Practical Psychiatry in Medicine

Practical Psychiatry in Medicine Part 8. Sexual Dysfunction In recent years, sexual behavior their family physician about sexual pected since the rearing persons has received a great deal of atten problems believing that he will be take their cue from the anatomic tion in both professional and lay able to help them or refer them to sex of the infant in assigning the circles. Indeed it has been said that specialists in this field. role of male or female to him of a “ revolution” has occurred in the her. However, for reasons that arc Western world, particularly in the not entirely clear, there may on United States, in attitudes toward rare occasions be a disparity be and mores concerning sexual be tween anatomic sex and gender havior. People have become “lib Some Basic Features of role development resulting ini erated” in the sense that they are Human Sexuality transsexualism or gender role dys freer to talk and write about sex Like other aspects of human be phoria; this is often a painfull] and perhaps to engage in sexual havior, sexual functioning is de conflictful state which leads the behavior, in or out of marriage, termined by a combination of individual to seek treatment in the than was the case in their parents’ hereditary or constitutional factors form of psychotherapy and some and grandparents’ times. This lib on the one hand and environmental times, if psychiatric treatment has eration doubtlessly stems from or experiential ones on the other. failed, sex reassignment surgery several factors, among them the Gender role problems may also widespread availability of “the arise when congenital abnor pill” and the Zeitgeist of the mid- malities of the external genitalia re Sexual Identity and Gender 20th century with its almost obses sult in anatomic ambiguity and sional emphasis on freedom of ex Role hence in gender assignment in in pression, sexual and otherwise. Anatomic or biologic sexual fancy that proves to be inappro This new-found sexual freedom identity as male or female is de priate as the individual matures. has not, of course, eradicated dis termined by the individual’s Psychosexual develpment can orders of sexual function, but it chromosomal complement, XX for not be divorced from the overal does seem to have contributed to a the female and XY for the male, psychologic or emotional develop greater readiness on the part of in with corresponding male and ment of the individual. For exam dividuals and couples to recognize female genital and gonadal devel ple, a satisfying, fulfilled s e x u a l! sexual problems and to seek help opment. A rare but important ex depends in part upon successful for them. The pioneering and ception is seen in the testicular resolution of the oedipal stage of widely publicized work of Masters feminization or androgen insen development with conseque® and Johnson has significantly con sitivity syndrome characterized by freedom to relate to and love tributed to our understanding of XY chromosomes, undescended another individual as a truly sepa normal sexual functioning and to testicles, female external genitalia, rate person and not as a symbolic the understanding and management female secondary sexual charac representation (substitute) of an in of sexual disorders.4,5 In view of teristics, and female gender role. fantile object choice. Neurotic these changes in society’s attitude Persons with this syndrome are conflicts regarding object choice toward sex and the widely recog women in terms of psychologic sexual fantasies, or one’s own nized effectiveness of “sex identification and social role. therapy,” it is to be expected that As a rule, gender role matches patients will frequently consult anatomic sex. This is to be ex Continued on next page 436 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 2,1® SEXUAL DYSFUNCTION Continued from preceding page refractory period in which further In eliciting the sexual history arousal and erection do not occur. (whether this is initiated by the Women do not have this refractory physician or the patient) the physi period and thus are capable of hav cian uses a nonjudgmental, ing several orgasms in succession. matter-of-fact approach. He does adequacy can seriously interfere This is a general outline of the not shy away from asking relevant with the development of intimate sexual response cycle; there is questions but does so in a respect relationships and can lead to much variation from one individual ful and tactful manner, one which avoidance of sexual activity or to a to another and within a given indi takes the patient’s sensitivity into reduction of sex to its purely physi vidual at various times. The rate of account and which helps to allay cal components. arousal and rate of passage from tension or embarrassment. The one phase to another can vary. In physician must take care to use addition, not everyone has an or terms the patient understands, gasm each time. Knowing about which sometimes is best done by these variations can help allay a using terms which the patient him The Sexual Response Cycle patient’s apprehensions about self has introduced as long as their The sexual response cycle refers being abnormal. The mutual shar meaning is clear to both parties. In to the various stages of sexual re ing of pleasuring and the intimate history taking it is always impor sponse that occur in males and communication of sexual interest tant to allow enough time so that females in which orgasm is are more important than achieving one can unhurriedly listen to the achieved. This was elucidated by some stereotypical norm of per patient’s detailed description of his Masters and Johnson.5 formance. experiences and ask appropriate The first phase is that of excite questions; this is particularly the ment characterized by erection in case when sexual problems are the male and vaginal lubrication in being reviewed. Generally it is the female. This is followed by the helpful initially to direct one’s plateau phase characterized in the Assessment of Sexual Func questions toward those areas which male by increased penile tumes tioning are least personal or least apt to cence, contraction of the cremas The physician may discover the arouse anxiety. When the physi teric muscles with consequent po existence of sexual problems in cian suspects that the patient is sitioning of the testes close to the several ways.2,6 The patient may troubled with feelings of embar perineum, and in the female by directly present with an overt rassment or inadequacy, he may further vascular engorgement and complaint of sexual dysfunction, he make a casual comment which lets reddening of the labia minora. Or may indirectly do so by presenting the patient know that many people gasm is the third phase and in both with symptomatic complaints that have had the sort of experience or sexes consists of a highly pleasur suggest the presence of sexual feeling or problem that he has. able, rapid release from the preced problems, and, finally, the physi When a sexual dysfunction prob ing sexual tension. In the male, the cian may learn of sexual problems lem has been presented or elicited, first stage of orgasm consists of an in the course of routinely obtaining the physician proceeds to obtain a awareness of ejaculatory inevita the sexual history. detailed history of its development. bility followed by urethral contrac Here it may be said that includ This should include the life situa tion and a sensation of semen mov ing an inquiry into the patient’s sex tion concurrent with the onset, ing through the urethra. In the ual experiences as part of the initial, remissions, and exacerbations of female, orgasm begins wit'h a routine medical history is a way of the complaint. Particular attention momentary suspension of arousal letting the patient know that the should be paid to the quality of the followed by sensual radiations from physician is interested in and willing emotional relationship between the the clitoris into the pelvis and a to help with sexual problems. This sensation of warmth spreading in itself may help the patient feel from the pelvic region to the rest of freer to bring up questions or con the body. Resolution or relaxation cerns about his or his partner’s sex follows. In the male there occurs a ual functioning. Continued on next page THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 2, 1978 437 SEXUAL DYSFUNCTION Continued from preceding page cal complaint, when the patient’s medical evaluation to rule out or discomfort leads him or her to this ganic processes which may in. type of defensive operation. terfere with sexual function. During the assessment process it is often extremely valuable to in patient and his or her sexual part terview the patient’s sexual partner ner and to possible correlations be separately or conjointly with the tween changes in that relationship patient. This step of course can and sexual functioning of both only be taken after it has been dis partners. Of considerable diagnos cussed with the patient and then Common Sexual Problems tic importance is a history of situa only with the patient’s consent and The most common sexual prob tional variance in sexual function cooperation. When a couple is ex lems which the primary physician ing such as the presence of impo periencing sexual difficulty, it is is apt to see are those experiencd tence or anorgasmia with one part not uncommon for the individual by married couples.3,4 It is difficult ner but not another or during at whose sexual function is the least to define precisely what is good or tempted intercourse as compared impaired to be the one who seeks adequate sexual function because with masturbation.

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