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.
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:
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
Becoming comfortable listening to sexual stories
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:
Inquiring about sexual identity
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.
Understanding sexual function
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.
Steps in the classification of sexual symptoms
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.
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