack of interest in sex due to stressful work -and family conditions.
2. Sexual problems caused by the relationship and the partner include fear of abuse, discrepancy in desire, bad sexual communication, loss of sexual interest and loss of arousal due to health.
3. Psychological factors as causes for sexual problems exist from three subproblems, one is the sexual aversion due to prior experiences with emotional -and sexual abuse. Second is problems with rejection or attachment and third is sexual inhibition caused by the possible consequences of sexual acts.
4. Medical factors as causes for sexual problems is when sexual disorders are caused by medical issues.

What therapies can be used for sexual disorders?

Dependent on the nature and expression of the sexual disorder, a fitting type of therapy should be applied. There are four major therapies available to treat sexual disorders, these are cognitive therapy, behavioural therapy, biomedical therapy and couple therapy.

• Behaviour therapy works with the notion that sex problems are caused by prior experiences. These problems can be unlearned by conditioning using reinforcement and punishment. One goal in this therapy is to eliminate goal-oriented sexual performance. One technique to use is sensate focus exercises where one partner, the giving role touches the other, who plays the receiving role.
• Cognitive-behavioural therapy uses cognitive restructuring to help the client restructure thoughts or patterns of behaviour that lead to the sexual disorder.
• Couple therapy is based on the notion of conflict in a relationship. Couples-therapists use a combination of cognitive behavioural -and couple therapy. Spector (1994) proposed a five-part model that is being used for treatment of a men with erectile disorder. First the sexual -and performance anxiety must be reduced, then there should be education and cognitive intervention followed by scrips assessment and modification. The fourth step is conflict resolution and relationship management and finally there is relapse and prevention training.
• Online sex therapy is quite new. It has the advantage of anonymity, also people can seek help without their partner knowing. Also, online sex therapy can provide accurate educational information and communication with an online sex therapist can break the isolation walls down for a patient with a sexual disorder. However, there not yet a system for licencing online sex therapists and many of them are unqualified.

What are more specific treatments that can be used?

Besides these forms of therapy, there have also been more specific treatments developed.

• The stop-start technique is helpful for men with premature ejaculation. The woman stimulates the men until he gets an erection and stops until he loses his erection. She then stops again and so on. This learns a man to get an erection and be aroused without getting an orgasm.
• Masturbation is effective for women and men with orgasmic disorder.
• Kegel exercise is a form of sex therapy for women where the woman exercises the muscles around the vagina. It helps with an orgasmic disorder. The pubococcygeal muscle is trained that runs along the sides of the vagina. It can help with enhancing awareness of the genitals and with involuntary urination during the orgasm.
• Bibliotherapy is the use of a self-help book to treat a sexual disorder.

What kinds of biomedical therapies are used to treat sexual disorders?

For some people, drug or even surgical operations can be used to help the sexual disorder cure.

• Drug treatments can be used together with cognitive-behavioural therapy to increase positive outcomes. Viagra is widely used for treating erectile disorder. Viagra does not cause an erection, but erotic stimulation after taking the pill causes an erection more easily. Viagra is easily accessible but does not solve the psychological -or relationship causes of the erectile disorder.
• Intracavernosal injection (ICI) is another treatment for erectile disorders where a drug is injected into the corpora cavernosa of the penis. They dilate blood vessels so that an erection is produced. It is only used when the erection problem is organic, and a man does not respond to Viagra. It helps the man with performance anxiety and has positive psychological effects.
• Suction devices are placed over the penis and produce suction. This way a man gets an erection which is then maintained using a rubber band. This is used on men with diabetes.
• Surgical therapy can be used to implant a penile prosthesis. The men can pump up his penis to a full erection. It is a radical treatment that eliminates natural erections from ever happening again.

Which types of sex therapy are effective?

After the sexual therapy approach posed by Masters and Johnson, many more therapies have been developed. For certain therapies research evidence showed the effectiveness. There are several conclusions that can be drawn on research to therapies to treat sexual disorders:

1. When women experience primary orgasmic dysfunction, this is treated successfully with directed masturbation. This treatment can be enhanced with specific sensate focus exercises.
2. The treatment for acquired orgasmic dysfunctions are less straightforward. The combination of sexual skills training, education, body image therapy and communication skills training seem to work best. This is probably because there exists a wide range of different types of anorgasmia that have not been discovered by research.
3. The best treatment for vaginismus is relaxation and physical therapy. Kegel exercises might also help.
4. Drugs, such as antidepressants are effective for premature ejaculation. Especially when combined with CBT.
5. Women with hypoactive sexual disorder can be treated with cognitive behavioural therapy.

An important disadvantage or critic on this approach is the medicalisation of sexual disorders. Financial and political issues are involved when the prescription of drugs for these disorders becomes more common than psychological therapy. There is not only a cost to society, but also to the patient. The patient might be relieved quickly from the disorder, but underlying anxiety might not be resolved. The new view of women’s sexual problems is one alternative for the medicalisation of sexual disorders.

How can sexual disorders be avoided?

People could use some principles posed by sex therapists to avoid getting a sexual disorder. There are some principles that can be applied to achieve a good sexual health:

1. It is important to keep communicating with your partner¸ it should be clear what is pleasurable and what is not. Verbal communication works well, but non-verbal communication can be used in this context as well.
2. Try not to be a spectator, there is no constant evaluation needed of your sexual performance. It is better to focus on the pleasures.
3. Do not create goals for sexual performance, setting of goals cause failure. It is better to just relax and enjoy.
4. Be specific about the situations in which you have sex. Avoid having sex in a hurry or when you are disturbed. Trust in the partner is essential for good sexual functioning.
5. There will be failures, it is important how these are dealt with. Do not let them ruin a relationship but use them to make it better.

It can be difficult to find a good sex therapist, but the medical psychological association can provide a list with qualified sex therapists that have a special training in sex therapy. It is best to choose a therapist that uses an integrated approach because of the recognition of all factors that can contribute (cognitive, biological etc.).