25

PSYCHOSEXUAL DISORDERS Fones Calvin

Introduction Discussions about sex and sexual problems have always been shrouded in secrecy and taboo. Many doctors and health professionals feel uncomfortable or broaching the subject with their parents. Recently, though, the traditionally conservative attitude of Asian communities regarding sex has given way to greater openness, as a result of exposure to the mass media. Access to information has helped to create better awareness about sexual matters, and has led to more people seeking help for sexual problems. Estimates in the US show that up to 50% of couples experience sexual difficulties at some point in their lives and the situation is likely to be similar locally. Doctors are still perceived as the most appropriate people to turn to for advice on sexual matters, and they need to be prepared to respond to patients presenting with psychosexual problems. Patients may have questions about appropriateness of certain sexual practices or developmental concerns (e.g. masturbation, penis size) or they may have concerns about sexuality where it has become affected by illness, surgery or medication. An important role for doctors is to provide accurate sexuality education and allay anxieties about sexual concerns. Doctors should realize that sexual concerns are not readily or spontaneously volunteered and sexual functioning may need to be directly (and sensitively) enquired about, especially in certain categories of patients (e.g. the diabetic). Where sexual disorders are detected doctors should know how and to whom a patient may be referred for specialized evaluation and treatment.

Classification Sexual Disorders may be divided into three broad categories: 1. Sexual Dysfunction

Coital problems resulting from impaired expression of normal sexual desire, arousal or orgasm. Enjoyment or satisfaction is lacking.

2.

Disorder of Sexual Preference (Paraphilias)

Unusual or deviant sexual behaviour which fails to conform to general standards or normality. Such behaviour is habitually preferred to normal sexual intercourse.

3.

Gender Identity Disorders

Difficulties and distress concerning the assigned sociosexual role, biological sex or standards of masculinity or feminity. There is variance between the sense of identify and ones biological sex.

Dysfunctions

Sexual dysfunctions refer to impairment of normal sexual interest, enjoyment and/or performance. The individual would be unable to participate in a sexual relationship as he/she would wish. Impairment can occur at one or more points of the normal sexual response cycle desire, arousal (or excitement) and orgasm (see Table 1). Another group of disorders involve excessive pain experienced during sex.

Table 1 Classification of Sexual Dysfunctions

Impairment Appetive dysfunction (Desire) Impaired genital response (Arousal) Orgasmic Dysfunction (Orgasm) Pain during sex

Types of Dysfunction 1. 2. 3. 4. 5. 6. 7. 8. 9. Hypoactive sexual desire disorder Sexual aversion disorder Female sexual arousal disorder Male erectile disorder (Impotence) Inhibited female orgasm (Anorgasmia) Inhibited male orgasm (retarded ejaculation) Premature ejaculation Vaginismus (female) Dyspareunia (both female and male)

Aetiology Most cases of sexual dysfunction arise from a combination of psychological and cultural relationship and organic factors. Together, they often give rise to performance anxiety and spectatoring (critical monitoring of ones own sexual responses), which are distracting and preclude sensual pleasure which is vital for enjoyable sexual experience.

A.

Psychosocial and Cultural Factors

1. Ignorance and misinformation Many parents and schools fail to provide even basic sex education. Cultural beliefs may contribute to anxiety or guilt experienced by some people. Masturbation is believed by Chinese to lead to weakness and poor stamina or to make one stupid and mentally ill. Physical illness has been ascribed by traditional healers, to loss of semen. A variety of sexual myths may also exist involving gender roles, age and appearance or performance expectations. 2. Conflict of values Normal recurring sexual feelings especially during adolescence may be in conflict with what is portrayed by parents, school or religion. A commonly held attitude is that sex is shameful, dirty or sinful. 3. Fears and trauma Fears of impregnation, pregnancy, sexually transmitted disease, e.g. AIDS, may exist. Sexual abuse, rape, premarital pregnancy or abortion could have occurred in the past. 4. Unconscious conflicts

Parental sanctions against sexual enjoyment, dissociated memories of early sexual trauma or ingrained religious scruples may remain unconscious but give rise to conflicts.

B.

Relationship Factors

Sexual problems should be understood in the context of the relationships in which they are manifest. Issues of trust, power and control or anger at the partner are common themes. Difficulties with communication, conflict and commitment are often present.

C.

Organic Factors

A variety of drugs and medical illness may cause disturbances of the sexual response cycle (see Tables 2 and 3). Most frequently they affect male erectile function, but they may also affect arousal and orgasm in both sexes. Table 2 Medical Conditions Associated with Sexual Dysfunction

Congenital Hypospadias / phimosis Spina bifida Inflammatory Prostatitis / urethritis / cystitis Peyronies Disease Mumps Neurological Pituitary tumour Parkinsons Disease Peripheral neuropathies CNS Syphillis Metabolic Cirrhosis / liver failure Chronic renal failure

Endocrine Diabetes mellitus Addisons Disease Thyroid Disorders Acromegaly Vascular Arteriosclerosis Leriches Syndrome Penile arteriovenous shunt Traumatic or surgical Penile urethral injury Spinal cord injury Pelvic fracture Radiation therapy Sympathectomy Radical bladder / prostate surgery

The importance of organic factors in the aetiology of sexual dysfunction especially of erectile dysfunction has been greatly emphasized in recently years. This has stemmed from a better understanding of sexual physiology and from the discovery of effective pharmacological treatments. The role of psychological and relationship factors has tended to be ignored. The adaptation of a dichotomous paradigm of sexual dysfunction being either organic or psychogenic; or holding the assumption that organic factors necessarily take precedence over psychosocial factors, should be cautioned against. Where an important physical factor is assessed to be the major contributing course, referral to a urological/medical clinic would be appropriate.

Table 3. Drugs Associated with Sexual Dysfunction

Antihypertension drugs Methyldopa Clonidine Hydrochlorthiazide Propranolol Anticholinergic Drugs Antiparkinsanion agents Antihistamines Atropine Other Prescription Drugs Cimetidine Digoxin Indomethacin Disulfiram Estrogens

Psychotropic drugs Antidepressants Antipsychotics Benzodiazepines Drugs of Abuse Alcohol Amphetamines Opiates heroin, morphine Cocaine

Clinical Assessment Patients often feel embarrassed bringing up sexual problems directly and may complain initially of physical complaints instead, e.g. feeling tired and weak, having urinary symptoms etc. A careful and detailed sexual history should be elicited from both the patient and ideally from the partner as well. Areas covered should include: i. The exact nature of dysfunction in relation to the phases of the sexual cycle and what conditions produce or reduce it. ii. Duration of the problem. If brief and of recent onset, its relation to recent stress or adjustment. iii. Variation with different settings, partners, erotic fantasies or masturbation. iv. Past and current sexual experiences including masturbation and partner experiences. The relationship with the partner/spouse is especially important. Consider: Areas of conflict, difficulty or stress. The level of trust, understanding and love. Commitment to each other. Communication and ability to resolve conflicts. Individual attitudes to coital frequency, birth control, having children, etc.

i. ii. iii. iv.

The existence of a psychiatric disorder like depressive illness, anxiety phobic disorder, or psychosis may also adversely affect sexual function. A concomitant medical disorder and consumption of drugs or alcohol can cause sexual dysfunction and should be carefully considered in every case.

Specific Sexual Dysfunctions Hypoactive Sexual Desire and Sexual Aversion Lack of desire for sexual activity even though there is an ability to perform the sexual act, can occur in both men and women. It may actually arise from differing sex drives in a couple, with one partner having a weaker drive than the dissatisfied partner. Psychological and relationship factors account for most cases, although organic factors may occasionally be the cause. Sexual aversion disorder refers to a near total avoidance of sexual activity and may be associated with extreme fear, anxiety or contempt. Lack of libido is a common symptom of psychiatric disorders, especially depression, and should be excluded.

Male Erectile Dysfunction (Impotence) This consists of the inability to achieve or maintain erection of the penis that is adequate for sexual intercourse. Primary impotence, in which erection for penetration and ejaculation has never been achieved is rare; most patients have secondary (acquired) impotence where there is loss of previous ability to do so. Erectile failure is the major reason for males seeking help for sexual difficulty. Traditionally, the aetiology of impotence is divided into organic and psychogenic. An organic basis is suggested if the onset is gradual, progressive and has no clear precipitant. There is a generalized lack of response to all stimuli including masturbation. There may be a loss of nocturnal and morning erections and nocturnal emissions. Even when an organic course is well-established, psychological and relationship factors should still be carefully evaluated.

Premature Ejaculation This refers to ejaculation, which occurs earlier than wished during sexual intercourse because of a persistent lack of voluntary control. It is important to consider the patients age, novelty of the sexual experience, and the frequency and duration of coitus. Diagnosis also relies on the females pattern of sexual response and the satisfaction she derives from her partner.

Inhibited Male Orgasm Ejaculation failure following an adequate phase of sexual excitement is rare. Even patients with impotence are usually able to experience ejaculation and orgasm. Medications (e.g. psychotropics, antihypertensives) or extensive alcohol consumption may block ejaculation. Certain bladder and prostate operations may lead to inhibition of orgasm.

Vaginismus There is involuntary spastic contraction near the vaginal entrance. It is a conditioned response of the muscles around the introitus. The diagnosis is made on physical examination and, in extreme cases, vaginal examination may be virtually impossible. Severe cases result in non-consummation of marriages.

Dyspareunia Pain during sexual intercourse may be due to pelvic pathology, e.g. vaginitis, cervicitis, etc. and should be excluded. Males who have local organic pathology, e.g. Peyronies disease also complain of painful intercourse.

Treatment Most treatment programmes for sexual dysfunction are based on principles of Behaviour Therapy, although other psychological approaches are often incorporated at the same time, including marital therapy or psychodynamic approaches. Pharmacotherapy and surgery are appropriate for specific cases. Although drug treatment is effective e.g. for erectile dysfunction, an exclusively biological approach is not satisfactory and increases the chance of treatment failure or relapse.

a.

Sexual counselling and therapy

The aim is to establish proper verbal and sexual communication between partners. Initial assessment helps to identify antecedents of the problem and evaluate the nature of the couples relationship. Many techniques are derived from the Masters and Johnson approach, especially sensate focus. Prescribed exercises between sessions (homework) focus on verbal communication and on heightening sensory awareness to sight, touch and smell. Intercourse is prohibited and partners focus on mutual pleasuring by massage, caressing etc., without stimulation of genitalia. Performance anxiety is reduced by removing the focus away from orgasm as a goal. During subsequent sessions, encouragement is given for performing the exercises and resistance (e.g. excuses of having no time) is dealt with. Concerns about performance (spectatoring) is common and can be countered by using fantasies to distract oneself. Genital stimulation is prescribed only at a later stage, when expression of mutual needs is comfortably established. Finally, intromission and intercourse is permitted.

b.

Specific Techniques and Exercises

Unique to each specific types of dysfunction, specific techniques are used in conjunction with sensate focus: i. Premature ejaculation The squeeze technique entails the female applying firm pressure to the coronal ridge of the glans when the male experiences the sensation of ejaculation. Ejaculation is stopped and erection is diminished before stimulation recommences again. The stop-start technique is similar, where

ii. iii.

stimulation is stopped with increasing excitement, before ejaculation occurs. Constant practice increases the amount of ejaculatory control. The female-on-top position is recommended. Vaginismus graduated dilatation of the introitus with the fingers or prescribed dilators is taught to the woman and/or the partner. Impotence Sensate focus exercises emphasize total body stimulation and pleasure rather than penetration performance. Having and enjoying the erection without sexual intercourse builds confidence and quells anxiety, paving the way for intercourse to orgasm eventually.

c.

Pharmacotherapy

The introduction of sildenafil (Viagra) for the treatment of erectile dysfunction has been a recent revolution. As the first effective, acceptable and widely available treatment for erectile dysfunction, it has allowed for unprecedented interest and public awareness about sexual dysfunction. Sildenafil is a phosphodiesterase inhibitor and enhances and maintains penile responses to sexual stimulation in men with erectile problems. It however does not work without sexual desire and stimulation; nor will it make normal erections harder or last longer. Side effects include headaches, blurred vision, seeing objects in shades of blue or dizziness. Taking it together with Nitrates may lead to fatal complications. Oral medication with testosterone or yohimbine (an 2 -adrenoceptor antagonist) is of doubtful efficacy. Many men are increasingly being given androgen preparations for sexual complaints and male menopause. This is useless in the absence of established androgen deficiency. Intracavernosal injections of papaverine or prostaglandin (PGE1) is of particular value to men with otherwise irreversible organic erectile dysfunction, e.g. diabetics. Even in men with largely psychogenic factors, it has a role in increasing confidence by demonstrating the erectile capability of the penis. Indeed, intracavernosal injections can be used as an evaluative tool to determine penile capacity for erection.

d.

Mechanical Aids and Surgery

External vacuum devices are a viable option for some. Penile prosthetic implants or vascular surgery are indicated for specific cases of organic impotence.

II

Disorders of Sexual Preference (Paraphilias) and Homosexuality

This category of disorders is strongly influenced by prevailing social and cultural attitudes, since it concerns whether particular types of sexual behaviour are accepted as normal by society. Consider, for instance, how masturbation was openly condemned in Victorian England, or how homosexuality is still readily considered deviant in many segments of Asian society and we realize the controversy surrounding this subject. However, sexual behaviours would certainly be considered problematic if harm is caused to another person, e.g. forcible sexual intercourse with a child. Distress may also be

experienced by individuals who harbour moral conflicts, feel rejected by others or have relationship difficulties as a result of their sexual preferences. Homosexuality, though not considered to be a psychosexual disorder per se, is discussed in this section, because patients present quite commonly with distress directly relating to their homosexual orientation and lifestyle. The majority of people with paraphilias may not come to medical attention at all. Commonly, it is only when sudden, often accidental disclosure of the behaviour to a partner, relative or the Police occurs, that a referral for assessment and treatment is made.

Classification of Disorders of Sexual Preference A. 1) 2) 3) 4) Abnormal preference of sexual objects Fetishism reliance on inanimate objects, e.g. clothing or shoes, for arousal and gratification. Fetishistic Transvestism wearing of clothes of the opposite sex to obtain sexual excitement. Paedophilia Sexual preference for pre-pubertal children. Other objects of sexual preference, e.g. animals (zoophilia or bestiality), dead bodies (necrophilia), persons with particular attributes, e.g. a deformity, amputated limb, etc. Anormal preference of sexual acts Exhibitionism persistent tendency to expose genitalia to people in public places, usually for sexual excitement, but without attempts at closer contact. Voyeurism observing sexual activities of others for ones own sexual arousal. Sadomasochism sexual activity involving inflicting pain on others (sadism) or experiencing pain oneself (masochism). Frotteurism excitement gained from rubbing genitalia against strangers in crowded places.

B. 1) 2) 3) 4)

Aetiology Many individuals would show evidence of normal expression of heterosexual impulses being inhibited in some way, e.g. through excessive shyness or harbouring fears about relationships with the opposite sex. Learning theory has also been applied, postulating that sexual arousal has become associated with objects or acts other than conventional heterosexual practices, leading to conditioned responses and adoption of paraphilias. Psychoanalytic explanations involve theories of phallic object representation, repressed homosexuality or oedipal conflicts.

Clinical Assessment Other psychiatric disorders should be excluded first because intellectual disability, alcohol/drug abuse, depressive illness or mania may lead to abnormal sexual behaviour because of disinhibition and impaired judgement due to mental illness.

Assessing the personality is important in elucidating the role that the abnormal sexual behaviour plays in the patients life. The motivation for seeking treatment should be clearly understood. Coercive factors are often present in referrals (e.g. persuasions of a frustrated spouse/partner or legal difficulties) and there may actually be little or no desire for change.

Treatment of Disorders of Sexual Preference The aim of treatment should be clearly established in collaboration with the patient. Goals set may range from wanting to eradicate a behaviour totally, controlling urges better or merely better adjustment with less guilt and distress. Motivation and personal effort are vital for change to occur. Change entails establishing and encouraging conventional heterosexual relationships and sexual expression. Difficulties in establishing social ties with the opposite sex may need to be addressed. Social skills training may be useful. Sexual fantasies during masturbation can be modified progressively, suppressing abnormal themes and replacing them with ordinary heterosexual images. Covert sensitization entails pairing an undesirable image/thought with the abnormal sexual image in order to suppress the abnormal sexual images. Antiandrogens, e.g. cyproterone acetate and oestrogens may be used to reduce sexual drive. These have been used especially in behaviours which are in conflict with the law, e.g. paedophilic exhibitionists and rapists. Side-effects include feminization, testicular atrophy and liver impairment.

Case History Mr T was a 22-year-old undergraduate who was caught for shoplifting female undergarments from a Departmental Store. He had been using bras and panties to achieve sexual gratification. He was the youngest in his family and the only son. He had three elder sisters and, in his teens, had used their underwear to obtain sexual excitement whenever he masturbated. Mr T grew up to be very shy and socially inhibited especially when relating to the opposite sex. He had never had a girlfriend before, although he said he was interested in finding one. Mr T was heterosexual in orientation and was able to masturbate without fantasizing or touching female undergarments, but he found this to be much less exciting and satisfying. Lately, he had been deriving sexual satisfaction almost exclusively from touching underwear. On the day of the offence he had felt a strong urge to touch female panties and he stole the items because he was too embarrassed to buy them openly. Mr T was very motivated to give up his behaviour totally and was especially upset that his family now knew about his habit. Behavioural treatment focused on modifying his auto-erotic stimuli initially by masturbating without actually touching but mentally visualizing undergarments, and eventually modified to evoking sexual images not involving underwear at all.

He was also encouraged to join some activity to widen his social circle. He chose to join a class to learn painting which he felt was not too threatening. He met a girl whom he quite liked in the class. They went out on a few occasions and although it didnt work out eventually, his confidence with girls was much bolstered by the experience. He also found out that he was quite good at painting; and is favourite subject.? Nudes!

Psychological Problems associated with Homosexuality Although homosexuality is not a disorder, psychological problems associated with conflicts over sexual orientation are commonly seen in clinical practice. Homosexuality refers to sexual attraction towards persons of the same sex. Male homosexuality is more common than in females (i.e. lesbianism). It has been estimated that about 5% of the male population is exclusively homosexual in orientation with a further 10% who may have had homosexual experiences at some time in their life but are otherwise predominantly heterosexual. Others may be bisexual. Sexual orientation may be conceptualized as extending along a continuum, ranging from exclusively heterosexual at one extreme, to totally homosexual at the other. Homosexuality may be a transient phase in an adolescents psychosexual development. Individuals in particular situations may resort to homosexual behaviour because of a lack of female partners, e.g. prisoners, soldiers, etc. The cause of homosexuality is still hotly debated. Both biological and psychosocial factors probably play a role. There is no clear evidence to clearly establish a genetic or hormonal basis. Others have pointed to homosexuals having a poor relationship with the parent of the same sex during childhood, who may have been weak and ineffectual or cold and distant. Homosexual patients may present with a number of problems related to their orientation and lifestyle: 1. Uncertainty about Sexual Orientation

Doubt and guilt may be harboured about their feelings or behaviour. Reassurance or permission from a trusted figure may be what is desired.

2.

Adjustment Problems to the Homosexual Lifestyle

Social stigma is strong in our local setting and most prefer to be discreet and secretive. Fears of ostracization by family and friends or of discrimination by employers exist. Many go through a struggle of whether or not to inform their family and friends. Some homosexual relationships tend to be rather unstable and common fears include the infidelity of partners and AIDS. Sexual advice and reassurance may be sought from doctors about AIDS and HIV risks, testing or prevention.

3.

Wanting to Change their Orientation

10

Modifying sexual behaviour in those who request it is extremely difficult. Behavioural methods, e.g. covert sensitization or aversion therapy can be applied in treating those who are strongly motivated. A total change is rarely achievable.

III

Gender Identity Disorders

Case History TL had, since his teens, persistently felt that he had been born with a wrong body. From an early age he preferred to play with dolls and tea-sets and mixed with girls in his neighbourhood. He was teased and called sissy or Ah Kwa by schoolmates. When he reached secondary school, he began to cross-dress and put on makeup. He managed to find a group of friends who were like him and hung out with them most of the time. He later had a series of boyfriends and engaged occasionally in oral sex with them. His enlistment into National Service was a difficult time of adjustment for him and he became depressed and suicidal, before he was eventually seen by a psychiatrist. He completed his service as a clerk. On leaving the army, he worked as a hairdresser, saving up all he could for a sex-change operation. He had, by this time, cut off ties with his family as he felt he was a source of embarrassment to them, TL was assessed by a psychiatrist when he applied for sex reassignment surgery. For three years prior to his surgery, he lived as a woman exclusively. Hormone treatment produced some increase in the size of the breasts and hips. Electrolytic depilation was necessary to control facial hair growth. Eventually, TL underwent a series of operations including reshaping of the genital anatomy, breast augmentation, thyroid cartilage reduction and blepharoplasty. TL seemed satisfied with the surgery and was able to accept realistically the cosmetic limitations. He continued to work as a hairdresser and experienced no major adjuutment problems.

Transsexualism A transsexual person desires to live and be accepted as a member of the opposite sex. There is usually a great sense of discomfort with ones own anatomic sex, often with distaste/disgust with the genitalia. The person seeks to alter the body appearance to be congruent with the preferred sex. Males transsexualism is much more common than female (ratio of about 5:1). The aetiology remains unknown. Animal studies demonstrate that hormonal abnormalities in the prenatal period can influence gender identity, but no endocrine or genetic abnormalities have been found in transsexuals.

Clinical Features The individuals conviction that he/she belongs to the opposite sex usually starts at a young age, before puberty. It is common for dressing, games and interests to be that of the preferred sex, e.g. playing with dolls and tea-sets in male transsexuals.

11

Cross-dressing would usually be quite routine by early adulthood, together with adopting feminine gestures. The sexual drive is usually low and may be either homosexual or heterosexual in orientation, although local studies show a predominance of homosexual practice. Transsexuals usually experience great distress about their problem and have many adjustment difficulties in everyday life. Social stigma is extremely strong. The feeling of being trapped inside the wrong body may lead to depressive episodes or suicidal attempts.

Differential Diagnosis Male transsexuals cross-dress in order to feel like women, not to produce sexual arousal as with fetishistic transvestites. Dual-role transvestites derive enjoyment from cross-dressing but have no desire for permanent sex change. True transsexuals have to be distinguished from others with problems of sexual orientation and preference. Effeminate homosexuals may cross-dress to attract other homosexuals. Male prostitutes and transvestite engaged in fringe occupations in bars, nightclubs and massage parlours might request for a sex change for purely work-related reasons. Intersex, genetic or sex chromosome abnormalities are usually readily distinguished. Schizophrenia may give rise to bizarre delusions regarding ones own sexual identity but the characteristic long-standing history beginning since childhood would be absent.

Treatment Attempts at altering the transsexuals conviction that he/she is of the wrong sex rarely succeed. The role of the psychiatrist is often as part of an assessment team evaluating an individuals suitability for a sex change operation. The principle is to allow for an adequate duration of follow-up, during which the individual adopts the preferred sex role and lives the life of that identity completely. Supportive psychotherapy is offered for adjustment difficulties experienced. Hormone therapy follows, before sex reassignment surgery finally takes place. Following the operation, adequate follow-up and support is also necessary.

Further Reading 1. 2. Masters WH, Johnson VE, Kolodny RC. Heterosexuality. New York: Harper Collins, 1994. Barcroft J. Human Sexuality and its Problems (2nd Ed.). Edinburgh:

12