Psychiatrists and Clinical Sexuality

Any sexual behavior—normal or abnormal, masturbatory or partnered—ultimately rests on biological elements, psychological elements, interpersonal elements, and cultural concepts of normality and morality.¹ The psychiatrist who develops an interest in patients' sexual concerns will have many opportunities to build a deep understanding of these 4 elements as the physician-patient relationship evolves over time.

Patients generally bring sexual problems to psychiatrists in 3 ways. The most familiar is the presentation of a sexual chief complaint or its emergence during therapy for another problem. These concerns fall into 2 categories:

• Sexual identity, eg, cross-dressing, anxiety about the possibility of being a lesbian or a gay man, or violent sexual fantasies.

• Sexual dysfunctions, eg, new difficulty attaining orgasm, aversion to intercourse, painful intercourse, rapid ejaculation, inability to maintain an erection, or inability to ejaculate in the presence of a partner.

Second, psychiatrists may be asked for help by a couple who complain of difficulty orchestrating their sexual life. The couple's chief complaint may involve discrepancies in sexual desire, the husband's inability to bring a wife to orgasm because of premature ejaculation, the cessation of sex, infidelity, dyspar-eunia, erectile dysfunction in a recently married couple in their 60s, or a wife's distress over her husband's use of Internet pornography. Some individuals and couples are too shy to bring up their sexual concerns; they dwell on nonsexual matters and hope the doctor will ask about their sexual life.

The third avenue derives from the clash of a persons' sexual behavior with social values or laws. Judges, lawyers, state boards, clergy, or other physicians may ask for psychiatric assistance with those who are accused of sex crimes, who crossed sexual boundaries at work, or who have been sexually harassed, stalked, or otherwise victimized.²

Sexual concerns are extremely common in the general population³ and are more prevalent among those burdened by psychiatric disorders.^4-6 Psychiatrists, while skillful in assessing major psychiatric disorders, are not nearly as relaxed and confident about their capacity to respond to sexual complaints. Sexuality is so private a subject that most people, psychiatrists included, are not proficient in discussing their sexual lives. As a result, psychiatrists may experience personal resistance to exploring sexual issues in detail. This resistance presents with subtle fears of:

• Personal or patient sexual arousal while talking about sex.

• Not knowing what relevant questions to ask.
• Not knowing how to help with these problems.
• Sudden appearance of awareness of one's own sexual concerns.
• Having one's moral repugnance show to the patient.⁷

Sexual identity is a personal sense of the self that is usually clearly attained by the end of adolescence. It consists of self-labels involving the degree of comfort with the self as a masculine or feminine person (gender identity); the gender of those who attract and repel us for romantic and sexual purposes (orientation); and what we want to do with our bodies and our partners' bodies during sexual behavior (intention).

We have to be prepared to explore how the patient thinks of his or her sexual identity and to assess whether the patient's concerns indicate a gender identity disorder; whether the patient's orientation is heterosexual, homosexual, or bisexual; and whether the patient's fantasies and behaviors indicate paraphilic intentions. The countertransference problems posed by patients with conventional sexual identities are generally not as intense as those posed by patients with a gender identity disorder, homosexuality, or a paraphilia.

While the DSM-IV model of desire, arousal, and orgasm disorder categories is straightforward, its application is not. Desire and arousal merge into one another, particularly as middle age dawns or individuals settle down with one consistent partner in marriage. Desire is usefully thought of as having a youthful biological element called "drive," and a lifelong motivational element reflected in the willingness to engage in sex with a particular partner.⁸

Psychiatrists need to discern whether a patient's loss of desire for sex is manifested by an absence of sexual thoughts, fantasies, attractions, or masturbation (as might be seen in acquired hypogonadal states), or whether the patient is unmotivated to bring his or her body to the partner for sex (as commonly occurs for several years before divorce). Desire is also complicated by a gender difference.⁹ Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior with their partner precedes their intense desire for sex, while most men continue to express through much of the life cycle that their desire for sex precedes their arousal.