Practical Psychiatry in Medicine

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

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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

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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. help, since his or her self-esteem is what constitutes a satisfactory It was mentioned earlier that the less threatened than that of the situation for one couple may bt patient may not complain openly of more dysfunctional partner.6 quite unsatisfactory for another a sexual difficulty but may instead It is of considerable importance For most practical purposes sexual present with symptoms which are in the planning of management to dysfunction refers to sexual func the byproduct of sexual dysfunc assess etiologic factors as far as is tioning that is less than satisfactory tion or which serve as a means of feasible to do so. Some sexual dys for one or both members of the seeking help. Examples of such function problems appear to stem couple. It should be pointed oil complaints include headaches, from lack of information or actual that even when the sexual dys backaches, or some other discom misinformation about sexual function problem is clearly as fort which tend to occur in the anatomy and physiology. In other signed to only one member of the evenings or on weekends when the instances, a current interpersonal couple, both members of the mari spouse is at home, or which tend to problem or emotional difficulty tal couple are involved, ie, both are remit when the spouse is away on a such as depression may seem to be affected by the disability, both will trip. Such indirect presentation the primary issue of which the sex be affected by therapeutic out may or may not pose considerable ual dysfunction is but one manifes come, in some instances both hart difficulties to the interviewer de tation. It is always important to contributed to etiology and not un pending in part upon the degree to make careful inquiry into alcohol commonly both may need to partic which the patient is consciously and drug usage and to be alert to a ipate in the treatment process. aware of the associated in history of physical illnesses such as terpersonal and sexual problems. diabetes which may interfere with In the presence of considerable sexual function. Sometimes a anxiety and defensiveness the single instance of performance physician approaches the issue at failure in males will give rise to fear the level presented by the patient, of another failure sufficiently in eg, at first dealing with the physical tense that performance is in fact Sexual Dysfunction in Men symptoms, later broaching the in blocked, a very unpleasant sort of The most common sexual disor terpersonal situations connected self-fulfilling prophecy. Occasion ders in men are impotence: with the symptoms, and eventually ally, sexual dysfunction arises from premature ejaculation, and re the sexual aspects of the patient’s unconscious and deeply rooted tarded ejaculation. problems. This approach often re psychologic conflict which is only quires a number of interviews and approachable therapeutically by in the physician must be prepared to tensive psychotherapy. allow the patient to “ retreat” to a The assessment of sexual dys nonanxiety topic, such as a physi function always includes a general Continued on page 443

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Continued from page 438 mission. This condition is almost vide a basis for anxious concern always on a psychogenic basis al which interferes with the individu though inflammatory, irritating al’s freedom to function sexually. Impotence conditions affecting the glands, This refers to the inability to prepuce, urethra, or prostate have achieve an erection sufficient for been cited as possible contributing penetration or to maintain an erec factors. tion until intercourse is completed. In retarded ejaculation the male (Completion of intercourse usually finds it very difficult to achieve Dyspareunia refers to ejaculation. However, ejaculation or does not ejaculate at older males not infrequently dis all during intercourse while usually Painful sensations which prevent continue intercourse without hav being able to ejaculate by mastur coitus or make enjoyment of it im ing achieved ejaculation. The pa bation. This condition too is possible are commonly secondary tient with retarded ejaculation may usually psychogenic but can be to local pathology such as inflam “give up” and discontinue in mimicked by retrograde ejaculation matory conditions involving the tercourse because of discourage which may be associated with vulva or vagina, torn uterine liga ment or fatigue even though con urologic procedures. Thioridazine ment, pelvic inflammatory disease, tinuing to maintain penile erection.) administration may produce and endometriosis. These and Most cases of impotence, at ejaculatory inhibition as may in other organic factors must be care least in young and middle-aged toxication with CNS depressants fully excluded. A history of dys males, are psychologically caused such as alcohol. pareunia which is markedly af (“functional”), but organic causes fected by situational factors such as must be ruled out. Impotence sec being present with one partner but ondary to organic disease is usually not another supports the diagnosis characterized by complete impo of a psychogenic disorder. tence or progressively worsening impotence and the disability is rel Sexual Dysfunction in Women atively unaffected by situational factors. On the other hand, a his The most common types of sex ual dysfunction in women are anor- tory of being able to achieve an Vaginismus erection with one sexual partner gasmia, dyspareunia, and vaginis but not another or during mastur mus. In this condition there is con bation but not intercourse favors traction of the pelvic musculature the diagnosis of functional disor which renders penetration of the der. Similarly, the occurrence of vagina difficult or impossible. Here full and firm, nocturnal, full- too it is important that local physi bladder erections in an impotent cal disorders be excluded. Ability male favors the functional diag to function better under some cir Anorgasmia nosis. cumstances as compared with This condition is characterized others supports a functional diag by inability to experience orgasm nosis. despite apparently adequate stimu In addition to the above specific lation. Some patients with this dysfunctions, one or both members condition are unable to have or of the marital couple may complain gasm during either coitus or mas of a general decline in sexual inter Ejaculatory Disorders turbation. Others are able to est, activity, and degree of satis- Premature ejaculation refers to achieve orgasm during masturba the repeated experience in which tion only. This condition is seldom ejaculation occurs during foreplay, primarily caused by organic factors at the time of penetration, or after although physical illness, including only a few thrusts following intro gynecologic disorders, may pro Continued on next page

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Continued from preceding page ago there was a commonly held tact. The latter prohibition removes myth (perhaps disseminated by al the fear of failure and counteracts leged experts on sex) that the truly excessive emphasis upon the goal of well-adjusted couple regularly ex orgasm. The vicious circle of failure faction derived from their sexual perienced simultaneous orgasms. and tension is thus broken. A ftera relationship. The source of the dif One of the present authors heard a period of mutual pleasuring, the ficulty may be related to deficient well-known therapist confidently couple is instructed to include geni sexual techniques but more often assert to a mixed audience that tal touching and caressing and even than not the problem arises from there is no such thing as a frigid tually is led by graded exercises to' disturbance and conflict in the re woman, only inadequate men! sexual intercourse. In the case of lationship between the two per However, most persons who are premature ejaculation a special sons. Occasionally, of course, the uninformed or misinformed about technique, the “ squeeze” tech loss of interest by one partner may sexual matters may be so because nique, can be used. This allows the be accompanied by an extramarital they have been somehow person man to have relatively prolonged affair with all of the complications ally inhibited from learning about experiences with sexual play an which may be associated with that this aspect of life, perhaps because eventually coitus before he ejacu situation. of early environmental influences. lates. It is not unusual for the man to be In those instances in which it is I more or less unaware of the impor judged that a simple educational tance of foreplay because he is apt approach is not sufficient and thatal to reach the stage of arousal far Masters-Johnson type of treatment more quickly than does his partner. approach is indicated, the physi Neither party may have thought it cian should refer the patient to a of much importance to learn what psychiatrist or some other sp ecial is particularly pleasurable to his or ist who has had experiences ini Management3AS her partner. Through engaging the treating sexual disorders. The management of sexual dys couple in discussions of their sex Not uncommonly, sexually dys function is determined by careful ual experiences the physician has functional couples have difficulties assessment of those factors which an opportunity not only to supply in their relationship with each have contributed to etiology. As a information and correct distortions other, of which the sexual dys general rule it is necessary to in but also to convey to the couple function is one manifestation. For volve both members of the couple that sexual function is a legitimate this reason, it is the usual practice in the therapy. topic in which to be interested, and for the therapist(s) to engage the If, during a thorough review of that they can learn from each other couple in exploration of their the couple’s sexual history, the if they are willing to communicate. feelings, attitudes, and behavior: physician has concluded that one A common experience of men toward each other, and to supple or both of them lack basic informa who are impotent is that fear of ment the more mechanical aspects tion about sexual functioning, and failure actively interferes with per of sexual therapy with counseling that this lack has contributed to formance. With anorgasmic women for interpersonal difficulties. It is faulty techniques and/or in appro there is often an inhibition of en not rare for sexual dysfunction ii priate expectations, the physician joyment of physical, sensuous one or both members of the couple may adopt what is basically an stimuli and a self-defeating over to be based on deeply rooted,® educational or information-giving emphasis on the goal of achieving conscious conflict. When this is the approach. This approach of course orgasm to the exclusion of simply case more intensive psychoan# must be carried out in a respectful, enjoying the sexual experience. In cally oriented psychotherapy # unhurried fashion, usully over a the Masters-Johnson approach, or psychoanalysis is indicated. period of several office visits, and one of its modifications, the couple with due attention to the possibility is instructed to engage in activities that problems other than lack of in in which they give each other pleas formation may be contributing to ure through kissing, petting, and the couple’s difficulty. A decade caressing, but to avoid genital con Continued on page 449

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Sexual Deviations Continued from page 444 illnesses such as myocardial infarc Sexual deviation refers to a tion usually want to continue or re group of sexual behaviors which sume sexual activity. In most in includes sadomasochism, pedo stances they can and should do so. philia, fetishism, voyeurism, ex In all patients it is obviously desir hibitionism, and transvestism. In able that resumption of sexual ac cest is also included in this cate tivity be a planned part of medical gory. These behavior problems are management so that anxiety related symptoms of serious emotional dis to performance capability or to the The Paraphilias turbance. In some instances, the physical effect of sexual activity The paraphilias include a variety sexual behavior poses a threat to can be minimized. of sexual behaviors which may or others and may require legal as well After recovery from a myocar may not be looked upon as abnor as therapeutic intervention. dial infarction, men can usually re mal or as constituting a problem by sume sexual activity commensu the individual who engages in the rate with their tolerance of other behavior. Included in the para physical exercise. Though there is philias are the following. a myth that postcoronary men have a high risk of dying during in tercourse, this is actually a rare oc currence. There does seem to be some risk associated with who the Gender Dysphoria Syndrome man’s sexual partner is rather than In this syndrome the individual, the fact of having intercourse. The male or female, is markedly discon stress of coitus with a new partner, tented with the gender role corre as in an extramarital affair, is evi sponding to his or her anatomic dently more risky than intercourse Sexual Orientation Distur sex. The patient may dress in with the marital partner.7 bance clothes belonging to the opposite In discussing sexual activity This refers to homosexuality sex not for sexual excitement or with a man recovering from a coro about which the individual is anx pleasure as with the transvestite nary, his recent and present level of ious or in conflict. Not infrequently but because of a desire to live as a activity should be ascertained. the practicing homosexual is con member of the opposite sex. Graded exercises under the super tent with his or her sexual orienta Management of the patient with vision of a physiotherapist are tion. Sometimes, however, the one of the paraphilias requires re often useful in rehabilitation of the overtly homosexual person is seri ferral to a psychiatrist or a sexual patient. When the patient is able to ously troubled because he or she therapy clinic specializing in the tolerate such exercise as climbing wishes to be married someday and evaluation and treatment of these two flights of stairs, he can begin to have a family or, in the event that and other sexual disorders. use this exercise capacity for sex the person is already married, has ual activity. It may be advisable for encountered serious difficulty in the patient to resume sexual activ the sexual relationship with the ity gradually rather than all at once, spouse. Strong homosexual incli eg, petting, perhaps masturbation, nations which are unconscious then intercourse. In intercourse he constitute latent homosexuality might use a position other than and may set the stage for homosex male superior, since the isometric ual panic if strong homosexual feelings erupt into consciousness. Mild or fleeting feelings of attrac Sexual Problems Associated tion to persons of the same sex are with Physical Illness not uncommon among psychologi Patients with chronic illnesses cally healthy adults. and those recovering from acute Continued on next page

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prevent some problems entirely heroin, morphine, and the barbitii- and can greatly limit the severity of rates frequently produces a marked others. decline in sexual interest. So® decrease in libido may also be ok- served with the use of antipsy. chotic drugs, especially when em contraction of arm and shoulder ployed in high doses. muscles in this position is strenu Impotence can occur with the ous.7 use of alcohol in large amounts, the Diabetes can be a cause of impo- phenothiazines, and sometimes tency due to autonomic nervous with anticholinergic agents. Altered Sexual Functioning system degeneration; this is gener A small percentage of patients j Associated with Medications ally irreversible. Occasionally the receiving thioridazine (Mellaril) re-1 impotence improves with better The historic quest for true aph port absence of ejaculate w h i c h is control of the diabetes. More rodisiacs is an ancient one indeed probably due to retrograde ejacu commonly, though, the man so and it would appear that in every lation. Premature ejaculation is I afflicted will have to replace in age there have been false claims commonly present following with tercourse with other sexual ac and rumors of agents that enhance drawal from opiates in persons ad-; tivities. If the couple is still inter libido and ability to perform. Our dieted to them. ested in having a sex life, they may age is no exception. In general, the try oral and manual techniques; al efficacy of drugs in enhancing sex though the man cannot have a full ual interest and activity is not very erection he may still be able to have impressive.1 an orgasm. Some agents such as alcohol, Paraplegia and arthritis cause amphetamines, hallucinogens, and reduction of motility. In addition, cannabis in low to moderate the paraplegic has little or no sen amounts may transiently produce sory input that he is aware of from an apparent increase in sexual in the genital area. Nonetheless, re terest and activity by decreasing flex activity at the spinal cord level inhibitions. Cannabis, am can lead to a firm erection, and phetamines, hallucinogens, and paraplegics can derive pleasure cocaine may also be associated from sexual activity. Helping the with a heightened awareness of References patient to be aware of this potential sensual experiences. However, 1. Carter CS, Davis JM: Effects oi should be part of his rehabilitation these effects are difficult to meas drugs on sexual arousal and performance program. The general approach to ure, many reports of drug effects In Meyer JK (ed): Clinical Management^ Sexual Disorders. Baltimore, Williams helping paraplegics and other pa are anecdotal, and it is difficult to and Wilkins, 1976 tients with neuromuscular or mus rule out placebo effect in many in 2. Green R (ed): Human Sexuality:Ai Health Practitioner's Text. Baltimore, culoskeletal disabilities includes stances. The administration of Williams and Wilkins, 1975 good communication between sex L-dopa to patients with parkin 3. Levine SB: Marital sexual dysfunc tion. Introductory concepts. Ann Intern ual partners, and experimentation sonism is sometimes associated Med 84:448, 1976 and innovation with feasible po with increased sexual activity; this 4. Masters WH, Johnson VE: Hum* Sexual Inadequacy. Boston, Little, Brown, sitions and techniques.2 may be due in part to overall im 1970 provement in the patient’s condi 5. Masters WH, Johnson VE: Hum* Hysterectomy can be followed Sexual Response. Boston, Little, Browo, by sexual difficulties for a couple.8 tion. 1970 In contrast with the relative inef 6. Meyer JK (ed): Clinical Manage The woman may become depressed ment of Sexual Disorders. Baltimore after this surgery, and either she or fectiveness of drugs in improving Williams and Wilkins, 1976 sexual function, a number of agents 7. Wagner NN: Sexual activity and®: her spouse may believe that hys cardiac patient. In Green R (ed): Hum* terectomy signifies loss of sexuality can clearly have an adverse effect Sexuality, A Health Practitioner's Texi on sexual desire, potency, and Baltimore, Williams and Wilkins, 1975 or femininity. Counseling before 8. W olfS : Emotional reactions to dye and after surgery is wise; it may ejaculation. Long-term addiction to terectomy. Postgrad Med 47:165,1970

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