Type of psychology: Psychopathology

Field of study: Sexual disorders

Sexual problems are influenced by both health-related and psychosocial factors. Stress-inducing situations, interpersonal communication problems, or chronic illness can affect sexual functioning in both men and women. Sex therapy is aimed at helping individuals and couples to understand the underlying causes of sexual distress and to adopt new behaviors conducive to a more satisfying sex life.

Introduction

A satisfactory sexual life is an integral component of a person’s physical and psychological health. It plays an important role in both an individual’s self-esteem and an enriching and fulfilling couple relationship. A strong association exists between sexual dysfunction and an impaired quality of life.

Sexual problems can be caused by various medical conditions, such as cardiovascular problems, diabetes, and hormonal imbalances. A majority of sexual disorders, however, are associated with significant psychological difficulties in an individual’s personal and interpersonal life. Those suffering from sexual problems are also likely to experience distress, reduced self-esteem, and symptoms of anxiety and depression. In some cases, psychological problems are a consequence of sexual problems. In other cases, sexual problems reflect coexisting psychopathology. In still other cases, sexual problems may even result in other unspecified physical, psychological, interpersonal, or social problems.

Treatment strategies include a comprehensive assessment of the physiological and psychological factors contributing to the dysfunction, appropriate psychotherapeutic interventions, interpersonal intimacy training, and, in certain cases, surgical procedures such as penile implants.

In the early twentieth century, Sigmund Freud conceptualized sexual problems as symptoms of deep-rooted disturbances of personality originating from early childhood experiences. Treatment usually consisted of lengthy psychoanalysis that did not always alleviate the problem. In the early 1960’s, behavior therapies such as systematic desensitization were used to treat sexual problems, specifically erectile dysfunction in men and so-called frigidity (lack of sexual desire) in women. These therapies, however, were mostly aimed at relieving symptoms rather than examining the underlying causes.

The Sexual Response

In 1966, William H. Masters and Virginia E. Johnson proposed a comprehensive model of the sexual response cycle consisting of four stages: excitement, the initial stage of increasing arousal in which the skin becomes flushed, the penis or clitoris becomes engorged with blood, and vaginal lubrication increases; plateau, the stage of full arousal in which the penis becomes enlarged to maximum erection and the outer third of the vagina becomes engorged with blood; orgasm, the stage involving muscle contraction throughout the body in which men ejaculate sperm-filled semen and women’s vaginal contractions facilitate conception by helping propel the semen into the vagina; and resolution, the stage during which the body gradually returns to an unaroused state in which muscles relax and engorged genital blood vessels release excess blood.

For the first time, Masters and Johnson documented the genital and extragenital physiological changes that typically occur during each of these stages. They argued not only that men’s and women’s physiological changes are remarkably similar as they approach and achieve orgasm but also that the physiological expression of an orgasm is similar regardless of how it is achieved. Based on their model, Masters and Johnson subsequently published the book Human Sexual Inadequacy (1970), which described a sex therapy combining behavioral and psychotherapeutic approaches. The focus of this therapy was mostly on the relationship between the couple. Their treatment of individuals using sexual surrogates raised certain ethical dilemmas.

During the late 1970’s, Helen Singer Kaplan observed that many of her sexually troubled patients complained of a lack of interest in sex or even an aversion to sexual activity. She concluded from her observations that there is an important stage preliminary to the excitement phase, one that she labeled sexual desire. This stage involves an individual’s cognitive and emotional readiness for and interest in participating in sexual activity. Masters and Johnson’s original sexual response cycle has since been revised to include sexual desire as a primary component, and the cycle is now recognized of having five main stages: desire, excitement, plateau, orgasm, and resolution.

The Definition of Sexual Dysfunction

The revised fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2000), more commonly known as the DSM-IV-TR, defines sexual dysfunction as a disturbance in sexual desire and the psychophysiological changes that characterize the sexual response cycle that causes marked distress and interpersonal difficulties. While the DSM-IV-TR provides a clear framework for classifying sexual problems, decisions about the presence or absence of a dysfunction may often reflect the values and standards of both clinicians and patients, which in turn are affected by the constantly shifting cultural opinions regarding sexual mores and behavior. Thus, the definition and understanding of sexual dysfunctions can be rather complex and, at times, controversial, particularly when the sexual behavior implies a reference to a perceived normal level of activity or interest.

Sexual dysfunctions can be classified under four major areas: sexual desire disorders, arousal disorders, orgasmic disorders, and physical pain experienced during intercourse. These dysfunctions are not always discrete, and specific problems may overlap as to their origin, presentation, and intensity.

Sexual Desire Disorders

Sexual desire disorders include hypoactive sexual desire, hyperactive sexual desire, and sexual aversion. Properly speaking, these disorders affect the brain’s arousal capabilities rather than physiological responses. Individuals with sexual desire disorders have the ability to respond physically but have little or no emotional investment in sexual activities. It is as if the brain’s erotic centers have shut down.

Hypoactive sexual desire, also known as inhibited sexual desire, is a low or absent sexual desire. The person suffering from hypoactive sexual desire has little or no interest in sexual matters, will not actively pursue sexual gratification, and, if a sexual situation presents itself, is not readily moved to avail himself or herself of the opportunity to engage in sexual activity. Hypoactive sexual desire generally stems from deeper, more intense sexual anxieties such as sexual performance anxiety. By developing a low interest in sexual activity, the person avoids the unpleasant feelings of embarrassment, loss of self-esteem, and frustration as a result of perceived sexual failure.

Depression can be one of the major causes of hypoactive sexual desire. Hypoactive sexual desire may also have roots in various unresolved relationship problems. Suppressed and unacknowledged anger and resentment toward one’s partner can often manifest in hypoactive sexual desire. Stress, a traumatic marital separation or divorce, or loss of employment can also result in hypoactive sexual desire. Drugs, hormonal imbalance, and chronic illness are major contributors to hypoactive sexual desire. Some individuals may use lack of desire as a defense against a generalized anxiety around situations involving intimacy, closeness, and even physical touch.

Individuals with excessive desire disorder often experience uncontrollable sexual urges. They are obsessed with sexual thoughts that permeate all their actions and feelings, and they demand immediate gratification. These individuals are unable to control their sexual appetite and view sex as a magical cure for depression. Sex becomes an addiction for such people. Hypersexuality can occur with or without frequent masturbation. A person with excessive sexual desire uses sex as a substitute for involvement in other activities. For such a person, sex is impersonal, with few or no positive feelings or emotions associated with the sex act.

Sexual aversion is a consistently phobic response to sexual activities or even thoughts of such activities. A person suffering from sexual aversion experiences an overwhelming anxiety about any kind of sexual contact. A mere kiss, touch, or caress may create fear that the initial contact might lead to sexual arousal or activity. Anticipating the sex act may provoke greater anxiety than actual participation in the sexual activity. Sexual aversion may result from strict and authoritarian parental attitudes during childhood, from sexual trauma such as rape or sexual abuse, or from consistent and increasing sexual pressure from a long-term partner. Sexual aversion may also be a result of adolescent difficulties with self-esteem and perceived body image.

Arousal Disorders

Arousal disorders among males include disorders of the erectile process, such as dysfunctional arousal and plateau phases. Erectile difficulties may be defined as persisting or recurrent inability to attain or maintain a penile erection sufficient to permit vaginal penetration and satisfactory conclusion of sexual intercourse. Erectile difficulties in men are commonly known as impotence and are the most frequently occurring male sexual dysfunctions. Impotence can be of great concern to not only the patient but also his sexual partner.

Total erectile dysfunction is rare and is caused by serious disruption in the blood supply to the penis or the leakage of blood from penile cavernous bodies. Cardiovascular problems and diabetes may sometimes cause nerve damage, leading to sexual arousal disorders. Situational erectile dysfunction, on the other hand, usually has a psychological basis. The man is able to obtain an erection but is unable to experience erection with his partner or cannot sustain his erection when sexual intercourse is attempted.

Among women, arousal disorders include failure of vaginal swelling, the lack of sufficient lubrication, and a lack of sensation that is usually associated with sexual excitement. For some women, the hormonal changes that occur after childbirth may impair the normal vaginal response to sexual stimulation.

Orgasmic Disorders

Orgasm is defined as the building up and release of tension. During release of the tension, contractions are felt in the genital area and, after the peak of excitement, a period of relaxation follows. In women, rhythmic contractions occur in the uterus, the vaginal barrel, and the rectal sphincter, gradually diminishing in intensity, regularity, and duration.

Women who are diagnosed as having primary anorgasmia have never experienced an orgasm. Women suffering from secondary anorgasmia are those who have previously experienced orgasm in sexual intercourse but either are no longer able to do so or are able to have an orgasm only in certain situations, such as masturbation. These women suffer from orgasmic infrequency and are not always aware of the conditions that restrict them from being orgasmic.

Orgasmic disorders among males include inability to achieve orgasm and disturbances of ejaculation. Premature ejaculation in men is a persistent or recurrent ejaculation with minimal sexual stimulation before, during, or shortly after penetration and before the man’s desire for it to occur. Men suffering from premature ejaculation fail to fully experience the orgasmic release, usually the most pleasurable sensation of the sexual activity. Failure to emit or eject seminal fluid can also raise concerns, primarily in those situations in which fertility is desired. A less common male sexual disorder is retarded ejaculation, which is the persistent or recurrent delay in, or absence of, orgasm following a phase of normal sexual excitement.

Physical Pain During Intercourse

In women, painful intercourse, or dyspareunia, often occurs because the woman is not entirely aroused before her partner attempts intercourse. Sexual inhibitions, lack of appropriate foreplay, a poor relationship with the partner, and hormonal imbalances can contribute to a woman’s dyspareunia. Postmenopausal women may suffer from decreased vaginal lubrication and, as a result, lose much of the vaginal elasticity. Related to painful intercourse is vaginismus, a condition in which the muscles around the vaginal entrance go into involuntary spasmodic contractions, preventing the entrance of the penis. Vaginismus is essentially a conditioned response that reflects fear, anxiety, or pain. It may be a result of negative attitudes about sexuality, harsh early sexual experiences, sexual abuse or rape, or painful pelvic examinations.

Sexual Minorities

Sexual problems experienced by gay men, lesbians, and bisexuals are not significantly different from those experienced by heterosexuals except that the traditional concepts of monogamous sexual relationship cannot always be taken for granted when working with members of such populations. As in the general population, gay men and lesbians also suffer from desire, arousal, and orgasmic disorders. They also have a variety of problems that set them apart from the general heterosexual population. Gay men, for example, tend to experiment with various forms of sexuality that may include open and frequently changing relationships, which sometimes leads to insecurity and instability in their relationships. Some gay men entertain fantasies of domination and overpowering others in their sexual repertoire.

Many lesbian relationships are based on feminist principles that incorporate equality and nonexclusivity in their relationships. Some lesbians tend to prefer bisexual relationships. They appear to be looking for a sense of community and spirituality in their relationships. Frustration in attainment of those ideals can sometimes lead to a generalized lack of sexual desire.

A Systems Approach to Sexual Dysfunction

Psychologist David Schnarch advocates a combination of physical stimulus and internal focus that brings together the physiological experience of sex and the phenomenological meanings that people attach to it. He distinguishes between clinical and subjective arousal and creates a clinical framework that can accommodate such subjective constructs as sexual potential and intimacy. He attempts to explore the roots of human inability to tolerate high levels of eroticism and intimacy, and he presents a model that integrates behavioral, object relations, and systematic approaches to help patients achieve the developmental maturity to tolerate a high level of emotional salience.

According to Schnarch, a couple’s sexual problems are a window to latent unresolved issues in the individual, in the couple, or in the extended emotional system of the couple, including the family of origin as well as lovers and friends. These unresolved issues can inhibit satisfying sexual-marital functioning and the full exploration of sexual potential.

Treatment of Sexual Dysfunctions

Sex therapists are nationally certified by the American Association of Sex Educators, Counselors, and Therapists on completion of the required training and supervision. Sexual dysfunctions are also treated by licensed marriage and family therapists, physicians, psychologists, psychiatrists, and social workers. Treatment usually begins with a comprehensive assessment of physiological and psychosocial factors that could be contributing to the presenting problem. In the absence of a significant medical finding, the therapist attempts to uncover the emotional and interpersonal issues underlying the sexual problem and helps the patients find ways to resolve them. In addition to office visits, some therapists may assign homework aimed at gaining greater awareness of one’s own feelings and those of one’s partner and enhancing interpersonal intimacy. Psychotherapeutic treatments may include cognitive behavior therapy, mental imagery, psychodynamic therapy, and systematic desensitization. For patients with physiological deficiencies, medical interventions may include the use of hormonal treatments, appropriate antidepressants, sildenafil (Viagra), and, where necessary, penile implants.

A Feminist Perspective on Sex Therapy

Traditional sex therapists mostly use the diagnostic framework of sexual dysfunctions as articulated in the DSM-IV-TR, which many feminist therapists consider as very poorly suited to women’s and sexual minorities’ sexual reality. Because it ignores the social context of sexuality, these minorities assert that the DSM-IV-TR nomenclature perpetuates a dangerously naïve and false vision of how sex really works.

Feminist sex therapy encompasses the two domains of insight and skill. The first includes corrective genital physiology education, assertiveness training, body image reclamation, and masturbation education. The second rejects sexual drive in favor of contact comfort, mutual masturbation, and new ways of sexual understanding and exploration.

Feminist sex therapy attempts to move beyond restrictions and inhibitions created by the prevalent body/mind conflict, depreciation of women’s sexuality, and preoccupation with procreation. It also attempts to bypass the restrictions and inhibitions embedded in gender roles and stereotypes. The focus in feminist sex therapy is on the personal meaning and subjective nature of sexual activity, feelings, and relationships.

Sources for Further Study