Leonard R. Derogatis
Arthur L. Burnett
Linda C. Rogers
Chester W. Schmidt Jr.
Peter J. Fagan
The past decade has seen dramatic changes in the management of male sexual disorders, particularly the sexual dysfunctions, as increasing numbers of safe, effective, pharmacologic agents have become available to practitioners to treat these conditions. Similar innovations in the treatment of female sexual dysfunctions also appear imminent, as a number of promising new drugs move closer to regulatory approval. In this environment, it is
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tempting to characterize sexual disorders in terms of a biogenic versus psychogenic dichotomy regarding both etiology and treatment. We believe, however, that such a polarized approach is both inaccurate and counterproductive in determining accurate diagnosis and effective treatment for sexual dysfunctions. Instead, we urge clinicians to adopt a posture that integrates biologic, psychological, and relational elements in their formulations of the majority of sexual disorders. Sexual problems accompany physical or mental illnesses, can be the result of endocrine deficiencies or imbalances, and are often secondary to side effects of medications or a result of the abuse of drugs. They may also be expressions of interpersonal conflict, intrapsychic distress, or cultural proscriptions that conflict with mainstream customs. Frustration, fatigue, and self-doubt can complicate the sexual life of a person who is aging, as well as those who are ill or recovering from surgery, and relational tensions and distrust can often interfere with the sexual response in a healthy adult. Conceptualizing these conditions in terms of multiple perspectives (1) greatly enhances our capacity to understand them in a comprehensive manner. While the primary care physician may not be in a position to explore all related perspectives, viewing sexual disorders as simultaneously biologic, psychological, and relational phenomena significantly improves our diagnostic acumen, and our potential for effective treatment.
Ultimately, the task of the primary care clinician is to ensure that the patient's sexual disorder is diagnosed accurately and treated effectively, weighing all of the factors that can be identified at the time. Given the pharmacologic developments in recent years, many patients’ problems can be effectively addressed in the office of the primary care clinician. However, if either the psychological or somatic factors are too complex, the primary care clinician may wish to refer the patient to a specialist, a maneuver which at this point in time may be more demanding than referrals for other conditions. If available, a reliable Center for Sexual Medicine should be a first choice; however, good working relationships with urologists, gynecologists, or mental health professionals with an expressed interest and expertise in sexual medicine can often lead to an equally effective resolution of the problem. The encouraging news is that although effectiveness data for treatment outcomes in primary care are limited, the information available suggests that outcomes for reversible sexual problems are usually good, with clinically significant improvement seen in a majority of cases.
Human Sexual Response Cycle
To assess sexual disorders rapidly and accurately, it is helpful to be familiar with the human sexual response (HSR) cycle and the major physiologic factors that mediate each phase of the cycle. The HSR cycle is traditionally divided into four phases: desire, arousal, orgasm, and resolution. It is important to view the HSR as a construct to understand sexual behavior. In practice, many dysfunctions coexist and do not occur in the neat sequential order implied by the HSR cycle.
The Four Phases
The first phase of the HRS cycle is one of desire and consists of fantasies and wishes to engage in sexual activity. This response is psychic in origin, but the psychic stimulation is mediated, in all probability, by circulating androgens.
The second phase is the arousal phase. It consists of a number of physiologic changes plus the subjective sense of sexual pleasure and excitement. In both sexes there is an increase in heart and breathing rates, and development of muscular tension throughout the body, which is most pronounced in the pelvic area and thighs. For both sexes, the major physiologic change is the development of vascular congestion in the genital area. For females, the manifestations of vasocongestion are vaginal lubrication and swelling of the external genitalia. In males, vasocongestion leads to erection. These changes may be mediated by either of two neurologic pathways: (a) a local reflex pathway initiated by tactile stimulation of the penis or clitoris and mediated by sensory fibers entering the dorsal root ganglia, or (b) a cortical pathway initiated by psychic stimuli and mediated by sympathetic fibers. Each pathway promotes rapid inflow and retention of blood in the penis and the vulva. In addition to neurologic pathways, erection in the male and vasocongestion of the vulva and vagina in the female depend on intact arterial blood flow from the right and left internal pudendal arteries.
The third phase is orgasm. Subjectively, for both sexes, orgasm is a peaking of sexual pleasure accompanied by a sense of release from sexual tension. Physiologically in the male, the most obvious manifestation of orgasm is ejaculation. Ejaculation is mediated by the sympathetic nervous system and consists of two processes: emission, resulting from contraction of the vas deferens, prostate, and seminal vesicles; and actual ejaculation, resulting from rhythmic contraction of the muscles of the pelvic floor and from closure of the internal sphincters of the bladder (preventing retrograde ejaculation). In the female, the rhythmic contractions take place within the musculature of the outer third of the vagina and in the perineal muscles. The subjective component of orgasm is a cortical sensory phenomenon; it can be experienced without peripheral correlates such as ejaculation or bladder neck closure in men and vaginal contractions in women.
The fourth phase is termed resolution, which subjectively is accompanied by a sense of pleasure, warmth, well-being, and relaxation. Physiologically there is a gradual return of heart rate, breathing rate, and muscle tension to the baseline state. Most men are refractory to entering
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another cycle of sexual activity for some time (minutes in younger men, an hour or longer in middle-aged and older men). Women are not subject to this refractory period and may have multiple orgasms after continued or additional stimulation.
Alternative Model for Women
Recently, there has been much debate about whether the traditional HSR model is appropriate for all women in all circumstances (2). A less linear, more cyclic, model of sexual response may more accurately reflect the experience of many women, particularly those in long-term relationships. Many sexually satisfied women report that they seldom have spontaneous thoughts about sex but are able to express responsive desire to sexual cues from their partner. Desire for them is typically experienced subsequent to arousal, and the two states become mutually enhancing. Motivational factors include a desire for intimacy with the partner, and emotional and physical satisfaction, beyond specific sexual desire, which may or may not augment the experience. At times, men's sexual desire patterns may also fit this model. Under such a model, patients should not be considered candidates for a diagnosis of desire disorder even if they experience few spontaneous sexual thoughts and fantasies as long as their capacity for “responsive desire” is intact.
Common Sexual Disorders
The nomenclature and criteria used to classify sexual disorders in this chapter are based primarily on the American Psychiatric Association'sDiagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (3). More recent work, which is highly consonant with the DSM-IV paradigm, but further refines and explicates certain criteria and definitions, has also been integrated into the model (4,5). The assessment and management of sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders across multiple etiologies are discussed here.
Tripartite Model of Etiology
As alluded to earlier, current thinking about the etiology of sexual dysfunctions tends to represent causality as deriving from multiple perspectives (1). Biologic/medical factors, psychological/intrapsychic issues, and relationship/interpersonal conflicts, among other influences, may play causal roles in these disorders. Obviously, the primary care provider is not equipped to evaluate an exhaustive list of potential causal agents, nor to weigh their relative contributions. For this reason we recommend a tripartite model for conceptualizing the etiology of sexual dysfunctions, one with three principal aspects: a biogenic aspect, a psychogenic aspect, and a relational aspect. Basically, this “three-legged stool” model describes a three-dimensional Cartesian coordinate system that locates each patient within the space of the primary axes, and identifies any discernible factors on a particular axis that may play an etiologic role. Once identified, putative causal factors (e.g., diabetes, performance anxiety, marital conflict) can be noted and a relative weight can be tentatively assigned by the physician. The primary care professional can then discuss findings with the patient, and decide which aspects (if any) of the case should be treated in the primary care office, and which are better referred to a specialist.
Example
Mrs. W, a 56-year-old married school teacher presented to the clinic with a primary complaint of complete loss of sexual desire. She indicated that she had noticed a slight reduction in her sexual desire upon entering menopause at the age of 49 years, but over the last 5 years her loss of desire has been extreme. She was very distressed by her situation, indicating that she had been a very sexual person throughout her life, and now is left simply going through the motions—sexually speaking, a shell of the woman she was. When she was age 52 years, the patient's father, to whom she was very strongly attached, died suddenly without warning. Her grief was profound, and within 6 months she was diagnosed with a Major Depressive Disorder. After several trials with a variety of antidepressant medications the psychiatrist to whom she was referred by her gynecologist selected an effective selective serotonin reuptake inhibitor (SSRI) regimen. She responded very well to treatment, and when seen in our clinic was essentially in complete remission from her depression. Her gynecologist had also prescribed a hormone replacement therapy (HRT) regimen to which she responded positively. Although the patient could achieve moderate levels of sexual arousal, and somewhat muted orgasms, her desire for sex was completely absent. The patient questioned why, after having done so well with other aspects of her treatment for depression, her sexual desire could not be restored.
An evaluation of the primary axes of the tripartite system revealed no problems in the patient's marital relationship (an excellent marriage of 25 years), and no other familial conflicts. All evidence indicated that Mrs. W was currently free of depressive disorder and clearly in remission, with psychological conflicts appearing minimal. These facts directed focus to the biogenic axis. The patient did remain on a maintenance dose of SSRIs; however, she indicated that she had not noticed a further decline in her sexual desire associated with treatment with antidepressants at initial therapeutic doses. Because her very first awareness of a decline in her sex drive was attendant upon the beginning of her menopause, an endocrine assay was ordered to establish her endocrine status. Total serum testosterone and free testosterone were observed to be in the “low” range. The patient was in remission from her depression, was on maintenance doses of SSRIs, and was free of potential marital conflicts, all possible
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causal factors in her desire disorder. Discontinuation of her SSRI was a treatment option. However, because she was responding well to a recent serious episode of major depression, and neither she nor her psychiatrist wanted to risk a recurrence, we did not choose this option. We recommended a trial with a regimen of exogenous testosterone in the form of percutaneous topical gel (2%). After 4 weeks of treatment the patient reported a definite awakening of her libidinal drive, as well as increased feelings of energy and well-being. By the fifth week of treatment Mrs. W reported feeling “sexually restored.”
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TABLE 6.1 Medical Conditions That Can Affect Sexual Response in Either Sex |
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In the case of Mrs. W, a biologic etiologic agent emerged as the fundamental cause of her desire disorder, a problem shared by many women during the perimenopausal and postmenopausal transition. Although not true in this instance, even when biologic problems are clearly central in the case, it is important to be aware that secondary relational (e.g., partner frustration) and/or intrapsychic (e.g., diminished self-concept) conflicts can serve as ancillary contributors to the problem. Tables 6.1,6.2,6.3,6.4 list medical conditions and medications that affect sexual response.
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TABLE 6.2 Medical Conditions That Can Affect Sexual Response: Men Only |
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TABLE 6.3 Medical Conditions That Can Affect Sexual Response: Women Only |
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TABLE 6.4 Common Drugs and Substances That Can Affect Sexual Responsea |
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TABLE 6.5 Prevalence Ranges of Sexual Dysfunctions among Women and Men |
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General Characteristics
Frequency
The data in Table 6.5 suggests that the prevalence of sexual disorders in the general population of the United States is substantial, and swells to even more dramatic proportions in clinical and aging populations. This being the case, screening for such conditions deserves the attention of the primary care physician. The table describes the prevalence of sexual dysfunction in surveys conducted in the United States as well other countries. Queries address the prevalence of problems analogous to the sexual dysfunctions discussed in this chapter, and use time frames of either currently, or within the past 12 months or less. The primary source for these data is the National Health and Social Life Survey (NHSLS) conducted with a randomly selected and stratified sample of 18- to 59-year-old participants in 1992 (6).
Age at Onset of Common Sexual Disorders
Psychological and behavioral antecedents of sexual disorders can sometimes be found in both adolescent and childhood sexual experiences and fantasies; however, a common age at onset is early adulthood. Menopause is also a peak time of onset for women's sexual dysfunctions, often as a result of dramatic changes in endocrine levels associated with this life epoch. There is also a well-defined relationship between aging and the prevalence of erectile disorder (ED) in men. Nowhere is this more clearly demonstrated than the Massachusetts Male Aging Study (7), which shows an increase in prevalence of ED from 8% among 40-year-old men to 40% among men age 69 years. Onset can basically occur at any time during adult life, particularly for dysfunctions associated with medical conditions or use of drugs or other substances, and for those dysfunctions that are situational or transient.
Predisposing Personality Factors
In general, effective and satisfying sexual function is usually considered to be associated with a healthy and adaptive personality development. Consequently, defects in personality structure accompanied by maladaptive personality traits (see Chapter 23) or psychopathology can certainly affect sexual function. However, such additional psychiatric problems are neither necessary nor sufficient conditions for the development of sexual problems. A study done in our clinic involving 288 patients, who were referred to us because of a diagnosis of a sexual dysfunction, revealed that only 30% of the sample fulfilled criteria for an additional psychiatric disorder (8) beyond the sexual dysfunction.
Course and Severity
The course of sexual dysfunctions varies. Dysfunctions may develop after a period of normal functioning or they may be lifelong. They may be generalized, occurring with all partners and in all contexts, or situational, limited to specific partners or contexts. There are differing degrees of impairment, from partial or intermittent to total and unremitting. Usually, early age at onset and total functional compromise indicate chronicity and predict a poorer treatment outcome. Conversely, a history of prior adequate sexual function, situational symptoms, and partial
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impairment are predictive of a more limited course for the disorder and a higher probability of a favorable treatment outcome.
Related Problems
Fundamentally, the major complications of sexual dysfunctions are disrupted marital or sexual relationships. In addition, presence of the dysfunction, particularly one of an unremitting nature, may give rise to a variety of negative emotions such as depression, anxiety, guilt, shame, frustration, and anger. These affect states not only affect the patient but also may intrude into many of the patient's broader life relationships. Most sexual dysfunctions of a substantial nature or duration also have a disparaging effect on the individual's self-concept, as they serve to undermine the individual's feelings of psychological integration and well-being.
General Approach to the Patient
Most patients do not feel comfortable initiating discussion with their primary care provider about their sexual activities and any sexual problems they may be having. For this reason it is very important to inquire about sexual function as a systematic part of the primary care workup of each patient. Table 6.6 outlines interviewing approaches that may be useful in this inquiry. One should not presume exclusive heterosexuality in a new patient but should ask questions that are gender neutral until orientation has been established. In patients who name a problem, the history of the present problem may be imprecise. Therefore, sufficient time should be set aside with the patient to obtain a clear account of the difficulty. For patients whose difficulties involve a partner or a spouse, it is important to have the partner's view of the problem. Sometimes the more-functional partner will seek help to gain support for bringing the less-functional partner into the evaluation.
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TABLE 6.6 Suggested Questions Regarding Sexual Practices and Problems |
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The evaluation should be organized to obtain information about the onset and duration of the problem; about factors that make the problem better or worse; about concurrent events such as birth of children, changes in relationships or vocation, or onset of physical or emotional illness; and about use of new medications. Also, it is always important to elicit from patients their ideas about the cause of sexual problems and their expectations of treatment.
If it is determined that a referral to a specialist in sexual medicine is appropriate, the clinician should advise the patient to consult with his or her health insurance program to ascertain whether such treatment of sexual dysfunction or disorders is a covered benefit. Most plans do not cover marital therapy, and many exclude sexual therapy
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(especially nonmedical) as a covered benefit. Diagnostic medical procedures, including laboratory assays, are typically covered, however.
Female Sexual Disorders
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder (HSDD) is defined as, “the persistent or recurrent deficiency (or absence) of sexual fantasies, thoughts and desire for [or receptivity to] sexual activity.” The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age, sex, and the context of the person's life. The disturbance causes the patient marked distress or interpersonal difficulty, and it does not occur exclusively during the course of another axis I disorder nor is it caused exclusively by the direct physiologic effects of a substance (e.g., drugs of abuse, medication) or a general medical condition.
Assessment
A multitude of factors can be involved in the loss or reduction of sexual desire in a woman. Age, menopausal status, psychiatric status, and quality of relationship should all be established as potentially important parameters in an attempt to understand the patient's condition. The presence of medical disorders, surgical interventions, specific pharmacologic therapies, or any substances of abuse should also be established and evaluated for etiologic potential.
In terms of prevalence, HSDD is the most prevalent of the female sexual dysfunctions (6). Among postmenopausal women, the condition is even more prevalent. Although many experts believe loss of desire peri- and postmenopause is related to the marked reduction in circulating androgens associated with this stage of life, a definitive causal relationship has not yet been established. HSDD will almost certainly be the most frequent sexual complaint that primary care providers will see, with perhaps 35% to 40% of postmenopausal women experiencing a clinically meaningful loss in levels of sexual desire.
As just discussed, although desire disorders are the most prevalent female sexual dysfunctions, with numerous possible origins, the clinician must take care to ensure that the complaint of low desire is a primary condition. At times, complaints of low desire are actually secondaryresults of cumulative frustration and loss of sexual interest because of repeated failures to become aroused, or to achieve orgasm. Facility with language can also play a role in these instances, in that many women are not familiar with, or do not fully understand, the term sexual arousal and as a result will use the phrase “loss of sexual interest” to communicate the global sexual experience as opposed to a specific symptomatic manifestation, that is, problems with sexual arousal.
Treatment of Hypoactive Sexual Desire
In deciding on a plan of treatment, the clinician must first establish what he or she believes is the primary etiologic agent, recognizing that there may be multiple causal factors in HSDD. Addressing the biogenic axis first, the presence of numerous diseases, surgical interventions, or medical conditions needs to be evaluated for a potential causal role (Tables 6.1 and 6.3). If a drug (Table 6.4) is suspected of interfering with sexual desire, several questions should be addressed. Is it possible to put the patient on a drug “holiday” for several weeks as a diagnostic challenge? If not, will an adjustment in dose be sufficient to effect a therapeutic change? Can a different pharmacologic agent be substituted for the drug of concern to see if any changes ensue? Finally, in some instances the addition of a known prosexual agent (e.g., adding bupropion hydrochloride [Wellbutrin] to an SSRI antidepressant regimen) can counteract the effects of the problem drug sufficiently to restore functioning. In a related vein, if loss of sexual drive is secondary to alcohol or substance abuse, treatment should be aimed at controlling the abuse (see Chapters 28 and 29).
Turning to the psychogenic and relational aspects of HSDD, transient hypoactive sexual desire disorders that are a consequence ofpsychological factors, such as stress or anger, or interpersonal problems can usually be managed effectively with short-term counseling. This assumes, however, that normal levels of sexual desire were present prior to the problem. If problems with sexual desire are long-term or lifetime in nature, then resolution of the problem is apt to be more complex and prolonged. When alcoholism, depression, or another psychosocial disorder is the primary problem, specific treatment for that disorder should accompany the counseling. Many cases of depression, even those that do not appear to be of a profound nature, can have a negative impact on sexuality. The design of a counseling program should include an agreement between the patient or couple and the clinician to meet for a specified number of sessions (usually two to five) for approximately 30 minutes per session.
Pharmacologic Treatments for HSDD
There are currently no drugs specifically approved by the U.S. Food and Drug Administration (FDA) for the treatment of the female sexual dysfunctions, including HSDD. In spite of this fact, off-label treatment of HSDD has been ongoing for about 40 years. Principal among the agents employed for this purpose are various androgens, principally testosterone, administered through a variety of modalities. Testosterone can be administered orally (in methyltestosterone and undecanoate preparations), intramuscularly, subcutaneously, via transdermal patch, and in a variety of gel applications. Of these, the only FDA-approved application is Estratest, a combination of methyltestosterone (MT) and esterified estrogen (EE), which is available in several doses. Estratest is officially approved for the treatment of moderate to severe
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vasomotor symptoms associated with menopause, and has been successfully used with both surgically and naturally menopausal women. Another regimen that has become popular is the use of testosterone 2% percutaneous gel, which is applied to the tissues of the vulva for 2 weeks and subsequently applied to the inner thigh. Response times to these courses of therapy are variable, but it is not uncommon to take 4 to 5 weeks of application before a restoration of desire is experienced. Adverse effects tend to be minimal in the large majority of patients, consisting primarily of minor androgenic skin effects, such as acne and hirsutism.
Although testosterone remains unapproved by the FDA for the treatment of sexual desire disorders, a recent review of a large number of clinical trials concluded it has clearly demonstrated efficacy in restoring libido and the capacity for sexual arousal and sexual satisfaction, with few safety concerns (9). Two recent, large, randomized clinical trials, one with surgically menopausal and the second with naturally menopausal women, both reported obvious efficacy and minimal adverse events (10,11).
Although there is a dearth of FDA-approved pharmacologic agents available to treat female desire disorders, there is no scarcity of investigational agents under development, most of them in Phase II or Phase III clinical trials. The transdermal testosterone patch Intrinsa and the testosterone gel application Tostrelle are both well along in development, as are a number of nonhormonal agents. The dopamine agonist apomorphine is under development as a treatment for HSDD in men and women, using both sublingual and inhaler delivery systems, and an inhaled form of the melanocortin-stimulating hormone PT-141 is in Phase II trials. Also, several sponsors are about to move into Phase III trials with drugs that can be best characterized as “atypical” antidepressants that have shown prosexual effects on libido. In addition, it is worth noting that several drugs not accurately labeled as “investigational” are also being studied for their therapeutic potential in this area. The atypical antidepressant bupropion (Wellbutrin) has shown consistent evidence of having a modest therapeutic influence on sexual desire (12,13), and the HRT drug tibolone (Livial), a synthetic steroid with androgenic as well as estrogenic and progestogenic properties, is also in U.S. trials, with a focus on postmenopausal women with HSDD (14). How soon any of these drugs will become approved by the FDA for this indication depends on numerous scientific, regulatory, and commercial factors; however, the fact that the level of activity in this area has grown almost geometrically in the past decade suggests that it will be sooner rather than later.
Female Sexual Arousal Disorders
Diagnostic Classification
Female sexual arousal disorder (FSAD) is defined as the absence or markedly diminished feelings of sexual arousal (i.e., sexual excitement or sexual pleasure) from any type of sexual stimulation. In addition, there may also be present a persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate vaginal lubrication–swelling response of sexual excitement. The disturbance causes marked distress or interpersonal difficulty, and is not better accounted for by another axis I disorder (except another sexual dysfunction) or caused by the direct physiologic effects of a substance (e.g., drugs of abuse, a medication) or a general medical condition.
Assessment
Problems with sexual arousal are common in women and may actually be at the root of many other sexual dysfunctions. As an example, orgasmic dysfunction is frequently secondary to difficulty with arousal, and if arousal disorder becomes chronic, it can lead to a loss of interest in sexual activities. Coitus with insufficient arousal can also play a role in the etiology of a variety of pain syndromes, in some instances because of a lack of vaginal lubrication and in others because of a failure of the “tenting” response of the distal vagina during intercourse.
The traditional focus in arousal disorder has been on genital changes in the arousal process in women as a corollary of the erection process in men. Recently, there has been a recognition that arousal in women is much more complex. Because women's genital changes are less obvious than men's, women can be completely unaware of them. They may attend far more to other somatic changes, such as heart rate, muscle tension, or breast sensations, or to their own subjective state of arousal (5).
Several research methodologies that reflect changes in blood flow in the vaginal walls or labia are used to study women's genital reactions to sexually arousing stimuli. Studies consistently find a lack of correlation between women's feelings of subjective arousal and the genital changes associated with arousal. For instance, women frequently react to a sexual stimulus with changes in genital blood flow, but they may be unaware of the changes, often do not feel aroused subjectively, and in fact may feel negatively about the stimulus (15).
Inability to attain and maintain levels of arousal that permit a smooth and trouble-free progression from the beginning of a sexual experience to its completion can be caused by both external and internal psychological events that may interfere with the patient's ability to focus on the physical and psychological stimuli that maintain sexual arousal. A vivid example of an external event is the ringing of a telephone during the sexual experience. An internal psychological event might be a recurring thought about how long one's partner may be able to sustain his erection. Often patients complaining of arousal disorders will report that they have great difficulty staying focused on the sexual experience and staying in the moment. For these women a combination of factors acts to render them easily distractible and unable to concentrate on the
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pleasure inherent in the sexual experience. The history and assessment should be structured to uncover the presence of external events and the specific content of psychological events when present. A common finding is a persistent preoccupation and anxiety about the patient or partner performing successfully. This problem may be primary, or it may occur as a secondary response to the frustration associated with organic dysfunction. When partner dysfunction is an issue, worry about a successful partner performance can become increasingly absorbing during the course of the sexual experience, so that the concern crowds out the patient's capacity to focus on the sexual stimuli that maintain the arousal response. When such patients realize arousal is diminishing, they try all the harder, shutting off completely their ability to respond to sexual stimuli. This process is called spectatoring, a term coined by William Masters and Virginia Johnson (16). The term describes a process whereby patients, through observation of their performance, psychologically take themselves out of the experience. The mental process is guaranteed to result in loss of sexual arousal. Typically it may begin after one or two failed experiences secondary to external events or stresses. Once the process begins, it becomes internally reinforcing, leading to further worry and further failure. When this process is suspected, the history should focus on the patient's mental experiences during sexual intercourse.
Other common causes of psychologically inhibited sexual arousal are stressful life situations. Patients who have recently lost a job, lost a relative, are concerned about retirement, or have developed an illness, may be unable to clear their minds of their worries during a sexual experience and therefore cannot respond. Similarly, negative emotions, feelings of anger or resentment directed toward the sexual partner can interfere with the ability to become sexually aroused. All women have difficulties becoming sexually aroused at some times in their lives; it is the persistent and chronic nature of poor arousal that is the hallmark of FSAD.
Treatments for Female Sexual Arousal Disorder
Psychological Treatments for FSAD
The strategy for management of sexual arousal disorders with psychological or relational etiologies is the same in both sexes and depends on whether the patient has had the dysfunction for a sustained period or whether the dysfunction has appeared recently and there is a history of competent sexual functioning. As discussed earlier, transient inhibition of sexual excitement is often secondary to stressful life situations or marital discord. These clinical situations often respond to brief counseling. The role of the therapist is to help the couple recognize the effect of the stress on their relationship as well as the effect of their feelings (often anger) on their ability to relate sexually. Encouragement of collaborative contingency planning for resolving problems reduces anxiety and anger, often helping the couple to return to their baseline level of sexual function. The same principles and steps are applicable to an individual patient.
When spectatoring is a major factor and does not remit after open discussion, referral to a professional skilled in sex therapy usually brings excellent results. Sensate focus therapy, first developed by Masters and Johnson, combines cognitive and behavioral techniques to replace spectatoring with appropriate sexual focus and behavior.
The following factors favor a good prognosis after treatment for psychogenic arousal disorder: history of adequate prior sexual functioning, acute instead of insidious onset, short duration of sexual impairment, stable social situation, high motivation for treatment, presence of sexual desire, partner willing to participate in treatment, absence of severe marital conflicts, and absence of significant concurrent psychopathology.
Even in patients for whom excellent function can be expected to return, sexual arousal may be impaired by worry and hesitation. This is especially true when impaired arousal has been present for more than a few weeks, which is often the case. Such patients may be invited to discuss this situation freely and given permission and encouragement to experiment with their partner in one or more ways (e.g., masturbation, erotic pictures or movies, new techniques) in order to test or promote their sexual functions. Of course, such advice should be consistent with the patient's personal beliefs.
Patients who have experienced a sexual arousal disorder over a long period, or who have never functioned competently (lifetime), may be given a trial of short-term counseling (see Chapter 20). If the counseling does not result in reasonable improvement, referral for more expert help should be considered.
Oral Pharmacologic Treatments for FSAD
Fresh with the flush of success accompanying the introduction of the phosphodiesterase type 5 (PDE 5) inhibitors (e.g., sildenafil) for the treatment of arousal disorders (erectile dysfunction) in men, pharmaceutical sponsors were encouraged to investigate the same drugs for the treatment of arousal disorder in women. Unfortunately, several large, controlled, clinical trials did not demonstrate an equivalent consistent efficacy in treating FSAD. As a result, the programs in this area (e.g., the female Viagra program) were discontinued. It is now clear that a significant reason for this failure was that the definitions of FSAD used in the inclusion criteria for clinical trials were too broad, and many patients were entered into the trials with arousal symptoms but not true arousal disorder. In these patients, many of whom were probably suffering from hormonal insufficiencies as a primary etiology, there would be no reason to expect that a PDE 5 inhibitor alone
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would be effective. In spite of these negative results, there is evidence that the PDE 5 inhibitors work in FSAD (17). It appears important, however, that the presentation be relatively uncomplicated, with explicit appreciation of genital symptoms and an absence of comorbid symptoms of desire disorder (18). In addition, there is also some evidence indicative of efficacy in arousal disorders for tibolone, the synthetic steroid (19).
Other Somatic Treatments for FSAD
The somatic treatment of biogenic arousal disorder in women follows the threefold goals of stabilizing disease process, reversing any medication side effects, and improving the genital environment. Any form of estrogen therapy will benefit atrophic vaginal tissue, but local applications (creams or a vaginal ring) are particularly effective. Women receiving estrogen-replacement therapy may also benefit from the addition of vaginal estrogen, especially in the early menopausal years. Estrogen improves lubrication, makes the vaginal epithelium thicker, and may improve vaginal sensitivity. Absorption from the vaginal mucosa is good, so if the uterus is intact a progestin must be used either continuously or cyclically to protect the endometrium.
There are some concerns that hysterectomy may affect sexual functioning. However, such concerns remain unsubstantiated. Clinical investigations have suggested that hysterectomy often produces no change in sexual function for the majority of women or in some cases may even enhance sexual functioning (20). Nonetheless, theoretical concerns that radical extirpative pelvic surgery in women may compromise the nerve supply involved in optimal sexual functioning have led to the development of techniques to preserve genital innervation.
In April 2000, the FDA approved an innovative device for the treatment of arousal problems in women known as Eros-CTD (Urometrics, St. Paul, MN). This is a battery-operated suction device that applies suction to the clitoris and improves sensation, lubrication, and orgasmic capacity. The erectile tissue of the clitoris was recently found to be more extensive than previously described in anatomy texts, through research by an Australian team who performed a series of cadaver dissections on women of various ages (21).
Female Orgasmic Disorder
In the NHSLS, 74% of women in the 18- to 29-year-old age group reported being usually orgasmic during sex, as opposed to 78% of women in the 40- to 49-year-old age group. The study also found that only 29% of women overall reported always having an orgasm during sex, and that 40% of women reported feeling extremely physically pleased, with 39% reporting feeling extremely emotionally satisfied (6).
Diagnostic Classification
Orgasm disorders caused by medical conditions or medications should be diagnosed as symptoms associated with the responsible conditions or medications (Tables 6.1, 6.3, and 6.4).
Female orgasmic disorder (FOD) is defined as a persistent or recurrent delay in or absence of orgasm following a normal sexual arousal phase, and an adequate course of sexual stimulation. Women exhibit wide variability in the type and intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, her sexual experience, and the adequacy of sexual stimulation she receives In addition, the disturbance must cause marked distress or interpersonal difficulty for the patient, and not be better accounted for by another axis I disorder (except another sexual dysfunction) and is not caused exclusively by the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Organic conditions that affect orgasm comprise for the most part hormonal deficiencies, neurologic disorders, drugs that affect the autonomic system, and surgical or traumatic interruptions of the involved neural pathways (Tables 6.1, 6.3, and 6.4). History taking and physical examination should focus on these possibilities. In women, diabetic autonomic neuropathy is one of the most common organic causes of orgasm disorders, although certainly other neurologic diseases have sexual effects (22).
Psychologically caused orgasmic disorder is a common problem in women. Studies estimate that up to 25% of the female population has orgasm problems, and 30% to 50% of all women are sometimes anorgasmic with intercourse. Assessment should focus on the duration of the problem, a history of sexual functioning, the status of the relationship with the spouse or partner, and the presence of a stressful situation. A history of recent onset, competent past functioning, and identifiable precipitating stresses predicts a good response to treatment. Patients who have been anorgasmic for many years and are seeking help because of a change in their relationship or life situations are more difficult to treat.
Some women complain of anorgasmia, but evaluation reveals that the patient is actually experiencing a sexual arousal disorder. Because treatment may differ for these disorders, clarification of the phase in which the dysfunction is operating may be important.
Treatment for Female Orgasm Disorders
As with biogenic arousal disorder, the somatic treatment of biogenic orgasmic disorder in women follows a similar strategy. In patients with known neuronal damage, including diabetic neuropathy, the goal of therapy should be to help the patient adjust to the permanent loss
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or decrease of sexual responsiveness. This can be done by helping the patient value the role of sensual pleasuring, as distinct from sexual pleasuring that has as its single goal intercourse and orgasm.
Transient forms of anorgasmia caused by psychogenic factors are amenable to treatment with counseling. A history of previous orgasmic response is a good prognostic indicator. The block in orgasmic response is often caused by the process of spectatoring. The interfering process is usually secondary to stressful life situations or marital discord. Counseling for married women and others who have a regular sexual partner should include the partner, provided that this is agreeable to the patient. Counseling should be aimed primarily at resolving the dominant problems, which are usually life stresses or interpersonal strife. With the single patient, counseling should be directed at helping the patient suppress or remove the psychological events (i.e., spectatoring) that are occurring at a critical time, when the patient has reached a high plateau level of excitement and is prepared for orgasmic release. The interfering psychological events may be removed by having the patient focus to the best of her ability on the physical stimuli that she is experiencing during the excitement phase.
Women with anorgasmia of long duration can be given a trial of counseling. If counseling does not result in substantial improvement, referral for additional evaluation and treatment should be made.
Directed Masturbation
Orgasmic difficulty in women can be regarded as a skill deficit, and books are available that give women instructions on how to have an orgasm by using masturbation or a vibrator, and then to “bridge” this ability to coitus with a partner. This method is described well in two commonly used books, which can be recommended to patients (23,24). Success rates reported with this method are high; in one study, 95% of patients were able to achieve orgasm through masturbation, 85% with the direct stimulation of a sexual partner, and 40% with penile–vaginal intercourse (25).
Antidepressant-Related Side Effects
Sexual dysfunction caused by treatment with a SSRI antidepressant is a frequent complaint. Decreased libido and orgasmic dysfunction are the most common problems, but arousal difficulties are also reported. The incidence ranges from approximately 35% to 75% of patients treated. SSRIs probably impair sexual function because of a blockade of the 5-hydroxytryptamine 2 (5-HT2) receptor, which is believed to inhibit dopaminergic function in the areas of the brain that are involved with sexual function. Peripheral mechanisms have also been postulated, such as effects on cholinergic receptors or on nitric oxide (26).
The common strategies for dealing with antidepressant-related sexual dysfunction were evaluated in a review article by Zajecka (27). Gradual reduction of the dose of the SSRI may be helpful, but the patient must be observed closely for the re-emergence of depressive symptoms. Some clinicians wait for tolerance to develop, but only 19% of patients reported any improvement over 4 to 6 months (26). Skipping doses of the antidepressant for 48 hours was helpful in improving sexual function for 50% of patients on the shorter-acting SSRIs, such as sertraline or paroxetine (28). Patients at risk for noncompliance should not be encouraged to try this strategy. Many agents have been used as antidotes for sexual dysfunction, but little well-controlled research has been done, and most recommendations are based on case reports or observational studies (Table 6.7). One placebo-controlled trial found that 59% of patients receiving buspirone augmentation had improved sexual function, as opposed to 30% of patients receiving placebo. Another strategy is to switch the patient to an antidepressant that does not block reuptake at the 5-HT2 receptor, such as nefazodone, buproprion, or perhaps escitalopram (29).
Antidepressant-related sexual dysfunction is frequently a difficult problem and can lead to early discontinuation of antidepressant therapy. Because there are potential problems associated with all of the strategies mentioned, the best approach may be to choose an antidepressant that is less likely to cause sexual dysfunction in patients for whom this is an important concern (see Chapter 24). It is critical, when initiating antidepressant therapy, to assess baseline sexual functioning and to consider the potential impact of sexual dysfunction on that patient's recovery. If the patient is warned about the possibility of sexual dysfunction when started on an SSRI, it may be easier for the patient to bring it up if it does occur.
Female Sexual Pain Disorders
Diagnostic Classification
Dyspareunia.
Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse in either a male or a female. The disturbance causes marked distress or interpersonal difficulty for the individual, and is not caused exclusively by vaginismus or lack of lubrication, is not better accounted for by another axis I disorder (except another sexual dysfunction), and is not caused exclusively by the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Vaginismus.
Is defined as a recurrent or persistent involuntary spasm of the musculature of the outer third of
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the vagina that interferes with sexual intercourse. The disturbance causes marked distress or interpersonal difficulty for the individual, is not better accounted for by another axis I disorder (e.g., somatization disorder), and is not caused exclusively by the direct effects of a general medical condition.
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TABLE 6.7 Antidotes for Selective Serotonin-Reuptake Inhibitor-Related Sexual Dysfunction |
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Assessment and Treatment
In both sexes, the complaint of discomfort or pain during intercourse requires a careful history, physical examination, and laboratory testing. The most common causes are infections or atrophic vaginitis in women, and urethral or prostatic infection in men. As is true of the dysfunctions discussed previously, it is probably counterproductive to consider dyspareunia as either psychogenic or physical, because it is now recognized that nearly all cases have elements of both physical and psychological causes. Genital pain disorders are different from pain disorders elsewhere in the body only because the activity affected is frequently more emotionally charged than other activities. In fact, the term sexual pain disorder has been criticized by some because it focuses on the activity affected by the pain rather than on the anatomical location of the pain, or on the pain itself (30). This may have contributed to the long-held assumptions of many that painful sex was largely a psychological problem, an assumption that has undoubtedly contributed to the fact that only recently have these disorders begun to be rigorously studied. On the other hand, because sexual difficulties have an impact on one's self-esteem and relationships with partners, most patients with sexual pain disorders can benefit from counseling with an experienced mental health provider. This suggestion is sometimes met with resistance from the patient, but should be persistently encouraged by the provider.
Dyspareunia.
Pain with vaginal intercourse is characterized as introital (or insertional), vaginal, or deep (pelvic pain with penile thrusting). Deep dyspareunia can be caused by almost any type of pelvic pathology and is addressed in Chapter 102. Dyspareunia can also be caused by insufficient arousal. With adequate arousal, there is engorgement of clitoral erectile tissue surrounding the anterior distal vagina, vaginal lubrication, ballooning of the vaginal apex, and uterine elevation. These changes all facilitate pain-free penetration. Women frequently recognize the lack of lubrication with insufficient arousal and may use a lubricant, but are unaware of the vaginal changes that accompany arousal. It is important, when discussing the use of a vaginal lubricant, to caution women and their partners not to abbreviate the arousal phase, because lubrication often is not enough to prevent pain with penetration. The experience of pain can then lead to the expectation of pain, which causes muscle tension and less arousal, creating a painful cycle.
Introital dyspareunia is quite common. A recent population-based survey found that 16% of female respondents reported histories of chronic burning, knifelike pain, or pain on contact that lasted for at least 3 months or longer, and nearly 7% were experiencing the problem at the time of the survey (31).
When a patient complains of introital dyspareunia, a careful examination, including wet preparation and pH
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(see Chapter 102), should be done to look for vaginal infections or dermatologic conditions. A vulvar biopsy is often required to assess skin changes, and fungal cultures should be sent on any patient without an obvious cause for vulvar burning or pruritus because the vaginal wet preparation is only approximately 50% sensitive for the diagnosis of a candidal infection (32). The vulva is typically also examined with the cotton swab test in which a moistened cotton swab is touched lightly to points around the vulvar vestibule and then to other areas on the vulva and perineum. The patient is asked to rate her pain on a scale of 0 (no pain) to 10 (severe pain). A diagram and a pain map can be used to document and track the pain.
The importance of evaluating the pelvic floor muscles in any patient with dyspareunia cannot be overstated. Muscular hypertonicity and trigger points are frequently contributing factors. A physical therapist with specialized training in pelvic floor treatments is a vital part of the treatment for many types of dyspareunia.
Women with dyspareunia are often unknowingly participating in behaviors that may cause or exacerbate their pain. A study of 503 women with “benign vulvar disease” found that 69% remained sexually active in spite of arousal failure and unlubricated and painful intercourse. The reasons given were timidity, unassertiveness, feeling guilty if they refused, and habitual passive compliance. Sixty-eight percent of patients participated in “potentially harmful hygiene or self-treatment” (33). Soaps and over-the-counter vaginal treatments are frequent causes of irritant or allergic reactions. A careful history is necessary to discover any possible contributing factors. Soaps with perfume or antibacterial components should be eliminated (sometimes even for the partner), fabric softener sheets should not be used in the dryer, douching should be stopped, and products applied to the vulva should be carefully reviewed for the potential to cause a reaction.
A frequent cause of dyspareunia in perimenopausal, menopausal, and in postpartum or lactating women is atrophic vaginitis. This can usually be treated quite easily with topical low-dose estrogen, and is covered more fully in Chapter 102.
Vulvodynia.
Vulvar burning, irritation, soreness, rawness, or stinging in the absence of objective clinical and microbiologic abnormalities that has been present for 3 months or more can be diagnosed as vulvodynia. Other terms that have been used for this disorder are vestibular adenitis, vulvar vestibulitis, and vestibulodynia. Friedrich first described and defined this condition in 1987 (34), but it is, unfortunately, still unrecognized by many providers. In Harlow's 2003 population-based survey, 60% of patients saw three or more physicians for this condition, many of whom could not provide a diagnosis (31). These patients may also present to mental health providers after being told that there is “nothing wrong” physically. This condition is now understood as a form of neuropathic pain and is described more fully inChapter 102.
Vaginismus.
Vaginismus and vulvodynia are frequently comorbid, and can be difficult to distinguish from each other. The diagnosis of vaginismus is typically made with a pelvic exam, by palpating a spasm or by an involuntary muscle contraction in the distal vagina. The salient characteristic of vaginismus has been described as a muscle spasm or involuntary contraction, but some recent studies have found that electromyelogram (EMG) measurements in vaginistic women do not differ from vulvodynia patients or from normal controls. Other studies have found more hypertonicity and muscle spasms in women with vaginismus than in other women. Patients with vaginismus often have hyperesthesia at the introitus, or in the distal vagina, as well as in the hypertonic muscles. To complicate the diagnosis further, vaginismus may be situational and can be present only during sexual activity, or only with pelvic exams, or with both. A study by Reissing et al. (35) found that the characteristics that best differentiated vaginismus from vulvodynia were the degree of distress exhibited during the pelvic examination and the level of interference with coitus. More than 70% of women with vaginismus reported never having experienced vaginal penetration, whereas all of the women with vulvodynia had experienced coitus.
There are no good estimates of the prevalence of vaginismus, and much of the research that has been done has involved clinic populations and has not included control groups. Vaginismus is a difficult disorder to study because women are often phobic about pelvic examinations and are reluctant to come in for treatment or for research studies.
The cause of vaginismus is unknown. Many of the older theories about causation are largely discredited, including unconscious conflicts and extreme religiosity. Studies looking for histories of sexual abuse are conflicting, but a recent study by Reissing found an increased incidence of “sexual interference” prior to age 13 years in vaginismus patients (36). Vaginismus may begin as an appropriate response to a painful sensation, but then become self-perpetuating. Theories about the etiology of other chronic pain syndromes may provide the best explanations for this disorder, such as central or peripheral sensitization, catastrophization, and illness attribution (30). Many women with severe vaginismus have satisfactory relationships with their partners, and they frequently have satisfactory sexual relationships with noncoital sex. Many have no orgasmic difficulties.
A useful way to explain vaginismus to a patient is to compare a vaginistic patient's response to vaginal penetration to the typical, automatic, protective response of a person trying to put a contact lens in for the first time. The
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muscle contractions around the eye are quite involuntary at first, but can be eliminated with practice.
The most effective treatments for vaginismus are behavioral, and success rates of 80% or greater are frequently reported (37,38). However, dropout rates are frequently high, and very few studies actually consider coital pleasure after treatment. Success in treatment is highly dependent on the motivation of the woman, and the desire for pregnancy may be a more effective motivator than the desire to function sexually. Vaginal dilators are generally used, and the patient is taught to do the exercises at home. The vagina is not actually “dilated” during this process, but rather there is a deconditioning of the pelvic floor and pelvic muscles’ response to vaginal penetration.
Treatment usually begins in the office, so that the patient can be taught to insert the dilators. Soft silicone vaginal dilators are usually purchased, but other cylindrically shaped objects can be used, such as culturette tubes, candles, or syringes with the needle tips cut off. Relaxation techniques and Kegel exercises are also taught. The patient is instructed to practice inserting the dilator regularly at home, and then to use progressively larger dilators. Vaginismus patients are often very uncomfortable with their own genitalia and may find it helpful to initially use a mirror, or to wear gloves for their practice sessions. Followup visits in the office are important to motivate the patient to practice consistently. She should be re-examined periodically for introital tenderness or muscle tenderness, because recovery will necessitate treatment of these problems as well.
Dilation exercises can be done by women themselves, or they can be incorporated into the couple's sexual activity. Most patients want to keep the dilation exercises under their own control at first, but some patients are comfortable having their partners insert the dilators, or may use the partner's fingers.
Medication is sometimes helpful. Antidepressant medications can be quite useful to diminish general anxiety, or benzodiazepines can be used for practice sessions. Some antidepressants such as tricyclics or venlafaxine may have the dual benefit of reducing anxiety and of helping to treat any comorbid vulvodynia. Topical lidocaine (2% to 5%) gel or cream can be used for vaginal or introital hyperesthesia. There are case reports of the successful use of botulinum toxin for vaginismus, but there are no published studies to date.
Sexual Aversion Disorder
Diagnostic Classification
Sexual aversion disorder is characterized as a persistent or recurrent extreme aversion to and avoidance of all or almost all genital sexual contact with a sexual partner. The disturbance causes marked distress or interpersonal difficulty, and it is not caused by another axis I disorder (except another sexual dysfunction).
Assessment
Certain patients may give a history of aversion to or avoidance of all forms of genital contact with a sexual partner, in contrast to a history of gradual or sudden loss of sexual desire. The complaint is often of long standing but may be of recent onset. The aversion may be so severe as to be associated with panic attacks should the patient find herself confronted with a sexual experience. It is important to recognize that fundamentally this disorder is an anxiety–phobic disorder in which the sexual expression serves as a focus for extreme anxiety. Sometimes the patient's presentation will minimize the anxiety component of the condition, making it appear to be a case of loss of sexual desire or chronic sexual disinterest. In these instances, the clinician must probe the respondent in some detail as to the nature and course of the problem to establish the anxiogenic nature of the condition.
Treatment of Sexual Aversion Disorder
Treatment usually requires a course of individual and couple treatment by a skilled sex therapist. The treatment goal is to replace the negative affect and avoidant behaviors associated with phobic-like stimuli with relaxation and pleasure in mutual sexual expression. The treatment of any associated panic attacks may be augmented with low-dosage antidepressant medication (see Chapter 22).
Male Sexual Disorders
Hypoactive Sexual Desire Disorder
Diagnostic Classification
As is the case with females, HSDD in the male is defined as the persistent or recurrent deficiency or absence of sexual fantasies thoughts or desire for sexual activity. The judgement of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning (e.g., age, presence of a partner, health status). As with women, the condition must cause the individual marked distress or interpersonal difficulty, and not occur exclusively during the course of another axis I disorder, nor be caused by a pharmacologic substance or another medical condition.
Assessment
As seen in Tables 6.1, 6.2, and 6.4, many medical conditions and drugs have the potential to decrease or eliminate sexual desire. In practice, many of these conditions are well known and easily diagnosed by the patient's physician. Numerous factors can be involved in the loss or reduction of sexual desire in males. Unlike women, however,
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it is extremely rare to see lifetime absence of sexual desire in a man, except in the case of specific endocrinopathies or other explicit medical conditions. The presence of medical disorders, trauma, surgical interventions, pharmacologic therapies for other medical conditions, and substance abuse are all potential etiologic agents and should be reviewed and ruled out. A laboratory assay of endocrine levels, including free, total, and biologically active testosterone, as well as sex hormone-binding globulin (SHBG), is often useful in gaining further insight into the nature of the basis for the condition. In some instances the physician may also want to request prolactin levels to rule out the presence of a pituitary microadenoma, which affects both men and women.
It is also important to bear in mind that beginning at about age 30 years, serum testosterone levels in males decrease approximately 1.6% per year. The sources of this decrease are both central and peripheral, and it occurs over a period when serum levels of SHBG are rising as a consequence of the aging process. This combination of effects can result in an androgen-deficiency syndrome, referred to as ADAM (androgen deficiency in aging men) (40).
In addition to low or absent sexual desire, men in this hypogonadal state manifest losses in strength, bone density, and muscle mass; experience fatigue and loss of well-being; and report a loss of initiative and confidence in themselves. Such a clinical presentation with a total testosterone level of <300 ng/dL is often associated with ADAM, and is estimated to have a prevalence of >20% in men older than age 60 years (41,42). Some in the field refer to this condition as andropause; however, many believe this term is inappropriate and a misnomer because the analogy with menopause in women fails at a number of levels.
Depression is also an extremely common cause of reduced sexual desire in both genders, and is itself a highly prevalent clinical condition. In addition, many of the drugs used to treat depression (e.g., the SSRIs) are themselves etiologic in desire disorders, with rates as high as 60% to 70% being reported (26) (Table 6.4).
Treatment
Effective treatment of HSDD in men greatly depends on correct identification of the underlying cause of the condition. If an androgen deficiency syndrome is found to be present, there are numerous options for testosterone replacement. Although other modalities exist testosterone gel and patches best approximate the normal circadian cycle. Both are available in a variety of doses, and once treatment has begun, total and free serum testosterone should be evaluated at 3, 6, and 12 months after initiation.
If it is determined that a loss of desire is secondary to the initiation of treatment of a clinical depression with SSRIs, a number of alternatives are available. As discussed earlier under Treatment for Female Orgasmic Disorder, the physician can try reducing the dose, switching to another less-problematic antidepressant, looking into the possibility of drug “holidays,” or adding a prosexual agent (e.g., bupropion) to the therapeutic regimen. Usually, with patient cooperation, some experimentation will result in a favorable outcome.
Finally, it is worth noting that some patients present with a complaint of loss of sexual desire that is actually a secondary manifestation of another primary sexual dysfunction, usually ED. Repeated attempts resulting in erectile failure often humiliate and frustrate the patient to the point that he loses interest in sex, to some extent as an ego defense against his inability to perform. Care must be taken when interviewing the patient presenting with loss of sexual desire to ascertain that the condition is primary, and not the secondary result of another more central problem.
Male Erectile Disorder
Diagnostic Classification
Assessment
Early detection and screening are useful actions in many patients, particularly those considered to be at high risk for erectile dysfunction. For instance, patients who have a sedentary lifestyle or are heavy cigarette users may be identified as at-risk individuals. Patients with medical histories consistent with cardiovascular disease, including diabetes, dyslipidemia, and hypertension, could also suffer from erectile dysfunction and benefit from intervention. Patient self-reported questionnaires that inquire about and rate levels of attainment and maintenance of erection, confidence in sexual performance, and even sexual satisfaction can be used. Although such tools were designed primarily for clinical trial use, they may serve as screening devices, if not as a means to monitor treatment responses in individual patients. As an example, the Sexual Health Inventory for Men, an abridged version of the International Index of Erectile Function, is commonly used for this purpose (43).
Diagnostic assessment begins with defining the presenting condition and then taking a thorough medical (including medications), surgical, and social history followed by appropriate laboratory testing. Confirmation of the problem adheres precisely to its definition as the inability to attain or maintain an erection sufficient for satisfactory sexual performance or intercourse (44). The
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initial history may lead to its attribution as either organic or predominantly psychogenic. Organic etiologies include neurogenic, hormonal, vascular, or medication-associated erectile dysfunction, whereas psychogenic etiologies include depression, stress, performance anxiety, relationship issues, and sexual arousal difficulties. Table 6.8 lists features of the clinical history that may be helpful in supporting this distinction. Physical examination may cover all aspects of the patient's health, although particular focus should be given to the neurologic and vascular systems, as well as to the genitourinary system. The patient's genitalia should be examined for any unusual characteristics, such as deformity, scarring, or angulation of the penis suggestive of Peyronie disease or prior trauma. Laboratory testing is purposefully done to confirm or exclude underlying disease and is generally tailored to the individual clinical presentation. Tests may include blood glucose, lipid profile, urinalysis, and complete blood count. An endocrine assessment, such as morning-time total testosterone measurement, may be performed when hypogonadism is suspected. Other endocrine tests, such as thyroid-stimulating hormone measurement, may be carried out if there is clinical suspicion of thyroid disease.
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TABLE 6.8 Clinical Features Differentiating Predominantly Psychogenic from Predominantly Organic Erectile Dysfunction |
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Subsequent management should be goal-oriented, in recognition that patients’ preferences and expectations regarding management options for erectile dysfunction vary greatly. Accordingly, patient and partner involvement in such clinical decisions is a critical component of the full evaluation and treatment process.
Depending on the complexity of the clinical presentation, a referral to a urologist or erectile dysfunction specialist for additional tests may be appropriate. The contemporary role of such specialists has been reduced as a consequence of the recent introduction of effective first-line oral therapies for erectile dysfunction, which can be administered and evaluated for therapeutic success irrespective of the organic or psychogenic etiologic distinction. However, referral would be warranted prior to initiation of second- or third-line therapies, which are considered to be semi-invasive and possibly nonreversible. Recommended tests may include combined penile injection of vasodilators and sexual stimulation, duplex ultrasonography, cavernosography, pelvic-penile arteriography, nocturnal penile tumescence testing, and/or neurologic tests. A patient who presents with an atypical presentation, such as an adolescent or young adult with primary erectile dysfunction, is a reasonable candidate for referral. In addition, some patients may request referral for assurance that the problem has received an appropriate and comprehensive evaluation. Cases having medicolegal ramifications may also be subject to extensive diagnostic testing.
Treatment
Consistent with the principle of goal-directed assessment for the evaluation of erectile dysfunction, a similar principle may guide its treatment practices. It is imperative to consider what the patient (and partner) actually wants or expects to accomplish through treatment. Patients vary in their level of acceptance of their sexual disorders, and some may not wish to pursue treatment beyond easily administered, minimally invasive options. At the same time, a more significant, invasive intervention may be provided, depending on the extent of the problem and the manner of satisfaction derived with treatment. For instance, penile prosthesis surgery may be promptly pursued as a definitive option in patients desirous of this intervention despite the understanding that it is invasive and nonreversible.
First-Line Therapy.
Management of erectile dysfunction is most commonly initiated by a combination of pharmacologic therapy (Table 6.9) and counseling, along with a modification of lifestyle habits. Patients should be counseled to modify any detrimental behaviors, such as cigarette smoking, excessive alcohol use, recreational drug use, lack of exercise, and uncontrolled diabetes, so as to improve their sexual ability or prevent progression of the problem. If a medication is viewed to be the offending element, the medication regimen may need to be adjusted. Psychosexual counseling is often appropriate, even when the etiology is largely organic, as psychosocial overlays
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coexist in many patients. Interventions regarding anxiety management, cognition, and/or behavioral interventions may be beneficial.
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TABLE 6.9 Pharmacotherapies for Erectile Dysfunction |
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Androgen-replacement therapy constitutes first-line treatment when hormonal factors are judged to be involved in the presentation, although it is also recognized that this therapy is mainly useful for libidinal issues. The therapy is arguably worth implementing even in the presence of confounding etiologies. Androgen therapy may have other recognizable benefits other than sexual function restoration, with indications for decreased muscle mass, lethargy, depression, and osteoporosis, all of which are linked to reduced androgen levels. It is particularly noteworthy that risk associations, should be discussed, and a risk-to-benefit
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evaluation should be considered prior to implementing therapy.
PDE 5 inhibitors, a relatively new class of vasoactive drugs, currently represent the centerpiece of erectile dysfunction treatment. The PDE 5 enzyme is highly expressed in the smooth muscle of the corpora cavernosa and hydrolyzes cyclic guanosine monophosphate (cGMP), which is the intracellular mediator of the nitric oxide signaling pathway. Nitric oxide causes relaxation of the smooth muscle, enabling the vasodilation necessary for erection to occur. Selective inhibition of PDE 5, which prevents the breakdown of cGMP, represents a mechanistic approach to facilitate penile erection. Currently, three commercial, FDA-approved PDE 5 agents are available for treatment of erectile dysfunction in the United States: sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Their biochemical potencies and selectivities are relatively similar, although slight differences exist with regard to maximal serum concentration, time to maximal concentration, bioavailability, clearance, and protein binding. The most salient difference among these agents is the longer half-life of elimination described for tadalafil (17.5 hours, compared with 3 to 5 hours for sildenafil and 4 to 5 hours for vardenafil) (45, 46, 47). Differences in molecular structure of tadalafil may account for this distinction. In healthy men, peak serum levels of the medications after oral ingestion occur at 1 hour for sildenafil and vardenafil and 2 hours for tadalafil, suggesting time intervals needed for optimal efficacy. Common to all drugs of this classification is the need for sexual stimulation to induce nitric oxide release, upon which the therapy acts pharmacologically.
Current published reports on the efficacy of the PDE 5 inhibitors describe comparative analyses with placebo and not to each other, such that a true comparative basis to judge the superiority of one agent relative to the other is not possible. Trial parameters and patient characteristics may vary between studies. The treatment end point of most relevance from the patient's perspective—success in completing sexual intercourse—is similar across studies of the PDE 5 inhibitors, ranging from 61% to 71% for the recommended starting dose for each (48, 49, 50, 51). Success with the PDE 5 inhibitors is heightened through patient–partner involvement in treatment decisions, as well as modification of existing risk factors that influence the patient's ability to achieve an erection. In patients with comorbidities, if the condition is optimized, success rates of responsiveness to PDE 5 inhibitors are elevated; for example, 85% for treated hypogonadism (vs. 75% for untreated hypogonadism) and 62% for controlled diabetes (vs. 44% for uncontrolled diabetes) (52).
Special considerations with PDE 5 inhibitors exist based on drug metabolism, drug interactions, and cardiac risk. Because they are commonly metabolized by the cytochrome P450 3A4 isoenzyme pathway in the liver, a lower dose should be prescribed initially for patients who are taking medications that are also metabolized by this pathway, such as cimetidine, erythromycin, ketoconazole, nifedipine, saquinavir/ritonavir, and the statins. A lower starting dose should also be prescribed in instances of older age (<65) hepatic impairment, and renal impairment because of the increasing serum levels that may result from these factors. Adverse effects reported with the use of PDE 5 inhibitors include headache, flushing, and dyspepsia, which are discernibly vasodilatory and vasorelaxant responses occurring in other parts of the body that express PDE 5 (package insert references). Sildenafil-treated patients have also reported nasal congestion, visual disturbances, and diarrhea; vardenafil-treated patients have also reported rhinitis, sinusitis, and flulike symptoms; tadalafil-treated patients have also reported nasal congestion, back pain, and myalgia. All three PDE 5 inhibitors have been shown to potentiate the hypotensive effects of organic nitrates and are therefore contraindicated in patients using nitrate therapy, such as nitroglycerin and amyl nitrate “poppers.” Although there were early concerns in relation to the cardiac safety of PDE 5 inhibitors, long-term studies have not shown increased myocardial infarction or death rates. However, the drugs are contraindicated in patients for whom sexual activity is inadvisable because of underlying cardiovascular disease, unless appropriate cardiovascular intervention has been performed (53).
A long-touted erectogenic and aphrodisiac agent, yohimbine (Yocon) has been rigorously evaluated to establish its role as an orally delivered agent for the treatment of erectile dysfunction (54,55). The medication is an alkaloid derived from the bark of the yohimbe tree and is reported to exert central effects on the mediation of penile erection as an α2-adrenergic receptor antagonist. Conventionally, the medication is used at an oral dosage of 5.4 mg three times daily with clinical observation for at least 1 month to assess responsiveness. Although some evidence suggests that the medication may be more effective than placebo, its efficacy beyond placebo has not been affirmed in patients with confirmed organic erectile dysfunction. Adverse effects appear to be relatively infrequent but include hypertension, anxiety, tachycardia, and headache. Although yohimbine may be well tolerated, its modest results suggest that the medication is best limited to men with psychogenic erectile dysfunction.
Second-Line Therapy.
When first-line therapies are ineffective or contraindicated, patients may be best directed to consider second-line therapies such as intraurethral therapy, intracavernosal therapy, and vacuum constriction devices. These options are understood to be more intrusive and invasive than first-line therapies.
Intraurethral pharmacotherapy, which implies the administration of vasoactive drugs via the urethral channel of the penis, offers a potentially less-invasive procedure for local pharmacotherapeutic intervention than intracavernosal pharmacotherapy, as the latter requires needle injections. A synthetic formulation of prostaglandin E1
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(alprostadil) can be delivered through a novel transurethral drug delivery system known as medicated urethral system for erection, or MUSE (56,57). Several technical points optimize success of the treatment, including the patient's properly depositing and manually distributing the medication into the penis and then standing for several minutes after its application to increase penile engorgement. A final responder rate to the medication is documented at approximately 40%, with typical responses including tumescence without full rigidity. The combined use of an adjustable penile constriction band (ACTIS), designed and FDA-approved to enhance the local retention and effect of the medication, improves response to this treatment (58). The most common side effects of MUSE include local urogenital pain associated with metabolism of the medication and minor urethral bleeding associated with traumatic delivery of the medication.
Intracavernosal pharmacotherapy requires needle injection of vasoactive medication into the corpus cavernosum (59). Three medications are regularly used, either individually or in combination: prostaglandin E1, phentolamine, and papaverine. In-office titration is recommended because of the technical demands of this therapy, and because of the need to determine the dosage that yields an erection of sufficient rigidity for sexual intercourse yet lasts no more than 1 hour. Rates of successful sexual intercourse range between 70% and 90% (60). The treatment is contraindicated for men with psychological instability, a history of or risk for priapism, sickle cell disease, locally advanced pelvic or hematologic malignancy, histories of severe coagulopathy or unstable cardiovascular disease, or reduced manual dexterity (although the partner can be trained in the injection technique). Risks of complications include priapism (1% of men), penile fibrosis at the penile injection site (5% to 10% of men), local trauma such as hematoma (10% of injections), and penile pain (10% of men) (60).
Vacuum constriction devices offer a nonpharmacologic, mechanical means to produce an erection (61). A cylinder is temporarily placed externally around the penis with a seal that allows the creation of negative pressure for blood engorgement of the penis. The erection is maintained by placement of a constricting elastic ring around the base of the penis, after which the cylinder is removed and the erectionlike state allows sexual intercourse to occur. The treatment is generally pursued with instructional videotape or in-office teaching. The erectionlike state is achieved in at least 95% of applications. Significant complications are rare, with typical concerns related to cumbersomeness, coldness of the erect penis, and local penile trauma, such as petechiae and ecchymosis.
Third-Line Therapy.
Penile prosthesis surgery is an alternative treatment for erectile dysfunction, often applied after nonsurgical options have been found ineffective or unacceptable (62,63). The devices are surgically implanted within the corporal bodies of the penis. The two main varieties of devices are semirigid malleable devices and hydraulic inflatable devices. Use of the devices requires basic instruction. They reliably produce penile rigidity permitting sexual intercourse. Because their immediate use circumvents issues of lack of spontaneity, high satisfaction rates are frequently reported. Potential complications (<5% at 5 years) include infection, erosion, and malfunction of the device, and usually require device removal or replacement (63). Penile revascularization surgery is beneficial to a minority of patients with a confirmed vascular lesion of probable traumatic origin amenable to vascular bypass techniques (62).
Premature Ejaculation
Diagnostic Classification
There are three DSM-IV diagnostic criteria for premature ejaculation (PE): (a) persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it; (b) the disturbance causes marked distress or interpersonal difficulty; and (c) the disturbance is not exclusively caused by a substance (e.g., withdrawal from opioids).
Assessment
A fundamental aspect of the assessment of premature ejaculation is its accurate differentiation from other sexual dysfunctions. Of primary importance is the evaluation for erectile dysfunction, as many men may profess premature ejaculation when, instead, the actual problem is the patient's haste to achieve orgasm before the failure of erection. In such cases, successful treatment of erectile dysfunction may resolve the complaint of secondary premature ejaculation. Subsequent focus is given to sexual and psychosocial history. Key elements of the history taking is the determination of level of distress experienced by both the patient and his partner, discussion of the patient's perception of ejaculatory control, and inquiry into the onset and duration of premature ejaculation. The latter has importance to establish whether the condition is primary or secondary. Psychosocial aspects of the patient history, such as a history of childhood physical or sexual abuse, are relevant and may establish a need for psychotherapy as part of the treatment approach. A comprehensive medical history may lead to the identification of certain medical conditions that are associated with ejaculatory dysfunctions, such as diabetes and other neuropathies (64,65).
Treatment
Approaches to managing premature ejaculation are conventionally divided into two broad categories: psychotherapeutic–behavioral and pharmacotherapeutic. The former has long been advocated, mainly because of the
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paucity of other effective therapies. The strategy is to promote the patient's understanding of his progression through the human sexual response cycle and then, with his partner, practice one of two behavioral control techniques: the “squeeze” and “stop–start” techniques. The squeeze technique requires the partner to place her thumb and first two fingers around the coronal ridge of the penis and press firmly for 10 seconds. The pressure results in a 10% to 25% loss of erection and a decrease in the subjective sense of arousal. The technique teaches the couple a method of control that can be practiced well before the patient reaches high levels of sexual arousal. The stop–start method accomplishes the same result by discontinuing all forms of stimulation. The patient and his partner alternately stimulate and practice control with these techniques until they are confident of their ability to exercise control. At this point, they progress to coitus interrupting the experience with the behavioral techniques as necessary. Requirements of these techniques include a stable relationship and time to learn and use them. Reports are mixed with regard to their practicality and long-term efficacy.
An alternative approach is to use pharmacotherapies that strategically serve to reduce sensory input to the penis, prevent penile detumescence after ejaculation, and suppress apparent ejaculatory reflex mechanisms. Topical anesthetics, such as the lidocaine–prilocaine combination, as well as some herbal preparations, such as the Korean product SS-cream, are applied to the glans penis, diminishing sensitivity and delaying the threshold for ejaculation (66). Advantages are their simplicity and low cost. However, some of these preparations can cause local irritation as well as penile hypoanesthesia. Additional possible adverse effects include vaginal numbness and female anorgasmia, unless a condom is used. Pharmacostimulation of erection, such as oral PDE 5-inhibitor treatment and intracavernosal pharmacotherapy, has been used to promote the erectile response, perhaps even enabling erection after ejaculation has occurred, but such treatment has not been convincingly shown to delay ejaculation per se or operate through any direct mechanism of action to control the ejaculatory response. Oral retardants of ejaculation constitute the most common pharmacologic approach. Most of the currently used medications are centrally acting antidepressant drugs that involve central 5-hydroxytryptamine neurotransmission. These include clomipramine, a tricyclic antidepressant, and SSRIs such as fluoxetine, sertraline, and paroxetine. Clomipramine use is limited by drowsiness and significant anticholinergic side effects such as dry mouth and blurred vision. Although SSRIs are better tolerated, they often require long-term dosing regimens to be effective and they are also associated with nausea, drowsiness, cognitive impairments, and sexual side-effects, including decreased libido and erectile dysfunction. Pharmacotherapies currently in development may come closer to the ideal characteristics of well-tolerated, on-demand oral therapy for this very common male sexual dysfunction.
Male Orgasmic Disorder
Diagnostic Classification
There are three DSM-IV diagnostic criteria for male orgasmic disorder: (a) persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase, taking into account the patient's age; (b) the disturbance causes marked distress or interpersonal difficulty; and (c) the disturbance is not caused by another axis I disorder or exclusively by a substance (e.g., a drug of abuse or medication) or a medical condition.
Assessment
Although anorgasmia is a rather uncommon disorder in men, certain organic and psychogenic associations can be explored in evaluating this presentation. The organic conditions that affect orgasm comprise, for the most part, neurologic disorders, drugs that affect the autonomic nervous system or lower genitourinary tract, and surgical or traumatic interruptions of the invoked neural pathways for ejaculation (67). Clinical history taking and physical examination should focus on these possibilities. Accordingly, the workup may reveal such associations as the presence of diabetes, SSRI or alpha-blocker medication use, prior retroperitoneal lymph node dissection for malignancy, or radical pelvic surgery. It is important to evaluate ejaculatory ability and orgasm separately, because they do not necessarily coincide. The disorder referred to as anejaculation, or failure to ejaculate, is associated with disruption of the sympathetic nerve supply to the accessory male reproductive tract structures, primarily causing failure of emission, although orgasm may still be experienced because of the intact somatic innervation of the striated musculature of the pelvic floor. Distinct from this problem, retrograde ejaculation involves dysfunction of the internal urinary sphincter mechanism such that the ejaculate readily enters the bladder following sexual stimulation as a consequence of a drug or transurethral surgery. In this entity, subjective sensation of orgasm is typically preserved. Psychogenic anorgasmia in men is a rare disorder associated with personality disturbances. Obsessive–compulsive, avoidant and, infrequently, sadomasochistic traits are observed. Commonly, anorgasmia is restricted to penile–vaginal intercourse whereas other forms of sexual stimulation, for example, masturbation, permit orgasm.
Treatment
Treatment of orgasmic disorders in men centers mainly on correcting reversible causes when possible. This objective may most feasibly apply to the situation in which a drug is associated and can be changed. Treatment of anejaculation is generally indicated to restore fertility and
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targets mechanisms that achieve seminal emission. Adrenergic receptor agonists, such as ephedrine sulfate, pseudoephedrine hydrochloride, and imipramine hydrochloride, have been used for this purpose. However, their roles have been limited because of their variable success and their causing sympathomimetic side effects such as dizziness, weakness, nausea, and sweating (68). Electroejaculation and other assistive reproductive techniques are mostly employed for this management. Penile vibratory stimulation has also been described as a technique to treat idiopathic orgasmic dysfunction.
Sexual Disorders Resulting from Medical Conditions or Substance Abuse
There are two additions to the diagnostic nomenclature in the DSM-IV (3) for sexual dysfunction: Sexual Dysfunction due to a General Medical Condition and Substance-Induced Sexual Dysfunction. As one might expect from the labels, these two diagnostic categories address specific organic etiologies of sexual dysfunctions, the former reflecting effects of a general medical condition, the latter based on findings of a connection between sexual dysfunction and substance intoxication or medication use. The DSM-IV sets the following criteria:
Gender Identity Disorders
The essential feature of the gender-identity disorders is cross-gender identification. The hallmark is the desire to be, or the insistence that one is, the opposite gender and significant, persistent distress about one's biologic sex. There are childhood and adult forms of the disorder. Children manifest symptoms by rejecting stereotypical dress, play activities, and behaviors associated with being a “boy” or a “girl.” The adoption of cross-gender roles is persistent, and attempts by parents to change the behaviors are met with strong resistance and emotional displays of anger and tearfulness.
Adolescents and adults are generally more circumspect about revealing or expressing their cross-gender identification, at least early in the process of coming to an understanding about their cross-gender desires. The consequences of expressing a cross-gender identification in childhood can be significantly adverse, especially for boys who are teased, physically abused, and ostracized by their peers. Coping with the disorder in adulthood has the potential of being extraordinarily disruptive to relationships, education, and professional/vocational development as the desire for cross-gender living, hormonal/surgical reassignment, and social acceptance in the cross-gender role becomes the central focus of the patient's existence. In the past decade, individuals with gender identity disorder have presented wanting to be a blend of both the male and female phenotype, presumably to match the gender-blending identity they strive to assume.
Etiology and Prevalence
No known genetic or biologic predisposing factors have as yet been elucidated. There is limited evidence from studies of families that cross-gender identification in children can be reinforced within the context of the parent–child relationship. Clinical studies of adults continue to reveal no specific pathologic personality features or psychiatric symptom clusters associated with the disorder. The disorders are rare. European epidemiologic studies reveal that 1 in every 30,000 adult males and 1 in every 100,000 adult females seek treatment for these disorders.
Course
Parents usually seek evaluation when the affected child enters school because the cross-gender identification and behaviors become public. One prospective study (69) found that almost 75% of the boys with this disorder reported a homosexual or bisexual orientation by adolescence or early adulthood, without any signs or symptoms of a gender identity disorder. One or two percent reported a gender identity disorder, and the remainder were heterosexual without evidence of a gender identity disorder. The course for girls is not known.
The course in adults is variable. For some it is chronic and unremitting, with the persistent, dedicated drive for
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living and functioning in the cross-gender role with or without hormonal/surgical reassignment. The ability to achieve the goal of surgical reassignment is usually more dependent on the intellectual and professional competencies and financial resources of the individual than on the influence of medical decision making. For the majority of adults, the combination of limited resources and a waxing-and-waning intensity of the desire to live and function in the cross-gender role leads to an on-again–off-again course.
Complications
The problems associated with the childhood form of the disorder have been noted. Adults who are thwarted in their attempts to achieve cross-gender living may become depressed; some have committed suicide, and males, on rare occasion, have attempted self-castration. The more common problems for adults are the disruption of marriage, social relationships, and vocational function associated with a change in gender role.
Assessment
For both children and adults, a complete medical and psychiatric evaluation is recommended. No specific laboratory tests are indicated. Adult patients may benefit from a personality assessment, such as the Neuroticism, Extroversion, and Openness–Personality Index Revised (NEO-PI-R) (70), more for treatment planning purposes than for diagnosis. The psychiatric or psychological component of the evaluation is best performed by professionals who have experience with patients with gender identity disorders.
Treatment
Children and adults who express dissatisfaction with their gender should be referred to professionals with expertise in these disorders. Therapy with children who are diagnosed with gender identity disorder is family oriented, with the goals of treatment being to explore the nature and characteristics of the child's or adolescent's gender identity, ameliorate comorbid problems in the patient's life, and help the patient and family make difficult decisions related to the management of the patient's gender identity. The treatment of adolescents and adults combines aspects of psychotherapy (for consideration of the decision to pursue reassignment), counseling (logistics of cross-gender living, referred to as “the real-life test”), endocrinology management (fully and partially reversible hormone therapy), and surgical management (surgical reassignment, age 18 years and older). The latter two medical interventions are available when the patient meets criteria, such as those of the Harry Benjamin International Gender Dysphoria Association (seehttp://www.hopkinsbayview.org/PAMreferences), which sets standards of care that are more or less accepted by most physicians in the United States.
Paraphilias
The paraphilias are sexual disorders with the following essential features in DSM-IV (3): recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving nonhuman objects, the suffering or humiliation of oneself and/or one's sexual partner, or children, or other nonconsenting persons that occur over a period of at least 6 months.
Exhibitionism
Exhibitionism involves the displaying of one's genitals to a nonconsenting person. Sometimes the individual masturbates during the episode; more commonly the person later employs the memory of the episode as a masturbatory stimulus. There usually is no attempt to have contact, sexual or otherwise, with the victim.
Fetishism
Fetishism is the use of objects for sexual arousal. Common fetishistic objects are women's underpants, bras, slips, stockings, shoes, or certain textures such as silk or rubberized material. The person usually masturbates while fondling or smelling the object. Some fetishistic behaviors involve body parts such as feet.
Frotteurism
Frotteurism involves touching or rubbing up against a nonconsenting person, usually in a crowded space. The person attempts to rub his genitals or hand against the breast, genitals, or buttocks of the victim. Orgasmic release usually occurs after the episode, with the fantasy of the experience being the sexual stimulus.
Pedophilia
Pedophilia involves sexual activity with prepubescent children. Individuals diagnosed with pedophilia must be at least 16 years of age, and their victim must be at least 5 years younger. Most individuals diagnosed with pedophilia are male, although there are cases of females who sexually abuse children. In most states, the discovery by health providers of sexual abuse of children mandates reporting to local child protective services.
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Sadism and Masochism
Sadism and masochism involve sexual activities during which arousal and gratification depend on either inflicting psychological and/or physical pain (sadism) or experiencing it (masochism). These paraphilias include a broad range of fantasies and behaviors, from awareness of potential cruelty or suffering to extreme physical injury and murder. Aspects of both sadism and masochism are often found in the same person, even though one or the other paraphilia is dominant.
Voyeurism
The essential feature of voyeurism involves the act of observing (peeping) unsuspecting victims disrobing or engaging in sexual activity. Orgasmic release is usually achieved through masturbation during or just after the episode of “peeping.”
Transvestitic Fetishism
The focus of this paraphilia involves cross-dressing by males in female attire accompanied by sexual arousal and orgasmic release through masturbation. Middle-aged transvestites often experience a decrease or disappearance of sexual arousal and report a “calming” or “anxiety reduction” effect associated with cross-dressing. The paraphilia can be differentiated from the cross-dressing associated with gender identity disorders and from the dramatic displays of homosexual “drag queens,” which usually do not result in sexual arousal. The transvestite experience often includes the fantasy that the patient is a woman, with singular focus on specific body parts (e.g., legs, breasts, lips).
Treatment of Paraphilia and Nonparaphilic Sexual Compulsion
Ideally, the goal of any therapeutic intervention is the elimination of the paraphilic behavior. Achievement of that goal is difficult because these behaviors are enjoyable or are positively reinforced by sexual gratification, or both. Often the best that can be done is continuous control of the behaviors using pharmacotherapy (antiandrogens) in combination with individual (cognitive–behavioral) psychotherapy and/or group therapy. Reports (71) indicate that the SSRI antidepressants may be helpful in some cases, in combination with individual or group therapy, especially among those with nonparaphilic, sexually compulsive behaviors. Based on the concept of paraphilia as similar to a sexual addiction, 12-step treatment programs are available for the control of paraphilias. Although these behaviors were once considered untreatable, combinations of the interventions described demonstrate that they can be controlled in compliant patients.
Sexuality and Special Populations
Homosexuality
General Characteristics
The American Psychiatric Association removed homosexuality from its list of mental disorders in 1973. The diagnostic term Sexual Disorder, Not Otherwise Specified may be used for patients who experience persistent and marked distress about their sexual orientation.
The NHSLS population-based study of sexual practices in the United States (6) reported that 2.8% of men and 1.4% of women identified themselves as homosexual or bisexual. These numbers are at variance with Kinsey's historic percentages of 10% male and 5% female self-reported homosexuality. The authors of the more recent study are quick to point out there are no easy answers to questions about the prevalence of homosexuality.
Predisposing Factors
Various attempts to relate homosexuality to abnormal pituitary and sex hormone function have been unsuccessful. The evidence to support the contention that homosexuality is genetically determined is scant. Many theories about the cause of homosexuality involving psychosocial predisposition have been proposed. However, no studies clearly demonstrate psychosocial precipitants. At this time, it is prudent to consider a multifactorial model in the genesis of homosexual behaviors.
Development
Most people who accept a homosexual orientation continue that orientation throughout life. Some homosexuals are socially open about their lifestyle; many are covert, largely because of negative attitudes (homophobia) that are common in American communities. Aspects of life as a homosexual that are predictably stressful include the process of discovering one's sexual orientation, disclosure to others (coming out), and the threat of hate crimes.
Psychosocial Consequences
In the past, but possibly to a lesser degree at the present time, the principal risk to homosexual individuals (aside from human immunodeficiency virus infection in men) was the social stigma. More recently, many American communities have enacted or are considering legislation
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that explicitly protects homosexuals from job, housing, and other forms of discrimination. On the other hand, some jurisdictions and many fundamentalist religious groups support legal and moral discrimination against homosexuality. In most states, but not all, criminal penalties for homosexual acts have been eliminated for consenting adults. The principal legal difficulty currently is for people who are promiscuous and who use public facilities for their sexual activities. Homosexuality is entirely compatible with the development of sustained, affectionate, long-term relationships. A series of recent studies do suggest, however, that young homosexuals are at greater risk for mood disorders, anxiety disorders, substance abuse, and suicidal symptoms, including suicide attempts (72, 73, 74).
Assessment and Management
Most gay men prefer their personal physician to know of their homosexuality and indicate that they are more satisfied with the care they obtain when their physician is aware of their orientation (75). Studies of lesbians show that many are reluctant to disclose their sexual orientation to their physicians because of fear of judgmental attitudes (76). Obviously those who do not disclose at-risk sexual behaviors pose a difficult management problem for the physician.
Homosexual men require special considerations in their routine medical care. Those who have multiple partners should always be asked about their knowledge of safe sex practices (see Chapter 39) and of symptoms of sexually transmitted diseases, including human immunodeficiency virus infection (see Chapter 39), and they should be screened periodically for type B hepatitis (Chapter 47), syphilis (Chapter 37), and gonorrhea (Chapter 37). Men who practice receptive anal intercourse are subject to both infectious and traumatic anorectal conditions (see Chapter 98).
Most sexually transmitted diseases occur less frequently in lesbian patients, with the exception of three forms of vaginitis—candidiasis, trichomoniasis, and nonspecific vaginitis—each of which should be considered when a known lesbian patient has a vaginal discharge (76) (see Chapter 102). It is possible that the risk of breast cancer is increased in lesbians. In the absence of adequate information, cancer-screening recommendations for lesbians should be the same as those for other women according to age group (76) (see Chapters 14, 104and 105).
Assessment of patients who express concerns about homosexual fantasies or experiences should focus on the frequency of the experience, on the patients’ decisions to continue with homosexual experiences, and on whether they feel comfortable with those decisions. Patients who ultimately identify with a homosexual orientation and are comfortable with that identity do not present problems. However, patients who are anxious or depressed about their homosexual inclinations may need therapy. Adolescents or adults who anxiously report isolated episodes of homosexual experiences or fantasies may need brief supportive counseling (see Chapter 20).
Aging Patients
Aging people do not lose their capacity for sexual function on the basis of the aging process alone. It is important to invite questions regarding sexual function in the general care of older patients, because they are often embarrassed to bring up this aspect of their health. Patients who have any of the sexual disorders discussed previously should be evaluated in the same manner as a younger patient. The predictable changes associated with aging are slower arousal phase, increased ability to stay at plateau levels of arousal, and, in men, a longer refractory period. Women commonly experience dyspareunia as a result of atrophic vaginitis after menopause; Chapter 102 describes the management of this treatable problem.
Dementia is more often marked by decreased sexual desire than by occasional inappropriate sexual behavior. Partners of demented individuals report that the sexual interaction has lost most of its intimate quality and that the partner has become impersonal and mechanical in sexual activity.
With 1.6 million elderly persons residing in 20,000 nursing homes in the United States, there is need of institutional sensitivity to their sexual needs as well as appropriate strategies for those occasions when sexual behaviors become problematic. A growing body of literature addresses these two seemingly contradictory issues (77).
Children
It is unusual for children to complain of sexual difficulties. However, parents occasionally ask their own physicians questions about the developing sexuality of their children. Parents may express concern about the appearance of sexual behavior in children, such as mutual exploration of playmates’ genitalia or masturbation. Parents can be reassured that such behaviors are normal and should be discouraged in a nonpunitive fashion. Failure to control the behavior may require further evaluation of both the child and the family. Sexual behavior that is coercive, inflicts pain, or involves a significant discrepancy in age should receive professional attention (78).
Occasionally, a physician recognizes the presence of sexual abuse within a family, either on the basis of physical findings or from information disclosed by a child during a medical visit. If someone outside the family has committed the abuse, both the child and the parents may require
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supportive counseling to help them vent their fear and anger about the experience. Discovery of sexual abuse within a family should be fully evaluated. This procedure should be initiated by reporting the problem to the division of protective services of the local department of social services. The health care professional should be cognizant of the requirements of the reporting laws within his or her jurisdiction, and of the limitations of those laws as they have been interpreted and implemented.
Adolescents
Adolescents with sexual difficulties (see Chapter 11) may be brought to the attention of the physician by either the adolescent or the adolescent's parents. Adolescents who are sexually active may have questions about their sexual function, birth control, venereal disease, or abortion. In most states, a physician may provide services for sex-related problems to an adolescent with or without parental consent.
Adolescents may request consultation about isolated homosexual experiences or homosexual fantasies. In most cases, the physician's role is to inform the adolescent that these experiences are not necessarily indicative of the development of lifelong homosexuality but may be expressions of adolescent sexual exploration. Adolescents who have developed a homosexual orientation or who are in the process of doing so may be brought to the physician by parents who are disturbed at the discovery of homosexual activities. In these instances, counseling should be given to the parents to help them accept the adolescent's orientation. Adolescents who are older than 17 years of age are unlikely to change their orientation. Younger adolescents have not yet consolidated their personality development and should be offered referral for psychiatric evaluation and possible treatment.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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