Psychiatrists and Clinical Sexuality

In listening to the patient's story, the psychiatrist first discerns whether the patient or couple is raising an identity or function problem. Then he or she defines its dimension: gender identity, orientation, paraphilia, desire, arousal, orgasm, pain. Then the distinction is made whether the problem has been present since the onset of sexual activity, that is, it is "lifelong"; or has followed a long symptom-free period, that is, it is acquired. If it is acquired, the psychiatrist determines whether it is currently always present, or is situational with one partner and not another, or is present sometimes with a partner. These decisions enable the psychiatrist to rationally pursue the cause of the problem.

Since biological, psychological, interpersonal, and cultural elements contribute to sexual concerns, the psychiatrist needs to understand their mechanisms. Biological causes can range broadly from congenital androgen receptor disorder¹⁰ to a current undiagnosed prolactinoma,¹¹ to obvious disease such as multiple sclerosis. The cause may be an adverse effect of medication or it could be heroin abuse.

Psychological causes may involve past developmental processes such as the early death of a good parent, neglect, or physical or sexual abuse. Current psychological states may involve an affective disorder or paranoia. Sociocultural influences may stem from the inability to free oneself of antisexual orthodox religious attitudes, homophobia, or beliefs about the abnormality of masturbation or oral-genital contact. Listening to many sexual histories enables the psychiatrist to gradually become more proficient in generating causal hypotheses and to use them to benefit his patients in individual or couple psychotherapy.

Each of the 4 etiological elements undergoes short-term oscillations (eg, changing phases in the menstrual cycle) and long-term changes (eg, maturation- al evolution of attitudes toward sex). The oscillations explain the subjective and physiological differences between one sexual experience and the next with the same partner. The gradual evolution of the 4 elements makes every sexual life a changeable or dynamic process. Dysfunctional sexual life is trapped in symptoms, has less oscillation, and tends to cause the disappearance of all partnered sexual behavior early in the life cycle.

A comprehensive understanding of the 4 elements is too complex, time consuming, and cumbersome for most busy practitioners. As a result, professionals in all specialties tend to oversimplify the subject in order to be efficient and thereby often miss the subtleties of pathogenesis. Many problems get dismissed, both in textbooks and in clinical settings, as having an unknown cause when, in fact, they have multiple causal contributions. If we are to be accurate in our assessments of individuals and couples, psychiatrists must be willing to consider the current and past contributions of the biological, psychological, interpersonal, and cultural factors in every case. We may declare after the first or second session that "this man's hypoactive sexual desire is due to his critical assessment of his wife's alcoholism," but we should be prepared to discover over time that the etiology was more complicated.¹²

Psychiatrists who develop an interest in clinical sexuality tend to employ 2 different paradigms, depending on the clinical situation. One is quite familiar to modern psychiatric continuing education. The patient has a disorder, we possess a range of medication treatments, and the etiological theories support our treatment. Lifelong premature ejaculation is an ideal example.

Another paradigm is necessary for most sexual disorders, however. We approach these disorders from the viewpoint of general etiology rather than disorder-specific causation. Sexuality unfolds in adolescence and continues to evolve over decades of adult maturation. The sexual problem serves as a window into personal development and individual and relationship psychology. Sex is understood to be about the unfolding of the individual self, the capacity to give and receive pleasure, the capacity to love and to be loved, the ability to be psychologically intimate, and the ability to manage expected and unexpected changes throughout adulthood.

Since few sexual dysfunctions have a specific treatment, diagnosis per se usually is not the determinant of treatment. Rather, it is the invitation to study the context in which the problem arose. Treatment rests on the clinician's understanding of how biological, psychological, interpersonal, and cultural factors combined in this case to create the symptom. This second paradigm reminds psychiatrists that the management of sexual disorders often requires interest and skills in psychotherapy.

In this special report my colleagues discuss a variety of issues pertaining to sexual disorders in a psychiatric setting, including such topics as DSM criteria for sexual disorders, the neuroendocrine and psychodynamic influences on sexual orientation, new findings in premature ejaculation, premenstrual dysphoric disorder, the link between anxiety and sexual disorders, and pharmacological treatments of sexual dysfunction. The goal of this section is to deepen readers' understanding of and interest in sexual disorders in their patients.