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Yerevan State Medical University after M. Heratsi Department of Sexology Nersisyan N.R, Azatyan R.E. Clinical Sexology Handout on Clinical Sexology for foreign students of general medicine faculty 2008 Yerevan State Medical University after M.Heratsi Department of Sexology Nersisyan N.R, Azatyan R.E. Clinical Sexology Handout on Clinical Sexology for foreign students of general medicine faculty Yerevan, YSMU, 2008 UDS 616.89-008.442(07) This handout is adopted by the Methodical Commission of Foreign Students of the YSMU Recenzent: Narimanyan Z. Michail Chairman of department Family Medicine of YSMU Recenzent: Gasparyan Kh. Chairman of department Medical Psychology Edited by prof. Hakobyan E. Aram ISBN 978-99941-40-77-0 ©Nersisyan N., Azatya R. ºñ¨³ÝÇ Ø. лñ³óáõ ³Ýí³Ý å»ï³Ï³Ý µÅßÏ³Ï³Ý Ñ³Ù³Éë³ñ³Ý ê»ùëáÉá·Ç³ÛÇ ³ÙµÇáÝ Ü»ñëÇëÛ³Ý Ü.è.,²½³ïÛ³Ý è.¾. ÎÈÆÜÆÎ²Î²Ü êºøêàÈà¶Æ² àõëáõÙÝ³Ï³Ý Ó»éݳñÏ ÎÉÇÝÇÏ³Ï³Ý ë»ùëáÉá·Ç³ÛÇ Ó»éݳñÏ ÀݹѳÝáõñ µÅßÏáõÃÛ³Ý ý³ÏáõÉï»ïÇ ûï³ñ»ñÏñ³óÇ áõë³ÝáÕÝ»ñÇ Ñ³Ù³ñ ºñ¨³ÝÇ Ø.лñ³óáõ ³Ýí³Ý å»ï³Ï³Ý µÅßÏ³Ï³Ý Ñ³Ù³Éë³ñ³ÝÇ Ññ³ï³ñ³ÏáõÃÛáõÝ 2008 Preface 4 Preface The book has been written on the foreign students’ advice and the aim of the book is to be of concrete assistance to future physicians, as they deal with the day-to-day concerns of their patients in sexual matters. The first chapters of the book discuss the psychosexual development and male/female sexual manifestations, the other chapters are devoted to classification of sexual disorders. The book centers on etiology, differential diagnosis, and clinical description of sexual dysfunctions, and consequently, it suggests effective methods of treatment. It also covers evaluation of sexual disorders, paraphilias and briefly some aspects of male reproductive function. The book mainly contains factual information and, therefore, provides a very thoroughly and carefully organized introduction to the whole of clinical sexology. It does not restrict to clinical and therapeutic aspects, but it also includes psychological, biological and sociological contributions. The last part of the book presents tests related to each subject covered in the book. The book is initially intended for medical students, and it also can be meant for sexologists, psychologists, psychiatrists, psychotherapists, sociologists and for the other specialists. We welcome any comment, well-founded criticism, and recommendation on the practical value of this book so that we can strive to come even closer to realization of that objective in succeeding editions. Acknowledgments Acknowledgments We are gratefully acknowledged to everyone associated with production of this book. We would like to express our most sincere gratitude to members of department of sexology and Special thanks to Hakobyan S.V.,Vardanyan G.V., Grigoryan A.D., and as consultant Davtyan R.M. We would also like to extend our special thanks to Bisharyan M.N. from department of foreign languages at YSMU. 5 CONTENTS 6 CONTENTS Preface ........................................................................................................................... 4 Acknowledgments...................................................................................................... 5 CONTENTS .................................................................................................................... 6 Chapter 1 The subject of clinical sexology and its methodological approaches ................................................................................................................... 8 Paradigms in sexology .......................................................... 9 Chapter 2 Psychosexual development through the life cycle ................. 11 Prenatal influences .................................................................................................. 13 Parapuberty (1 to 7 Years) .................................................................................. 15 Infancy (Birth to 15 Months) ............................................... 15 Toddlerhood (15 Months to 3 Years) .................................... 16 Preschool Period (3 to 7 Years) ............................................ 17 Prepuberty (7 to 11 Years) .................................................................................. 19 Puberty (11 to 16 Years) ...................................................................................... 20 Transitional period to mature sexuality (17 to 25 Years) ........................ 23 Mature sexuality (25 to 55 Years) .................................................................... 23 Involution (55 to 70 Years) ................................................................................. 26 Sexual constitution 27 Chapter 3 Sexual response cycle ...................................................................... 33 The desire phase ...................................................................................................... 36 Anatomy........................................................................... 37 Physiological mechanisms ................................................... 38 Disorders of desire phase ................................................... 40 The excitement phase ............................................................................................ 40 Male excitement - Erection .................................................. 40 Female excitement............................................................. 43 Disorders of excitement phase ............................................ 45 The orgasm phase ................................................................................................... 46 Disorders of the orgasm phase ............................................ 49 Chapter 4 Sexual disorders ................................................................................. 51 Classification of sexual disorders ....................................................................... 51 Disorders of sexual desire .................................................................................... 57 Female sexual arousal disorder.......................................................................... 69 Female orgasmic disorder .................................................................................... 77 Vaginismus ................................................................................................................. 83 Male orgasmic disorder ......................................................................................... 85 Male erectile dysfunction ...................................................................................... 93 Ejaculatory Pain Due to Muscle Spasm of the Male Genitals ................ 101 CONTENTS 7 Sexual Phobias and Avoidance ......................................................................... 102 Chapter 5 Paraphilias ........................................................................................... 104 Chapter 6 Gender identity disorders .............................................................. 111 Childhood .................................................................................................................. 112 Chapter 7 Ego-dystonic homosexuality ........................................................ 121 Varieties of homosexual expression ............................................................... 123 Preferential or obligatory homosexuality ............................. 123 Pseudohomosexuality ....................................................... 124 Situational homosexuality ................................................. 125 Exploitative homosexuality................................................ 125 Enforced homosexuality .................................................... 125 Chapter 8 Evaluation of sexual disorders ..................................................... 127 Chapter 9 Treatment of sexual disorders ..................................................... 134 Psychotherapy of sexual disorders ................................................................. 134 1. Hypnosis .............................................................. 134 2. Adlerian therapy .................................................... 134 3. Behavior therapy ................................................... 135 4. Existential therapy ................................................. 136 5. Gestalt therapy ..................................................... 136 6. Person-centered therapy ........................................ 136 8. Psychoanalytic therapy ........................................... 137 9. Rational-emotive and Cognitive-behavioral Therapy ... 138 10. Male reproductive function ...................................... 138 11. Transactional Analysis ............................................ 143 12. Sex therapy .......................................................... 144 Pharmacological therapy of sexual disorders.............................................. 144 Tests ........................................................................................................................... 146 Keys ............................................................................................................................ 156 References ................................................................................................................ 157 The subject of clinical sexology and its methodological approaches 8 Chapter 1 The subject of clinical sexology and its methodological approaches Clinical sexology is a medical discipline which studies behavioral, personal and emotional aspects of sexual functioning and develops methods of diagnosis, treatment and prevention of sexual disorders. At the beginning of development of sexology it is considered that the cause of sexual disorders is the presence of any basic disease (endocrine, urological, psychiatric), and patients were treated by the specialist who was competent in treatment of these diseases. But very often sexual dysfunction presents itself, e. without any coexisting basic disease. Furthermore, more resistant and hard-to-cure sexual disorders were observed at those patients whose thorough urological, endocrine, neurological and psychiatric examination did not find out any aberration. On the contrary, during serious illnesses, both somatic and mental, complete sexual health might be observed. Both in our country and abroad, doctors undoubtedly confirm that sexuality is the integration of several dimensionssomatic, emotional, intellectual, social and ethical. In order to sexual health could be maintained complex and integrated interactions of different functional systems are required. To summarize methodological approaches in sexology three of them could be mentioned: 1. Monodisciplinary approach - is limited to a service of only one expert: urologist, gynecologist, endocrinologist, neurologist, psychiatrist, clinical psychologist, marriage and family therapist, sociologist. Several aspects of sexual health are viewed separately. 2. Multidisciplinary approach - Various specialists work together to understand and treat patients referred to medical center with a wide variety of sexual problems. Those of them trained to do psychotherapy do the initial interviewing and the The subject of clinical sexology and its methodological approaches 9 majority of the therapy. Clinical psychologists administer objective and projective tests. Medical specialists do physical exams, obtain necessary lab tests, and participate in the formulation and planning stages of therapy. 3. Interdisciplinary or integrated approach – tries to integrate all (physiologic, psychological and social) aspects of sexual functioning. Sexology stands apart as separate clinical discipline and develops own system of scientific categories and understanding of sexual disorders. Paradigms in sexology According to three methodological approaches in sexology there are three paradigms that try to explain sexual functioning and pathogenesis of sexual dysfunctions. Mechanical paradigm associates all sexual dysfunctions with local changes in genitalia. Encyclopedic paradigm follows to the multidisciplinary methodological approach. Systemic paradigm tries to integrate all aspects of sexuality. The representatives of the first paradigm consider that sexual dysfunctions are consequence of urological lesion (for example: urethritis, prostatitis or colliculitis) and therapeutic approach was reduced to the treatment of these focuses, supposing mechanical recovery of the sexual function. The influence of this paradigm is obvious in practice of such medical specialties as urology, venereology and gynecology. Prescription of antibacterial drugs in an irrational amounts after diagnosis of inflammatory process does not bring to the recovery of sexual function and the patient leaves the medical institution with the same complaints he had before. Development of experimental endocrinology and chemistry of hormones makes all-powerfulness capacity of hormones to dominate in medical thinking. The experts with endocrine bias were considered as advanced ones in the field. As a result all variety of sexual difficulties and dysfunctions started to be interpreted by qualitative and quantitative changes of sexual and other hormones. The subject of clinical sexology and its methodological approaches 10 In our practice there are a great number of such visitors that for a long time were cured unreasonably by androgens for recovery of their sexual potency, though the true cause of disorder was the congestive process in the small pelvis, caused by “neurosis of failure expectation”. In these cases hormonal treatment is not only inefficient, but also full of danger of total disappearance of erections. The second – encyclopedic paradigm is characterized by the prevalence of multidisciplinary methodological approach of sexology. Sexual disorders are analyzed by several points of view. Many groups of factors are taken into account at once (urological, neurological, endocrine, and psychic) together with socio-psychological, cultural and other factors. The greatest achievement of multidisciplinary methodology is parametrical surveys which were carried out both in Russia and in the USA. In the USA these surveys were carried out by Kinsey (1948-1953). He collected numerous data and found out average rates on the basis of specially developed questionnaires. Further the data obtained by the scientist became a basis for development of clinical sexology not only as a branch of medicine, but also as a separate science which also includes other aspects of public life. The third – systemic paradigm and interdisciplinary model of clinical sexology in Russia developed by G.S. Vasilchenko, on the basis of theory of functional systems of Anokhin (1975) and a concept of phases and components of a copulative cycle developed by himself. It allows defining specific discrete forms of sexual disorders and developing treatment corresponding to these forms. There is also another model that gives systemic framework of sexual functioning developed by D. M. Schnarch. It is called quantum model. It offers an alternative to the widespread tendency to conceptualize sexual dysfunctions as separate “diseases”. The quantum model also avoids the tendency to dichotomize the causes of sexual dysfunctions into “organic” and “psychogenic” categories, as commonly occurs in urology, gynecology, and psychiatry texts. Psychosexual development through the life cycle 11 Chapter 2 Psychosexual development through the life cycle Psychosexual development is the continuing process by which each person becomes the sexual being he or she is. At any point in life, it represents the cumulative effects of many forces, and it is one facet of psychological and maturational development that is constantly being directed and shaped by three forces simultaneously. One force is biological, including hormonal, physiological and anatomical influences, innate maturational timetables. A second is cultural, including social learning in the family and influences outside the family. A third force is intrapsychic, including normal developmental conflicts; unconscious fantasies, conflicts and attitudes; and the influences of all earlier experiences and emotions that help determine how one approaches and copes with each new biological , cultural and intrapsychic event. The normal development of systems of a higher organizational level depends on the successful development of early related systems. Therefore, disruption of an early criticalperiod phenomenon impairs the successful acquisition of certain later systems. According to Vasilchenko G. S. the development of sexuality comprises of the following phases: 1. Prenatal phase-include the period of time from the conception up to the delivery. At this time brain structures of sexuality and gonads are differentiated. 2. Parapuberty (1 to 7 Years). The chief developmental event of this period is learning core sexual identity-the sense of being male or female. There are two stages of this process: first children become aware of their sexual identity and consider themselves either boys or girls. Then increased curiosity to explore anatomical differences between two sexes enforces admitted identity. Psychosexual development through the life cycle 12 3. Prepuberty (7 to 13 Years). At this period the sex he or she belongs to is fixed. Socialization in sex roles takes place during this period corresponding to the core sexual identity. Again two steps can be distinguished-one is the choosing the ideal prototype of masculinity and femininity and the other is practicing chosen stereotypes of appropriate behavior in plays. 4. Puberty (13 to 16 Years). The main psychosexual event in this period is the formation of psychosexual orientation. While the former two phases proceed in a relatively quiet background, this period is marked by blooming of endocrine system, especially the activity of gonads increases and the level of sex hormones become higher. This triggers the bodily changes and emerging of secondary sexual characteristics. In general, the sexual orientation develops in tree smoothly following stages, two of which accomplish at this period. It is necessary to highlight that the end of each stages marks with learned experience on the basis of previously stated position. These two stages are (1) the platonic libido stage that begins with platonic fantasies and thoughts, and ensuring after by platonic communications, and (2) the erotic libido stageevolving from erotic dreams to erotic contacts, such as hugging and kissing 5. Transitional period to mature sexuality (16 to 25 Years). The last stage of forming of sexual orientation takes place. This is the sexual libido stage. Sexual fantasies enhance with sexual intercourse scenes, person has his or her first sexual intercourse, and the sexual life with its excesses and abstinences is being established. 6. Mature sexuality (25 to 55 Years). During this period all the tree psychosexual development phases are over. Sexual identity, sexual socialization and sexual orientation are somehow formed and person who has a stabile sexual life enters in certain physiologic rhythm called conditional physiologic rhythm (CPR). 7. Involution (55 to 70 Years). At this period the sexual activity decreases, interest in sex lowers. The reverse dynamic of libido evolution is observed up to the platonic libido phase. Psychosexual development through the life cycle 13 Prenatal influences The presence of normal sex chromosomes (XX or XY) determines whether the undifferentiated gonadal analogs develop, respectively, into tests or ovaries. In the XY embryo, testes begin to develop and to produce androgens at a fetal age of about six weeks. In the XX embryo, ovaries begin to develop somewhat later. Sexual development begins at about six weeks and depends upon the presence or absence of fetal testicular androgens. The external genitalia of both sexes form from the same embryological tissue. In the presence of fetal androgens, the genital tubercle enlarges and becomes a penis. The urogenital folds fuse, enclosing the urethra along the underside of the penis. The labioscrotal swellings fuse at the midline to form the scrotum. At the same time, the Wolffian ducts will begin to form the vas deferens, seminal vesicles and ejaculatory ducts. A separate fetal testicular substance called antimullerian factor, reduces the Mullerian ducts to vestigial remnants. External male genital morphology is complete and irreversible by the end of the 14th week. In the absence of androgen, the genital tubercle becomes a clitoris. The urogenital groove remains open as the vaginal introitus. The urogenital folds remain in place as the labia minora; labioscrotal swellings remain unfused and enlarged to form the labia majora. The Mullerian ducts form the fallopian tubes the uterus and the major part of the vagina. The cause of the Wolffian duct to become vestigial is not known. Female genital morphology, like male morphology, is complete and irreversible by the 14th week. Psychosexual development through the life cycle 14 Pic. 01 Development of Male and Female Sex Organs Also beginning at six weeks, but probably extending for a longer period, fetal androgens start organizing parts of the developing brain, especially in the hypothalamus and limbic system, which may mediate behavior and temperament more characteristic of males than of females. At puberty, the hypothalamus will mediate the release of hypophyseal gonadotropins in the acyclic male pattern. In the absence of fetal androgens, central nervous system is organized so that at puberty gonadotropins will be released in the typical cyclic female pattern (which accounts for the menstrual cycle), and female behavior and feminine temperament may be mediated. Another result of normal fetal CNS organization is that, after gonadal maturation, sexual arousal is more easily elicited by a member of the opposite sex than of the same sex. This Psychosexual development through the life cycle 15 constitutes an innate heterosexual bias. However, this bias can be overridden by a variety of postnatal emotional and learning experiences. It seems that nature is predisposed to differentiate a female, unless effective fetal androgens cause male dimorphism. If there are no fetal gonads of either sex, as in Turner’s syndrome (chromosomes 45, XO), female morphological and feminine temperamental differentiation occur. They also occur if fetal testes are present and functioning but the androgen is not effectively used by the tissues, as in animal experiments with antiandrogens and in the human androgen insensitivity syndrome. If there are excessive levels of virilizing androgens in a chromosomal and gonadal female, as in congenital hyperadrenocorticism, male morphological and masculine temperamental differentiation occur. Parapuberty (1 to 7 Years) This period of time can be divided into tree pieces: infancy, toddlerhood and preschool period. Infancy (Birth to 15 Months) Learning core sexual identity- the sense of being male or female-is the chief event of this period. It determined mostly by brain structures differentiated in prenatal period. Some microsocial factors also play a role. Parents not only handle male and female newborns differently, they tolerate and elicit different behaviors from them. From the time an infant is named, a constant stream of cues teaches it that it is male or female. Other sexual experiences of infancy are derived from having a male or female body. The mostly invisible and internal female sex organs create more vague and diffuse sensations. In contrast, the more external, visible male organs provide more localizable sensations. These differences of body conceptions lay early bases for the different sexual self- Psychosexual development through the life cycle 16 concepts, body images, sexual attitudes and vulnerabilities felt by female and male. Another sexual aspect of infancy is learning to accept one’s own and others’ bodies as good, pleasureful, and trustworthy or as bad, unpleasant, and dangerous. This learning results largely from the manner of mothering-the quality and quantity of touching, holding, and fondling and of physical warmth or its lack. A sense of one’s body as good or bad also arises from parental responses to genital behavior. The capacity to form bonds with others is strongly influenced in early infancy as well, because of the interactions that produce trust of physical closeness. Infancy is probably the optimal period for achieving trust and enjoyment of physical closeness, as well as the capacity to form healthy and loving bonds, and for acquiring one’s coresexual identity. This latter development may continue into early toddlerhood, but core-sexual identity is usually irreversible by age 1, 5 to 2 years. Toddlerhood (15 Months to 3 Years) The chief developmental events of this period are the recognition of body autonomy and learning to balance control of oneself with acceptance of social controls. During this time, most children become aware of anatomical sex differences. Normally this awareness is not traumatic, but it really stimulates enormous curiosity. Circumstances expose many toddlers to the events of pregnancy and birth, to which they also respond with great curiosity. Along with increased drive to explore one’s body and physical environment, there is increased genital exploration, purposeful masturbation, and sex play with others. Toilet training has sexual implications because of proximity of sexual sensations to eliminatory functions. There is always the danger of learning an inappropriate association between “dirty” bowel functions and sexual sensations; this is a greater emotional hazard for girls than for boys. And as the toddler struggles with the inner conflict between wanting control of his own bowel action and the requirement to relinquish at least part of it, he Psychosexual development through the life cycle 17 may generalize this conflict to feeling that he also does not have an autonomous right to sexual sensations. Socialization in sex roles increases at this time. Social interaction exposes him to role models, chiefly within the family. Which sex he or she belongs to is already fixed; what it means to be that sex is the new horizon. Toddlers begin to identify with and imitate the same-sex parent; some temporary periods of cross-sex identification are normal, but persistent cross-sex identification is not. A toddler is encouraged and rewarded for behavior that his parents consider sex-appropriate and ridiculed or punished for deviations. Destructively rigid sex-role stereotyping, when present, begins its damaging constriction by toddlerhood, but the child probably has no awareness of it. Toddlers are affected by evidence within the family of how one or the other sex is valued, as reflected in parents’ attitudes toward one another, and by any differential treatment of siblings and other relatives according to sex. A toddler can begin to develop a deep-seated repudiation of his own or the opposite sex if he senses consistent overt or covert disparagement of males or females. Toddlerhood is the optimal period of language readiness; during these years, children must learn effective verbal communication or carry a major handicap through life. Toddlers’ sexual curiosity is not only physical and visual but verbal and cognitive. Accurate words are necessary to normal ego development. Without clear verbal concepts, one cannot bring order to one’s world or categorize one’s experiences realistically. Preschool Period (3 to 7 Years) Some subtle but important maturational changes in sexual physiology mark this period. The sensory nerves to the penis and clitoris become fully myelinated by about 3 to 3, 5 years of age, allowing for more discrete and intense erotic sensation. There is also probably a slight increase in androgen production in both sexes. Because androgen is largely responsible for erotic desire in both sexes and for sensitizing the clitoris and penis to respond sexually to tactile stimulation, this rise Psychosexual development through the life cycle 18 enhances the child’s sexual drive. These factors cause increasing genital eroticism, with an even greater increase in masturbatory activity than in toddlerhood. The most important change is that masturbation is now goal-directed with heterosexual fantasies. It is inevitable for the child to wish to gratify his desires with the opposite-sex person he loves mostusually the parent. This is a manifestation of the Oedipus complex, and it occurs largely outside awareness or in dreams and disguised masturbatory fantasies. But there is no substantial doubt that it occurs, and most parents can recall such seemingly naïve comments as, “when Daddy dies and I grow up, I’m going to marry Mommy”. These wishes produce fear and conflict. If the child wants to displace or destroy the parent, he fears that the bigger, stronger parental rival will be angry and destroy him. In a child’s logic, the punishment would fit the crime; the result is fearful fantasies that his or her sexuality will be destroyed. At the same time, the child loves the rival parent deeply and feels guilty over Oedipal impulses. A child’s sexual anatomy affects the kinds of fears and dangers he imagines. A boy’s penis is external and vulnerable; this invites fear of it being cut off, and he may regard female anatomy as proof of that possibility. A girl may believe that in the past her mother deprived her of a penis as punishment for her sexuality. The child’s fantasies cannot be sustained in the face of the fact that the “rival” parent remains loving and accepting and does not reinforce the fears. And the parents’ continued preference for one another in intimacy, a new arrival, a harsh punishment at the hands of beloved parent, and the physical impossibility of replacing the parent cannot forever be denied. So reality with its painful disappointments as well as fear divests the fantasy of much of its unconscious power and forces renunciation of the wish. The Oedipus-complex becomes extinguished by its lack of success, the result of its inherent impossibility. The Oedipal phase ends with the child beginning to accept and strive for a definitive identification with the parent of the same sex. Psychosexual development through the life cycle 19 Healthy parental response is crucial to successful resolution of Oedipal conflict, and parents can unwittingly fall short. It may be difficult for a father to be both patient and firm with a persistently intrusive and provocative son, especially when he does not know what the behavior means unconsciously. If he is unreasonably angry or punitive in return, the boy may attribute it to rivalrous retaliation, and this reinforces his fearful fantasies. If there is dissension between the parents, either one may turn to the child out of spite or value the child’s love more than the spouse’s, making the fantasized rivalry real. Oedipal feelings exist in parents, too; many a parent is shocked and horrified to discover erotic stirrings in response to childish imitations of coquetry or wooing. Frequently such a parent, more often the father, withdraws out of guilt and ends all physical affection and warmth, nonverbally teaching the child that heterosexual feelings are bad. What is needed is an openly welcoming attitude toward the child’s budding heterosexual interests. In such families, there is no reason to be jealous of the child or to fear one’s own responses. The child also should be shown gently but firmly that the parents’ physical intimacies are reserved for one another and that, while the child’s sexuality is accepted, it must be deferred and eventually directed toward a different partner. The successful resolution of complex Oedipal processes is essential for psychosexual development. This is the stage when the child first feels, and experiments in fantasy with, heterosexual urges; it is probably the optimal period for the acceptance and fixing of heterosexual preference. Although the child must defer and redirect his urges, he must achieve and retain a firm sense of their basic goodness and acceptability, his right to them, and his right to their ultimate gratification. Prepuberty (7 to 11 Years) This period has often been referred to as sexual latency, because of Freud’s belief that there is then an organic Psychosexual development through the life cycle 20 diminution of sexual energy. Studies and investigation have not support this view. There is a steady increase in the incidence of sexual activity among children during these years. One ego-development task that occurs in this period is consolidating sex-appropriate sex-role preference. This started in infancy with the beginning of core sexual identity, continued during toddlerhood as the child experimented with the samesex and cross-sex identifications, and finally settled on identification with the same-sex parent at the resolution of Oedipal conflicts. Now the child, by attending school, is thrust into the larger society. It is probably in these early school years that socialization is most intense and most strongly determines role preference. Sex-roles in the family may have been unusual; now the child learns more of how the sexes are treated and what is expected of them in the world outside home. Pathogenic family attitudes can be ameliorated, although early learning can be very refractory; family expectations can be so powerful that a child has difficulty learning or accepting different or broader sex-role definitions. On the other hand, a warm and loving family can often insulate a child from the effects of a larger social milieu that adheres rigidly to overly restrictive sex-role stereotypes and is less tolerant of normal but divergent interests and attitudes. The basic acceptance of satisfaction with one’s sex rolethe social expression and consequences of being male or female- are most influenced during this period. Sex play, if not suppressed, begins in early toddlerhood, and it continues in the school years. But solitary or mutual masturbation, visual or tactile curiosity about others’ bodies, and imitations of adult sexual activities are almost universally disapproved of or punished in this society. Puberty (11 to 16 Years) Puberty is the biological surge of maturation that results in reproductive capacity and adult appearance. Its midpoint is somewhat arbitrarily defined as menarche in girls and the capacity for seminal emission in boys. Psychosexual development through the life cycle 21 Puberty occurs about two years earlier in girls than boys, and all the body changes may take from one and one-half to four years. Usually at about 9 to 11 years of age, the ovaries produce the sex hormone, estrogen, in increasing amounts; this increase initiates breast and uterine development and the fat distribution that results in typical female body contours. Females also produce male hormones (androgens) which are responsible for the development of pubic and axillary hair and increased growth of the clitoris and labia majora. Androgen is also responsible for erotic desire and the intensity o genital sensation in both sexes. At about the middle of puberty (average, 12 to 12.5 years), the hypothalamus has begun its cyclic regulation of sex hormones, and menarche occurs. Testicles begin to enlarge at about age 12 and start producing increasing amounts of testosterone about a year later. This initiates growth of the penis, pubic hair, and prostate; deepens the voice; and causes characteristic male musculature and bone growth. The ability to ejaculate semen with viable sperm, the equivalent of first menstruation in females, usually is achieved shortly before age 14. Adolescence is marked by increasing emotional lability, irritability, and unpredictable shifts from striking maturity to regressive behavior. This turbulence is probably caused by the rising production of sex hormones, which influences behavior before any major physical signs appear; therefore, the youngster has nothing concrete to which to attribute these puzzling feelings. Even when external changes have begun, the youngster still feels more like a child than an adult, has not yet moved into the adolescent social world, and often conveys a sense of being at odds with him and the word. Masturbation increases, primarily among boys, and homoerotic play becomes the most frequent form of sexual exploration with others. For the vast majority of youngsters, such homoerotic activity is a developmental way station to heterosexuality. The rising tides of sex hormones press for gratification at a time when most youngsters’ egos are not yet ready to cope with the emotional risk of heterosexual interaction; they often find it easier to explore their changing Psychosexual development through the life cycle 22 bodies and stronger sex drives with their more familiar samesex peers. Normal puberty can occur as much as two and one-half years earlier or later than the average. However, markedly early or late puberty can cause serious emotional distress, even lasting problems of sexual self-confidence. There is a recrudescence of oedipal feelings; often they are stronger and more consciously disturbing than in childhood. It is not uncommon for early adolescents to have conscious fantasies and undisguised dreams of sexual activity with a parent. Both the intensity and potential reality of these feelings help precipitate one of the major tasks of adolescence. This task entails a shift from the parent as primary love object to a nonfamilial heterosexual peer. The early adolescent’s first expression of this is often crude distancing from the parents, especially the opposite-sex parent, by turning away and by derogation; this is a way of denying attraction and associated conflict. By the end of early adolescence, youngsters should have accomplished the resolution of their dependency and reawakened Oedipal conflicts with parents enough to move into the mainstream of adolescent socialization and to begin heterosexual pairing. And they should have gained enough familiarity with, and security about, their own and other’s bodies to begin turning their attention more to the partnerships. Masturbation remains the most common sexual outlet throughout adolescence, even for many of those with coital experiences. This is more true for boys. A few adolescents begin coitus by 12 or 13. Our society is more accepting of sexual activity in males than in females. Thus, the age at which male adolescents begin various sexual activities is lower then that of female adolescents. Adolescent sexual experience is natural and, regardless of much that has been written about the dangers of coitus to adolescent ego development, there is no evidence that heterosexual coitus per se is damaging. The matter is that the Psychosexual development through the life cycle 23 younger or less mature adolescents are, the less likely are they to think of such consequences as pregnancy and sexually transmitted disease. Abstract thought is not normally fully possible until about age 14; until this level of “formal operations” is reached, one cannot understand involvement and commitment, anticipate inexperienced consequences, or plan for the future. Those whose sexual interactions remain self-centered reveal a delay of both emotional and cognitive maturation. Transitional period to mature sexuality (17 to 25 Years) Adolescence is thought of as a time of exploration, but, because of the greater opportunities afforded most young adults, many of them engage in even more sexual experimentation. On the other hand, because the intrapsychic progress from adolescence to adulthood entails the crystallization of identity, values, and interests, other young adults will have experimented sufficiently during adolescence and found what they like sexually, and their current experimentation therefore is diminished. There is greater incidence of premarital coitus now among women, so that there is now much less difference between the sexes than in the past. A characteristic of healthy adult sexuality is the capacity to focus both tender and sexual love on the same person (not necessarily only one person in an individual’s lifetime). Both the successful resolution of adolescent development and the early adult experience in sexual relationships are important for the achievement of such fusion, a capacity that is necessary before genuine, lasting commitment to a partner is possible. Mature sexuality (25 to 55 Years) Marriage and parenthood are only two of various ways that individuals of the 25 to 40 age period deal with the sexual issues. There is no implication that marriage is either the only Psychosexual development through the life cycle 24 appropriate or the healthiest way to manage adult sexuality. Married persons and parents are not by definition healthier than unmarried childless people. Some of the continued development possible within marriage is also possible in unmarried partnerships, but marriage and parenthood are qualitatively different from nonmarriage and childlessness. Marriage legally commits couples to try to develop their sexuality cooperatively rather than as individuals. Marriage also provides an opportunity for resolving remnants of unconscious sexual guilt related to parental disapproval. Girl friends and boy friends are just that, but a husband or wife has a role earlier held by a parent. A spouse’s enjoyment of sex play, coitus and variety of sexual expression can promote guilt-free sexual pleasure. The intimacy possible in marriage, the daily experiencing of one another’s fluctuating moods and physiological changes can dispel the anxiety-producing mystery of the opposite sex. Parenthood is a potent force in resolving remaining unconscious sexual conflicts and in further development. Pregnancy awakens new levels of a woman’s identification with her own mother. For her husband, it evokes similar identification with both father and mother, since in his primary identification with mother he internalized some of her nurturing qualities. Pregnancy begins to trigger a woman’s maternalism and enormously expands her awareness and acceptance of her previously vague internal sexuality; now there are contents and sensations to define it in a new way. Childbirth turns husbands and wives into parents and even more powerfully precipitates identification with their own parents. The woman gains functional equality with her mother, the man sexual parity with his father. These identifications carry the seeds both of growth and regression or disorder. Becoming a parent may awaken unresolved Oedipal conflicts in a destructive way; sexual activity may be inhibited if the spouse is unconsciously identified with the sexually tabooed parent. Parents also identify with their child and continue to do so as the child grows. In each developmental stage, the child Psychosexual development through the life cycle 25 reawakens in the parent the emotions, the developmental tasks, and any residual conflicts from that stage in their own lives. Of course, the parent meets each recrudescence not as a child coping with a stage for the first time but with an adult’s ego development, able to repair maladaptations and achieve greater health. A child’s increased sexual activity during the Oedipal stage forces many parents to re-evaluate attitudes toward their children’s and their own rights to sexual expression, such as the right to masturbation. A man whose father was physically undemonstrative and avoided him, perhaps fearing homosexual taint in such behavior with a son, may discover how natural such father-son affection is and lose some of his own anxiety about affection among men. Adolescence is often especially trying for parents. Parents, who have enough ego flexibility to hear their adolescent children’s questions and challenges, and to consider them with respect and intellectual honesty, will benefit as much as their youngsters. They will find that their previously unquestioned values have been opened to the possibility of alternatives, and their own sexual identities may be richer for it. Replacement by the young is inevitable for all people and painful for many. It is not true that all parents of adolescents have begun to lose their vigor and sexual attractiveness and capacity; many are in their sexual prime. But it is true that they have fewer remaining years of peak sexuality and reproductive potential than their adolescent children. True replacement does not take place during these years, but the issue starts to become conscious. This can cause severe distress in psychosexually immature parents and in those whose adult sexuality has been less than fulfilling. However, the growing sexual independence of one’s children can permit greater sexual freedom and enjoyment. Many parents gain more free time and privacy than they have had since their first child was born. If they have made good use of their relationship, they know so much more about sex and about each other’s sexuality that feverishly active adolescents seem like fumbling novices. The reassessments of attitudes and the Psychosexual development through the life cycle 26 changes in life-style that accompany one’s children’s adolescence can bring major achievements in psychosexual development. Involution (55 to 70 Years) This period entail biological changes that make it improbable for most persons to maintain the level of sexual functioning and to have the same emotional responses as in young adulthood. Our culture has been, and largely continues to be, as antisexual toward older people as toward the young. Traditionally active sexuality is considered to be acceptable only in married people of reproductive age. The result is that relatively little normal psychosexual development has been acknowledged or studied in the older population. Diminished fertility and menopause force a woman to think about her sexuality differently. This can be a very difficult time, often of severe depression or even psychosis, especially for women who had emotional conflicts about childbearing or child rearing, whose childbearing potential or desire was unfulfilled, or whose self-esteem was exaggeratedly linked to maternal capacity. Hormonal changes can lead to unpleasant physical symptoms, and then to gradual vaginal changes that may impair sexual responsiveness and pleasure. There are no male biological changes comparable to menopause. Neither a man’s sexual function nor his fertility is lost or even declines sharply because of age alone. Paternity has been documented into the 80’s and 90’s, and while almost all authorities report a gradual decline of circulating testosterone in later life, there is not an inevitable correlation with a diminished capacity for paternity. However, some men become depressed or panicky in middle life over their imagined loss of sexual vigor and hurl themselves into ill considered sexual adventures or new marriages as a means of reassurance. The biological changes of middle life in women are a major impulse toward further psychosexual development. For women Psychosexual development through the life cycle 27 whose values have precluded the use of contraception, menopause offers the first opportunity for sex without fear of pregnancy and may bring a great increase in enjoyment. Since these changes typically coincide with the end of preoccupation with active parenting, they allow new leisure for parents to enjoy one another and, for the woman, the possibility of a new or resumed career. The enhanced self-esteem that accompanies a continued sense of personal and social contribution is an antidote to depression and therefore to sexual decline. In the absence of specific disease, male erectile capacity is never lost as a consequence of age alone. Sexual arousal and achievement of orgasm may. However, take longer, there are longer refractory periods after orgasm, and ejaculation is less forceful and may not occur on every coital occasion. Unless a man misinterprets theses changes as decreased virility, they can carry more advantages then disadvantages. One of the most dramatic examples of psychosexual development that sometimes occurs in middle life is that which follows the dissolution of a marriage that has been sexually unsatisfactory. Many couples maintain a sexually and interpersonally unhappy marriage out of the conviction that their children will benefit from an broken home. Often these are mismatched people who have tried unsuccessfully to make their relationship gratifying and are capable of previously unattained levels of sexuality with other partners. When their children are no longer dependent, they may wisely separate or divorce and make developmental gains with new partners that transform their many remaining years. Sexual constitution In the sexual practice ''sexual constitution'' is aggregate of steady biological properties, which are under the influence of hereditary factors, condition of development at prenatal period and early ontogenesis. It limits diapason of individual sexual needs and defines individual resistibility to pathogenic factors particularly considered with sexual sphere. Psychosexual development through the life cycle 28 Table 1 Definition of female sexual constitution Constitution Vectors 1. The age of sexual libido arising 2. The age of first ejaculation 3. Trochanter index (height/legs length ratio) weak 17 and later 19 and later < 1.85 middle strong 16 15 14 13 12 11 10 17-18 16 15 14 13 12 11 1.86-1.89 1.90-1.91 1.92-1.94 1.95-1.96 1.99 2.0 1.971.98 9 and earlier 10 and earlier > 2.0 Inclination 4. Pubic hairy spar Feminine for se hair type feminine Masculine type with Masculine type hypertrichosis type 5. Maximal excesses 6.Conditional physiologic rhythm (CPR) 7. The absolute age of CPR standing 0 2 3 4 5 6 7 8 - honeymoon 1 2-3 4-5 6-10 11-19 20-29 - before22 23-26 27-31 32-36 3740 41-45 46-50 9 and more 30 and more 51 and more Psychosexual development through the Definition life cycle of male sexual constitution 29 Table 2 Vector Constitution Weak The age of menarche 17 and later 16 15 14 Regularity Amenorrhea or rare menstrual cycle Prolonged menstrual cycle disturbance, without some kind of external factors' influences Menstrual cycle disturbance only due to external psycho-emotional or somatic factors Rare and episodic disturb ance of menstrual cycle The age of first pregnancy in regular sexual life _ 10 years and more 3-9 years 1-2 years I Menstrual function II Reproductive function Middle Strong 13 12 11 10 Regularly 3-6 month 1-3 month Even with using of contraceptives 9 and earlier Menstrual function disturbance _ Psychosexual development through the life cycle 30 - Grave pathology of pregnancy with abortion Threat abortion, grave toxicosis Toxicoses with mild course III Trochanter index 1.88 1.89-1.93 1.94-1.96 1.97-1.98 IV Axillary and pubic hairy A0P0 A1P1 A2P2 V. The age of arising erotic libido ≥17 15-16 14 Course of pregnancy First orgasm Normal course 1.99 Female type A3P3 2.0 Bent for male type 2.012.02 2.032.04 Bent for male type Male type with hypertrichosis 13 12 11 10 9 8 and earlier Absolute age - ≥35 31-34 26-30 21-25 18-20 15-17 12-14 11 and earlier After regular sexual activity - 10 years 3-9 years 1-2 years 6-11 month 2-5 month 1 month After CPR Before sexual life Absolute age - 40 35 30 25 20 19 18-16 15 and earlier After regular sexual activity - 10-15 years 5-9 years 3-4 years 1-2 years 6-11 month 2-5 month 1 month After first sex intercourse VI Orgasm 50-100% Psychosexual development through the life cycle 31 Sexual manifestations There are some sexual manifestations, each of them occurs at the definite period of life. The same sexual manifestation is commented differently at the different periods of the age. For instance, masturbation and night pollution takes place in the puberty, excesses and abstinence-in the transitional period, conditional physiological rhythm-in the mature sexuality, abstinences in the period of involution. Masturbation: There are different types and forms of masturbation, each of which has its specific meaning in sexology. 1. frustrational pseudomasturbation 2. early prepubertal 3. Masturbation of youth hypersexual period 4. Compensator 5. perseverator-obsessive 6. imitative The type of masturbation which takes place in the puberty considers as a substitute to ease physiological discomfort created by the consequence of the impossibility to have intercourse. Here we stop on the description of the other types of masturbation, as clinically they are cases of great importance. Vasilchenko distinguishes these types of masturbation. Frustrational pseudomasturbation is a type of masturbation accompanied with neither ejaculation nor orgasm. Early prepubertal masturbation reveals before arising of sexual libido. A characteristic measure is the dissociation between the ejaculation and orgasm, orgasm without ejaculation or the vice versa. Usually this disappears within the sexual maturity. Substitute masturbation reveals in the transitional period to mature sexuality, when there isn’t opportunity to have a sexual intercourse (abstinence period). Psychosexual development through the life cycle 32 Pereseverator obsessive masturbation: characterized by obsession. If the above mentioned types of masturbation vanish after some years or give way to another type, then this one goes on and even after the marriage. In the hardest cases it happens without erection, sexual desire and orgasm. The patient isn't able to rein the demand of masturbation and does not understand why he/she does it when he/she doesn’t have any need for it. Imitative masturbation is not on own initiative and isn’t realized alone, only in group of adolescence of the same age. Frustrational and imitated masturbations are considered to be pseudomusturbations that demand not medical but breeding treatments. Adult hypersexual and compensator types of masturbations are physiological. Obsessive masturbation is pathological and demands medical treatments against to the causes of it. Prepubertal masturbation can be just a type of imitation but also it can be result of early beginning sexual activity related to nervous system’s residual organic pathogenesis. Sexual excess - all intercourses with ejaculation in a day. It is specifically masculine phenomenon. It's essentially connected with the sexual constitution. Conditional physiological rhythm- is a masculine phenomenon, frequency of intercourses according to biological needs, and depends on sexual constitution. CPR takes place at the period of mature sexuality. Sexual abstinence is absence of sexual intercourses. This can be partial with masturbation or night pollution and total without any sexual manifestation. Night pollution is also a masculine phenomenon, involuntary ejaculation during the sleep. Usually it is the first sexual manifestation that takes place at the beginning of the puberty and accompanied with erotic and sexual dreams. Sexual response cycle 33 Chapter 3 Sexual response cycle Throughout history the human sexual response was seen monistically, as a single event that passed from lust to excitement and was climaxed by the orgasm. All the sexual dysfunctions were also perceived as though they were a single clinical entity. No distinction was made between premature ejaculation or impotence or lack of libido or sexual avoidance. All males who could not perform or enjoy sexual intercourse were termed impotent, while all women with sexual difficulties were labeled frigid. It followed that treatment was also undifferentiated. Since all sexually dysfunctional patients carried the same diagnosis, they also received the same therapy. At the same time, the etiology of sexual pathology was not clearly understood and so the nature of treatment was empirical. Not surprisingly, treatment for sexual problems was not very successful. The old monistic view of the human sexual response thus impeded advances in the field. Progress in understanding human sexuality required the separation of the component parts from the undifferentiated mass. Gradually, it was recognized that the sexual response is not an indivisible entity, vulnerable to a single pathogen, subject to only one disorder, and amenable to a single treatment regimen. On the contrary, the human sexual response is composed of three separate but interlocking phases which are each vulnerable to disruption in a specific manner by multiple physical and psychic pathogens, and which produce a variety of disorders that are responsible to specific and rational treatment strategies. Before the three phases could be accurately discriminated, it was necessary to obtain a clear description of the physiology of the sexual response of men and women. It was Masters and Johnson who first had the courage and good sense to regard Sexual response cycle 34 the human sexual response as a natural biologic function and who observed male and female sexual behavior accurately under the same kinds of laboratory conditions which serve the study of other biological systems such as digestive and respiratory physiology. Their work yielded the first clear and accurate description of the human sexual response. Masters and Johnson divided the sexual response into four well-known stages: excitement, plateau, orgasm and resolution. Masters and Johnson scheme describes only the genital Pic. 02 Sexual excitement during the time phases of the sexual response-excitement phase and orgasm phase. Plateau phase refer to different degree of the excitement phase and resolution merely refers to the absence of sexual arousal. Therefore, the biphasic concept represented a significant theoretical advance in the field which led to important clinical development. The understanding of the sexual response and its dysfunctions was completed and clinical data were sufficiently accounted for after recognition of a third, a central phase, the phase of sexual desire. The three phases are physiologically related but discrete. They are interconnected but governed by separate neurophysiologic systems. Sexual desire is an appetite or drive which is produced by the activation of a specific neural system in the brain, while the excitement and orgasm phases involve Sexual response cycle 35 the genital organs. In both males and females the excitement phase is produced by the reflex vasodilatation of genital blood vessels. By contrast, orgasm essentially consists of reflex contractions of certain genital muscles. These two genital reflexes are served by separate reflex centers in the lower spinal cord. Male-Female differences in the sexual response cycle. Typically, a young man in the resting phase can be aroused quickly, strives for rapid increase in pleasure and wants intensely to move quickly through plateau to orgasm. His sexual focus is sharp and strong and he approaches orgasm with rapid heavy breathing and pelvic thrusting. Orgasm is usually explosive and brief, often with local noises, an end of thrusting, retraction of the pelvis and brief loss of awareness. Then he rapidly loses sexual interest and returns to the resting state. In some women resolution occurs quickly. Some may return to the plateau and then to additional orgasms. For other women, perhaps a majority in our society, excitement builds more slowly, the plateau is prolonged and orgasm is less dramatic. For still other women, orgasm seems not to be a climax but a passing over to a more relaxed state, with little movement or noise, followed by slow resolution. What they describe as orgasm is not subjectively or objectively much different from a plateau experience, but afterward they feel release of tension, a sense of completion and a desire to talk, rest, cuddle or sleep, all of which suggests that orgasm has occurred. For a number of women, perhaps 10 to 30 per cent, orgasm never or rarely occurs. For many others, it is intermittently absent. Erection of nipples is an early sign of arousal in females and occurs in about half of all males. Vasocongestion enlarges the female breasts and areolae during the excitement and plateau phases, especially in nulliparas and women who have not nursed. The breasts and areolae quickly return to normal size during resolution. During sexual response, 70 to 75 per cent of women and about 25 per cent of men show sex flush a brush or rash-like Sexual response cycle 36 vasocongestion across the chest, breasts, back and neck. It develops during the transition from excitement to plateau, is most evident at orgasm and disappears quickly during resolution. The desire phase The neurophysiologic and neuroanatomic bases for sexual desire have not yet been delineated with the same degree of accuracy as other drives, such as hunger, thirst and the need to sleep. Current concepts regarding the biology of the sexual appetite are based on relatively few experimental studies, inferred from clinical evidence, and drawn by analogy from our general knowledge of brain functioning and of the neurophysiology of the other biological drives. The sex drive is basically similar to the other drives in that it: 1) depends on the activity of a specific anatomical structure in the brain; 2) contains centers that enhance the drive in balance with centers that inhibit it; 3) is also served by two specific neurotransmitters-an inhibitory and an excitatory one; and 4) has extensive connections with other parts of the brain which allow the sex drive to be influenced by and integrated into the individual’s total life experience. Sexual desire or libido is experienced as specific sensations which move the individual to seek out, or become receptive to, sexual experiences. These sensations are produced by the physical activation of a specific neural system in the brain. When this system is active, a person is “horny”, he may feel genital sensations, or he may feel vaguely sexy, interested in sex, open to sex, or even just restless. These sensations cease after sexual gratification, i.e., orgasm. When this system is inactive or under the influence of inhibitory forces, a person has no interest in erotic matters; he “lose his appetite” for sex and becomes “asexual.” Sexual response cycle 37 Anatomy The sex center of the brain consists of a network of neural centers and circuits. These are known to be located within the limbic system, with important nuclei in the hypothalamus and in the preoptic region. The limbic system is an archaic system which governs and organizes the behavior that ensures not only individual survival but also the reproduction of the species. Towards those ends it contains the neural apparatus that generates and regulates emotion and motivation. The limbic system exists even in primitive vertebrates, and has remained essentially unchanged even in man. However, it has been integrated into our complex brains so that it often seems to have disappeared. Yet it is very much alive and influential and comprises the biological substrate of our complex sexual experience. The sexual system has extensive neural connections with other parts of the brain. All of these pathways have not as yet been located precisely, but much of the structure, function and connections of the sexual system can be inferred from behavior. Because of pleasurable quality of sexuality, it may be inferred that the sexual circuits have intimate connections with the pleasure centers of the brain, and release a chemical for which receptor sites exist in the pleasure circuits. But sexual desire must also be anatomically and chemically connected with the pain centers, for if a sexual object or stimulation produces pain- i.e., is experienced as dangerous or destructiveit will cease to evoke desire. In other words, pain has the capability of inhibiting sexual desire, since our brain is organized so that pain has priority over pleasure, which makes sense from an evolutionary perspective. Behavioral observations also suggest that the sex circuits are extensively interconnected with those parts of the brain that analyze complex experience and also with the memory storage and retrieval systems. There is evidence that sexual desire is highly sensitive to experimental factors which determine and shape, in large measure, the objects and activities which will and will not evoke our desires. Sexual response cycle 38 It may be speculated that neural connections exist between the central sex centers and the spinal reflex centers that govern genital functioning. Input from the higher centers can enhance or diminish the genital reflexes. Thus, when libido is high, when a person feels sexy and sensuous, erection and lubrication are full and rapid, and orgasm is easily achieved. In fact, erection and even orgasm may at times be achieved purely on the basis of external stimuli and fantasy without any physical stimulation of the genitals. But the opposite is also true. When desire is absent and the sexual experience is flat and joyless, the threshold for the genital reflexes is much higher. When one is not turned on it can take “forever” and the physical stimulus must be intense before the genitals will function. Physiological mechanisms Information regarding the physiologic mechanisms, the electric and chemical events which govern the sexual system, is just beginning to be accumulated, and the information is still too fragmentary to build a coherent conceptual structure. In the natural state, libido and the sex circuits are governed by biological rhythms as well as by the availability of an attractive partner. Animals whose reproductive behavior is regulated by an estrus cycle are more subject to biological rhythms than man is. For example, female animals whose sexual receptivity is governed by the estrus cycle display a total absence of sexual desire and avoid sex except during periods of “heat,” are controlled by hormones. In infrahuman females, both sexual attractiveness and sexual receptivity depend on estrogen. The central action of estrogen on the brain makes them receptive, while the peripheral action makes them attractive. Specifically, estrogen causes the vaginal cells of some species of animals to manufacture pheromones which release sexual desire in the male. In human females, does not enhance sexual desire and its role in female attractiveness remains controversial. But humans, too, fluctuate to some extent in their sexual desire on a biological basis. The biological sex rhythms of humans are probably mediated by sex Sexual response cycle 39 hormones via their influence on the sex centers of the mammalian brain. The role of testosterone in human sexuality seems clearer. It is the “libido hormone” for both genders. In the absence of testosterone, there is little sexual desire in both males and females in all species studied so far, including humans. Presumably this effect is due to the crucial role testosterone plays in the functioning of the sex centers of both genders, although the mechanism of this action is not clearly understood as yet. Recent evidence indicates that luteinizing hormonereleasing factor (LH-RF), may enhance sexual desire even in the absence of testosterone or when testosterone is ineffective. It has been speculated that the sex hormones, testosterone and perhaps LH-SF, influence sexual behavior by some interaction with the neurotransmitters which are the mediators of neural impulses within the sexual circuits. Evidence suggests that serotonin acts as an inhibitor, and dopamine as a stimulant, to the sexual centers of the brain. Neurophysiologic studies have shown that the two genders have similar neurological bases for sex. For example, both genders require testosterone for activation. However, there seem to be major gender differences in the stimuli that evoke desire. Desire in male animals is normally aroused by the smell, sight and other sensory cues provided by a receptive female, by a female in “heat,”, while desire in receptive females is evoked by the presence of a sexually active, courting male. Slightly different spectrum of factors seems to be associated with inhibition of the sexual desire of males and of females. For example, while both men and women may be “turned off” if they are angry at their partner, this is more often true of women. The majority of women seem to lose their desire for a partner towards whom they feel hostile. This is also true of some men, but less frequently, and more males than females can experience intense desire for a partner with whom they are angry. Sexual response cycle 40 Disorders of desire phase Hypoactive sexual desire and inhibition of sexual desire (ISD) are common syndromes of males and females. The hypoactive individual is asexual; he behaves as though his sexual circuits have been “shut down.” He loses interest in sexual matters, will not pursue sexual gratification, and if a sexual situation presents itself, is not moved to avail himself of the opportunity. It may be speculated that hypoactivity of sexual desire can result from the lack of activity of the sexual centers or from their active inhibition. Inhibition is often selective in that the genital functioning of men and women with sexual anorexia may be maintained. These individuals may be able to experience erection or lubrication-swelling and orgasm, but in a mechanical manner, without much pleasure. The excitement phase In both men and women the physiologic signs of sexual excitement are produced by the reflex vasodilatation of the genital blood vessels. During sexual arousal two centers in the spinal cord, one at S2, S3, and S4 and one at T11, T12, L1, and L2, become activated and cause the arterioles which invest the genitals to dilate. This vasodilatation causes these organs to become swollen and distended and changes their shape to adapt them to their function. The reflex dilatation occurs in both genders. However, because of anatomic differences in the male and female genitals, this swelling takes different forms and so produces changes which are different but complementary. The penis becomes hard and enlarged to penetrate the vagina and the vagina balloons and becomes wet to accommodate the penis. Male excitement - Erection In the male, the cavernous spaces of the corpora cavernosi of the penis fill with blood and distend the penis against its tough, rigid outer sheath. This changes the flaccid, Sexual response cycle 41 soft penis into a hard and erect organ capable of penetrating the vagina. The penis is maintained hard and erect by a high pressure hydraulic which uses blood as its fluid. Erection is attained and maintained by a complex physiologic system which produces an increased flow of blood to the penis while at the same time decreasing the flow of blood out of the penis. This increases the amount of blood and traps it inside the penis at a relatively high pressure. The increased amount of blood is shunted into the cavernous sinuses which distend, thus enlarging the penis. Pic. 03 Male Excitement Pic. 04 Cross-section cut of penis Sexual response cycle 42 The enlargement is contained by the tough fascia which encases the penile cylinder. The pressure of the increased blood against this sheath hardens the penis and makes it erect. The increased penile flow during excitement is known to be caused by a dilatation of the penile arteries. This is brought about by parasympathetic impulses from the erection centers which cause the muscles in the arterial walls to relax. Pic. 06 cGMP dependent mechanism of erection beginnings The mechanism responsible for decreasing penile outflow is not yet entirely clear. Some hypotheses hold that it is caused by reflex constriction of the penile veins. An alternate hypothesis suggests that special penile valves control the outflow, while still another postulates that the outflow and also the shunting of blood to the cavernous sinuses are controlled by “polsters” or small smooth muscle structures located only on the penile blood vessels walls. The erectile response is primarily a parasympathetic one, although surgical and pharmacological evidence suggests that some sympathetic components is also required for potency, possibly by controlling outflow of erectile blood. However, it is well-known clinically that an intense sympathetic response, such as that produced by fear and anxiety, can instantly drain Sexual response cycle 43 the penis of extra blood and so cause a psychogenic loss of erection. Female excitement In the female, the excitement phase is also produced by reflex vasodilatation of the genital organs. Within 10 to 30 seconds after excitement starts, the vaginal walls begin a sweating-like process (transudation). The transudate is clear, slightly slippery, nonoily and has a distinctive odor and taste. This fluid seems to have at least three functions: It lubricates penile movement in the vagina, it neutralizes the usually acidic vaginal environment and its moisture aids sperm survival. In some women, especially after menopause, there is too little lubrication for comfortable coitus. This reduced wetting does not necessarily reflect lack of erotic interest or poor sexual technique, any more than copious fluids always indicate intense interest and pleasure. As excitement increases, the inner portion of the vaginal barrel begins to balloon; a space greater than is necessary for the penis is thereby created and perhaps provides a receptacle where semen van collect. Increasing vasocongestion turns the vagina from its normal pink color to red. The inner portion of the evagina continues to balloon, a process called tenting. Meanwhile, the outer third narrows and tightens; it is now called the orgasmic platform. Changes in the labia majora and minora during the excitement are affected by parity. In nulliparous women, myotonia makes the labia majora become flatter and thinner during arousal, and they remain so throughout plateau and orgasm. In women who have had children, the labia have developed an axtensive vascular network, which becomes congested dueing sexual response, the labia swell two to three times in size. In all women, the labia minora normally double or triple in size and become reddish purple. It is believed that, like male erection, the physiologic concomitants of female excitement, lubrication and swelling, which are produced by local vasodilatory reflexes, are governed Sexual response cycle 44 primarily by the parasympathetic nervous system, which controls the vasodilatation of blood vessels. Pic. 07 Female Excitement Erection in the male is governed by two spinal reflex centers, involving thoracic and lumbar segments, and one at the sacral level. Clinical evidence from spinal cord accident victims suggests that the upper center responds to psychic stimuli, while the lower one is stimulated by tactile input from the genitals. The lower reflex center can function without any higher input or outflow. This accounts for the well-known clinical fact that patients whose spinal cord has been transected above the erection centers can have erections by tactile stimulation of the genitals, on a reflex basis, even when sensation is lost below the level of injury. Under normal circumstances the excitement reflex centers receive input from the brain and provide outflow to the brain. These connections provide the biological basis by which excitement can be enhanced or inhibited, the pleasurable sensations augmented or blocked by experiential factors. Sexual response cycle 45 Pic. 08 Female plateau The neural apparatus that governs the female excitement phase has not yet been delineated precisely. It may be speculated, in view of the analogous embryologic development of the reproductive and nervous systems of the two genders that the spinal reflex centers as well as the higher neural connections are analogous in males and females. Disorders of excitement phase Disorders of the male excitement phase are called erectile dysfunctions. This consists of difficulties in attaining or maintaining an erection. This may occur with or without associated disturbances of libido or ejaculation. Female excitement disorders are marked by difficulty with lubrication and swelling during love-making. The complex physiology of male erection and the need to create a temporary high blood pressure system make this phase of the male sexual response the most vulnerable to biological factors, as well as to anxiety. It follows that erectile dysfunction is a highly prevalent sexual disorder. By contrast, dysfunction of the female excitement phase, i.e., the isolated Sexual response cycle 46 inhibition of lubrication and swelling, is a relatively uncommon clinical syndrome, except as the result of such local physiologic factors as estrogen deficiency with senile vaginitis. Excitement phase dysfunction of females can exist as a discrete syndrome, but the painful and uncomfortable experience of coitus with a dry and nondistended vagina can cause a secondary inhibition of desire and/or avoidance of sex. The orgasm phase The orgasm phase of the sexual response is, like excitement, a genital reflex that is governed by spinal neural centers. Sensory impulses which trigger orgasm enter the spinal cord in the pudendal nerve at the sacral level, and the efferent outflow is from T11 to L2. The spinal reflex centers for orgasm are in close anatomic proximity to those which govern bladder and anal control. For this reason, in injuries to the lower cord, orgasm, urinary and defecatory control may all be impaired. Orgasm does not, as does excitement, involve a vascular reflex but consists in both males and female of reflex contractions of certain genital muscles. The male orgasm is made up of two independent but coordinated reflexes which make up its two subphases: emission and ejaculation. Emission consists of the reflex contraction of the smooth muscles which are contained in the walls of the internal male reproductive organs: the tubuli epididymides, the vas deferens, the seminal vesicles and the prostate gland. This contraction deposits a bolus of seminal fluid into the posterior urethra. The internal vesical sphincter snaps shut, placing the seminal bolus into an enclosed space. This emission response is not pleasurable; it is reported to be perceived as a slight physiologic signal which has been called the “sensation of ejaculatory inevitability” by masters and Johnson. In the healthy male, emission is followed a split second later by rhythmic, .8 per second contractions of the striated muscles which are located at the base of the penis, the ishio and bulbo cavernosi muscles. The effect of these contractions Sexual response cycle 47 is to propel the seminal fluid out of the penis in a series of squirts. These contractions are accompanied by the typical pleasurable orgastic sensations. Pic. 09 Male Orgasm Female orgasm is strictly analogous to the second phase of male orgasm. There is, of course, no emission phase in the female. During orgasm, tenting continues and the orgasmic platform contracts, first strongly and rhythmically, then more weakly and at longer intervals. Rhythmic contraction occurs at the rate of 8 per second, just as during the ejaculatory part of the male orgasm. Orgasmic contractions may continue far longer than in men. The woman’s awareness of orgasm usually, although not always, corresponds with these contractions; longer more intense contractions are felt as a longer, more intense orgasm. For many reasons- e. g., prolonged excitement without orgasm-vasocongestion may remain after sexual activity; this chronic pelvic congestion can cause severe pelvic discomfort and emotional frustration. Sexual response cycle 48 Pic. 10 Female Orgasm Emission in the male is governed by the sympathetic nervous system. During emission, stimulation of the alpha adrenergic receptors of the smooth muscles of the male reproductive organs is causing them to contract. The neural connections which control the second part of the male, as well as the female, orgasm, which consists of contractions of striated muscles, are probably controlled by a different reflex center which has not yet been identified. The reflex center for orgasm in males is located in the sacral spinal cord, near the centers that govern defecation and urination reflexes. It is believed that the female orgasm center is similarly located. Spinal cord victims can have the physical component of orgasm and so father children. This can occur as a result of local stimulation of the genitals, as long as this center is intact, even if they experience no sensation. But under ordinary circumstances, the orgasm center receives input from the brain, and also contributes its output to the higher centers. Sexual response cycle 49 Pic. 11 Female Resolution These connections between the spinal orgasm centers and the higher brain provide the physiologic apparatus for learned inhibition of orgasm. Orgasm, unlike erection, which is not subject to voluntary control, can be, and under normal circumstances is, under the individual’s voluntary control. This means that there are probably neural circuits that connect the orgasm center to voluntary motor and conscious perception areas of the brain. It may also be speculated that orgasm has close connections with the pleasure center of the brain. It is this connection which under normal circumstances makes the experience of orgasm so pleasurable. Disorders of the orgasm phase Clinical syndromes produced by disorders of the orgasm phase include: premature ejaculation, retarded ejaculation, and its female analogue, orgastic dysfunction of females. Orgasm inhibitions of both males and females fall along a spectrum of severity from total anorgasmia to mild situational difficulties in reaching a climax. An interesting subvariety of retarded ejaculation is a syndrome of partial retardation. Such patients have a normal emission response, but the second phase Sexual response cycle 50 ejaculation is selectively inhibited. Clinically these men experience “seepage” of semen but no orgastic squirting and no ejaculatory pleasure. Return to the flaccid state is commonly delayed in these patients. Classification of sexual disorders 51 Chapter 4 Sexual disorders Classification of sexual disorders There are several sources to classify sexual disorders. The major one is Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV; American Psychiatric Association, 1994). The other source that is used by many physicians and mainly agrees with DSM-IV is the International Classification of Diseases (ICD-10; World Health Organization, 1992). DSM-IV describes the following sexual disorders: Sexual dysfunctions: 1. Sexual desire disorders 2. Sexual arousal disorders 3. Orgasmic disorders 4. Sexual pain disorders 5. Sexual dysfunctions related to a general medical condition 6. Substance-induced sexual dysfunction Paraphilias: 1. Exhibitionism 2. Fetishism 3. Frotteurism 4. Pedophilia 5. Sexual masochism 6. Sexual sadism 7. Transvestic Fetishism 8. Voyeurism Gender Identity Disorders: 1. Transsexualism 2. Gender identity disorders of childhood 3. Other gender identity disorders of adolescence or adult life Other Sexual Disorders: Sexual disorders not elsewhere classified Classification of sexual disorders 52 Sexual desire disorders are defined by decreased interest in sexual interaction. Hypoactive Sexual Desire Disorder (302.71) is manifested by persistently deficient or absent sexual fantasy and desire for sexual activity. Sexual Aversion Disorder (302.79) is a more extreme condition in which there is persistent aversion to and avoidance of all genital sexual contacts with another person. Sexual arousal disorders involve dysfunction of the lubrication-swelling stage of sexual response and are divided along gender lines. Female Sexual Arousal Disorder (302.72) is diagnosed when a woman manifests a persistent inability to maintain an adequate lubrication-swelling response in the presence of adequate stimulation. Male Erectile Disorder (302.72), commonly called impotence, is the persistent inability to maintain an adequate erection until completion of the sexual activity. Both of these disorders involve the blood flow response mediated by the parasympathetic nervous system and are thus vulnerable to medications that affect the autonomic nervous system. Orgasmic disorders include Female Orgasmic Disorder (302.73), formerly called anorgasmia or inhibited female orgasm, is marked by a persistent delay in or absence of orgasm following an adequate excitement phase. Thus a woman suffering from this syndrome is able to become aroused, to lubricate and feel excited, but is unable to reach orgasm in spite of adequate stimulation. Male Orgasmic Disorder (302.74) was formerly called retarded ejaculation, a term which is preferable as it is descriptive of the problem. A persistent delay in or absence of orgasm following an adequate excitement phase is the signifier of this disorder. Premature Ejaculation (302.75) is the inability to have a reasonable amount of control over the ejaculatory reflex. A man suffering from prematurity often reaches orgasm with minimal stimulation, usually before he wants it or is ready. Premature ejaculation has sometimes been diagnosed based on the length of time a man could delay orgasm, and sometimes by the degree of satisfaction the man’s partner experiences through sexual interaction. Neither of these Classification of sexual disorders 53 definitions is satisfactory, as they do not focus on the basis of the problem-control. Most men learn how to control the onset of orgasm by varying the amount of stimulation they are obtaining. In essence, most men learn how to regulate their excitement level, maintaining their arousal below the point of ejaculatory inevitability (that moment when the orgasm reflex begins). Sexual pain disorders include Dyspareunia (302.76), which refers to recurrent genital pain with sexual intercourse in a man or a woman. This is one diagnostic category that always requires a complete medical examination. Vaginismus (306.51) is the persistent involuntary spasm of the circumvaginal muscles when attempting penetration. It is most often noticed when intercourse is attempted, but sometimes is apparent during gynecological examinations. Sometimes a woman who is not aroused, and consequently is not lubricated, will complain of painful intercourse. A careful and complete sexual history will help differentiate cases of Female Arousal Disorder from dyspareunia and Vaginismus. Sexual dysfunction due to a general medical condition is a particularly important category of sexual problems. As the name implies, this diagnosis is made when history, physical examination, or laboratory tests indicate that the sexual dysfunction is fully explained by the direct physiological effects of a general medical condition. All of the symptoms found in the specific sexual disorders can be caused by a general medical condition; thus you can not rule out the possibility of a physical cause of sexual dysfunction based only on the presenting sexual symptoms. Most sexual disorders caused by a general medical illness are generalized, and usually the sexual symptoms are concurrent with the onset or exacerbation of the illness. Substance-induced sexual dysfunction is unfortunately all too common. To make the diagnosis, history, physical examination, or laboratory findings must indicate that the sexual dysfunction is fully explained by the substance use and either (1) the symptoms developed during, or within a Classification of sexual disorders 54 month of, substance intoxication, or (2) medication use is etiologically related to the disturbance. Paraphilias, commonly referred to as sexual perversions, include eight forms of recurrent, intense, sexually arousing fantasies, urges, or actions involving either (1) nonhuman objects, (2) the suffering or humiliation of self or another person, or (3) sexual interaction with children or nonconsenting persons. To make a diagnosis of a paraphilia, the sexually arousing fantasy or action must have been present for at least a period of six months and, like all sexual disorders, must cause personal or interpersonal difficulty. Many perverse sexual actions involve behaviors that are intrusive, and illegal, and thus patients with paraphilias are sometimes mandated to be evaluated by the court. The brief description of paraphilias according to DSM-IV: Exhibitionism (302.4), exposure of one’s genitals to an unsuspecting stranger Fetishism (302.81), use of nonliving objects for sexual gratification Frotteurism (302.89), touching or rubbing against a nonconsenting person Pedophilia (302.2), sexual activity with a prepubescent child or children Sexual masochism (302.83), sexual arousal by being humiliated, beaten, bound, or otherwise made to suffer Sexual sadism (302.84), sexual arousal by causing physical or psychological suffering Transvestic Fetishism (302.3), heterosexual male aroused by cross dressing Voyeurism (302.4), sexual arousal at watching an unsuspecting person who is naked, undressing, or having sex Gender Identity Disorders are characterized by the individual’s feeling of discomfort and inappropriateness about his or her anatomic sex and by persistent behaviors generally Classification of sexual disorders 55 associated with the other sex. Gender identity is a personal awareness of one’s sex (male, female, or ambivalent) or of one’s feelings of masculinity and femininity, it is the inner sense of masculinity or femininity. Core gender identity is a sense of maleness or femaleness. Gender role behavior is the outward expression of this personal awareness. Disturbances in gender identity and rolebehavior are severe disturbances, to be distinguished from feelings of inadequacy generated by thoughts that one is not living up to the concept of gender role behavior. Some feelings of inadequacy about masculinity and femininity are ubiquitous in childhood and adolescence, and remnants of these doubts are found in almost every adult. Transsexualism is an overriding feeling “of discomfort with one’s anatomic sex and a constant desire to be rid of one’s genitals and become a member of the opposite sex. The diagnosis is made only if the disturbance has been continuous for at least two years; is not symptomatic of another mental disorder, such as schizophrenia, and is not associated with physical intersex or genetic abnormality.” The differential diagnosis must be made among true Transsexualism, transvestism, crossdressing and homosexuality. Sexual dysfunctions may be overt or covert, lifelong or immediate, intrapsychic or interpersonal, and some of them may be traced to significant medical or psychiatric factors. In addition, the dysfunctions may be generalized or situational. Overt Sexual Disorders. “Overt” may refer to (1) patient’s knowledge, (2) presenting complaint, or (3) revelation of the sexual disorder in the course of history-taking in which the presenting complaint was nonsexual. The most overt situation occurs when the patient is fully aware of the sexual disorder, and presents it as his chief complaint. The sexual disorder is less overt when the patient, although fully aware of it, seeks help for another real or imaginary condition. For example, a patient may complain of depression but will reveal his impotence during the course of the interview. Sometimes the disorder is fully known to the patient, but he denies its importance. Denial as a defense Classification of sexual disorders 56 mechanism may cause the patient to withhold information or to make light of it. When the symptom or syndrome is overt, the physician’s task is somewhat easier because he does not have to overcome the patient’s resistance in order to uncover the connection between the presenting complaint and the underlying sexual disorder, and point out the connections to the patient. Covert Sexual Disorders. A “covert” sexual disorders is one in which the disorder is not connected in the patient’s mind with other symptoms he presents. Symptoms may include fatigue, headache, backache, gastrointestinal disturbances, menstrual irregularities or dysmenorrheal. Identifying and labeling the unconscious connection between symptom and sexual frustration becomes the task of the therapist. Lifelong and Acquired Sexual Disorders. If the sexual disorder follows a period of normal functioning, it is said to have been acquired. The man who develops impotence after he has been able to have satisfactory erections and coitus has “acquired” impotence or, as it is sometimes called, “secondary” impotence. If he has never had an erection sufficient for penetration, he has lifelong or “primary” impotence. The differentiation is important in the diagnostic evaluation of the etiology of the disorder. Generalized and Situational Sexual Disorders. If a disorder, is situational (i.e., occurring only in certain situations or only with certain partners), one can be certain that the problem is psychogenic (unless limited to association with alcohol or drugs). If the disorder occurs in all situations (i.e., is “generalized”), it may be psychogenic, biogenic or a combination of the two. The most typical situation is one in which the sexual dysfunction is restricted to the marriage. In this case the physician has to examine the nature of the marital relationship. Intrapsychic or Interpersonal Factors. Since anxiety or other negative emotions responsible for sexual disorder or dysfunction are intrapsychic, one might say that all sexual dysfunctions have an intrapsychic component. Differentiation between intrapsychic and interpersonal in this context means Classification of sexual disorders 57 that the dominant etiology can be traced to either intrapsychic or interpersonal factors. If negative associations to sex create retarded ejaculation in relationships prior to a man’s marriage, clearly the etiology is primarily intrapsychic. On the other hand, if there is a period of good functioning which later deteriorates because of marital conflict, the situation clearly is primarily an interpersonal one, although, as has just been stated, it has to have its intrapsychic components. Medical and Psychiatric Causes. Some sexual dysfunctions may be attributable to physical illness, for example erectile dysfunction stemming from diabetes. Some may be primarily due to a psychiatric disorder such as inhibition of sexual desire as a consequence of depression. Disorders of sexual desire Definition and description The DSM-IV describes the common desire problems as (1) Hypoactive Sexual Desire Disorder (302.71), deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty, not caused by a general medical condition; and (2) Sexual Aversion Disorder (302.79), aversion to and active avoidance of genital sexual contact with a sexual partner that causes marked distress or interpersonal difficulty, not caused by a general medical condition. Diagnosis Reliable and valid norms of human sexual behavior are not yet available and in the final analysis the diagnosis of ISD is made by comparing the patient’s experience with a sense of what the normal range of sexual desire is. This is based on deduction rather than on the kinds of direct scientific observation and measurement which are available for the genital responses. Thus, concepts of the normal parameters of the sexual drive of men and women are inferred from various statistical surveys of the frequency of intercourse and orgasm, as well as from diverse clinical observations and from personal experience. Classification of sexual disorders 58 The typical clinical versions of this problem are the selfdiagnosed patient, the patient identified by a partner, and the couple in which both partners wish they had stronger mutual desire. In each of these presenting complaints, there is recognition that sexual desire is not what it might be, what it should be, what it used to be, or what it is with different partner. The identified patient is often considered (by self or partner) inhibited specifically in contrast with the partner or with his or her own past functioning. Thus, there is relativity to this evaluation. The diagnosis of HSD rests in part on a comparison of the patient’s sexual history with the norm. In the healthy individual, some form of sexual appetite is present throughout life no matter what his cultural origins are. As with any human trait, e.g., height, intelligence, etc., the intensity of the sex drive varies widely, and in some cases, it may be difficult to determine what is pathologic and what is a normal variation. In other words, some normal persons apparently have such a low sex drive that their experience overlaps that of persons suffering from pathologic HSD. Sexual appetite changes in intensity with age and takes a gender-specific course of development. Infants seem to already have some capacity for erotic feelings. These are evoked when their genitals are stimulated. When a tiny clitoris or penis is touched in the course of bathing and dressing, the infant expresses pleasure by smiling and cooing. Children, if they are not stopped, will masturbate and later play sexual games which may entail looking at and touching each other’s genitals. We tend to forget or repress much of these early sexual fantasies and experiences but some memory is normally retained. And when during a psychosexual evaluation the patient remembers no prepubescent erotic feelings or sex play or fantasies, one can assume a certain amount of early sexual inhibition or repression. There is a substantial increase in sexual desire at puberty. This is probably correlated both with the maturation of the cerebral circuits which govern sexual expression and with the Classification of sexual disorders 59 increase in testosterone which is produced by the gonads at this time and which activates these circuits. After puberty sexual development takes a different course in the two genders. In the male sexual desire seems to peak around 17 years and then slowly declines. The normal adolescent male is intensely interested in sex, is easily aroused, and in the absence of a partner will masturbate, while conjuring up erotic fantasies, with frequencies varying from several times a day to several times a week. If there is no sexual outlet he will experience frustration. This phenomenon is so predictable that if the sexual history of a male reveals no adolescent increase in sexual desire as reflected in masturbation and/or fantasy and/or actual intercourse, one may suspect a problem in psychosexual development. The intensity of the male sex drive diminishes gradually after adolescence. At middle age he still desires sex, but often can go without sexual outlets for longer periods of time without experiencing frustration. Throughout his life, however, his sexual desire can be aroused under exciting circumstances. Female also experience increase in libido at puberty. However, this appears less intense than that of adolescent males. Girls seem more easily discouraged from sexual expression than boys. Thus, the absence of adolescent masturbation in a female psychosexual history does not carry the same clinical significance of severe sexual repression as it does in the male. The female sex drive does not decline after adolescence, but slowly increases and peaks somewhere around the age 40. Then female sexual desire is more variable than that of males. While women have a greater orgastic potential, their sexuality is also more easily suppressed. Throughout his life the normal person experiences spontaneous sexual desire, and also has the capacity to be aroused by an attractive partner. When the sex drive is high, the person will experience spontaneous desire and will be aroused by a wide range of stimuli. As desire diminishes, the range of stimuli that will evoke the sexual appetite narrows, and more intense psychic and physical stimulation is required to produce a response. Classification of sexual disorders 60 Factors apart from age also affect the sexual appetite. Physical health and mood are important determinants in reproductive behavior. Both genders experience an increase in sexual appetite when in love and both genders experience a decrease in sexual desire when they are under stress. Clinical description The person with low sexual desire will not feel “horny” or interested in sex. He will not be moved to seek out sexual activity, nor will he fantasize about sex. Also, in contrast to normal experience, sexual desire evoked by stimulation of the genitals will be absent or greatly reduced. The reflexes may, in fact, work if stimulation is permitted; i.e., the person may have an erection or lubricate and/or have an orgasm. But this experience is not really satisfying in the presence of low desire state pleasure is fleeting, perhaps just before orgasm, and is limited to and localized in the genitals. Patients describe such experiences as similar to eating a meal when one is not really hungry. In situations which would normally arouse their sexual desire, inhibited patients will report an absence of feeling or even negative sensations of irritation, tension, anger, anxiety and /or disgust. Clinical Variants of ISD Disorders of sexual desire can be described as primary or secondary and can exist globally or situationally. Primary HSD is a rare condition which is marked by a lifelong history of asexuality. The patient is devoid of sexual interest to the extent that he does not even masturbate. Primary HSD is characteristic of constitutionally low sex drive and certain disease states, as well as of severe psychopathologic states such as schizophrenia and chronic depression. Persons whose libido is severely repressed on the basis of neurotic conflict may also present an asexual picture. Secondary HSD, in which there is a loss of sex drive after a history of normal sexual development, is much more common than primary inhibition. Secondary loss of libido may be produced by a variety of physical factors and is also seen after psychological crises such as marriage, the birth of children, a traumatic rejection or object loss, anger at or Classification of sexual disorders 61 disillusionment with a partner, or nonsexually related stress such as a job loss or an accident. When there is a global loss of sex drive, the person ceases to desire or be interested in sex at all. He experiences no erotic wishes, fantasies or thoughts and, if male, may even cease to have morning erections. Global or total loss of libido is typically associated with depressive states, severe stress and physical causes. The most common clinical variant is situational HSD. This is the typical picture found in psychogenic inhibited sexual desire. Characteristically, the person feels desire only in situations that are psychically “safe.” It is usually the most appropriate and most desirable partner who represents the “psychic danger” that results in the inhibition of desire. Thus a man may feel desire for and be sexually active with prostitutes or strangers or a woman who treats him sadistically or women of a lower social class. But his sex drive becomes inhibited with his intelligent and attractive girlfriend with whom he would like to be intimately and tenderly connected. Also typical of the situational ISD group is the woman who feels very erotic during the many years of her precoital experiences. She felt desire and erotic pleasure during “petting,” but she loses sexual interest after she has engaged in coitus, or after marriage, or after childbirth, i.e., in situations which on a symbolic and unconscious level represent danger. Differential diagnosis The cardinal sign of ISD is a low frequency of sexual activity. However, this alone only denotes hypoactivity, which must, for clinical purposes, first be differentiated from sexual avoidance. In this condition, the frequency of sexual activity can also be low, but because of fear of sex and not because desire is diminished. Once it has been established that libido is indeed low, then an etiologic diagnosis must be made. Physiologic and primary psychiatric etiologies must be differentiated from psychogenic ISD and, finally, pathological lack of desire must be differentiated from those normal states where desire is appropriately inhibited or not generated. Classification of sexual disorders 62 Differentiation from orgasm and excitement phase disorders: One of the most important consequences of the separation of desire phase dysfunctions from excitement and orgasm dysfunctions is that it enables the clinician to sort out this patient population from those suffering from disturbances of the genital phases. Patients who complain of orgasm and excitement phase dysfunctions but who retain normal desire generally have an excellent prognosis when they are treated by sex therapy, but patients who have little or no sexual desire do not respond as well to these methods and require different treatment strategies. Sexual Avoidance: Low frequency or absence of sexual contact may also be a sign of sexual avoidance on the part of one or both of the partners. When sex arouses intense anxiety, a pattern of phobic avoidance can develop, regardless of whether desire is present or not. This is an important diagnostic point, because if sexual avoidance complicates the clinical picture of any of the dysfunctions, e.g., Vaginismus as well as ISD, this avoidance presents a clear obstacle to therapy and must be treated and resolved first. Normal Asexuality: Asexuality is certainly not always abnormal. It has already been mentioned that some persons’ sexual appetite falls on the low side of the normal distribution on the basis of constitutional determinants. Such persons are not bothered by the infrequency of their need for sex unless external circumstances exert pressure. Such pressure includes a partner with a relatively higher sexual drive as well as the high sexual expectations currently in vogue in our society. Finally, despite current propaganda to the contrary, it is not appropriate to find all potential sexual partners or situations attractive. Frequently the evaluation of a couple who complain of loss of sexual desire reveals that there is no real basis for attraction. The partners do not like each other-or her/his hygiene is so poor as to be repulsive-or there is a significant discrepancy in intellectual capacity, etc. the irrationality of these situations lies in the fact that persons think they should be attracted, should feel desire when it makes no sense. Classification of sexual disorders 63 The etiology of desire phase disorders Sexual desire is governed by multiple biological and experiential determinants; consequently, a wide variety of physical and psychological factors can disturb its functioning. An understanding of the physiology of sexual desire is basic to the understanding of its disorders. Sexual desire is a drive that serves the biologic function of species survival. It instills a strong erotic hunger that prods us to engage in species specific behavior that leads to reproduction. It moves us to find a mate, to court, to seduce, to excite, to impregnate, to be impregnated. The neural organization that governs libido is similar to that which produces hunger, thirst and the urge to sleep. Like these other drives, it is served by its own specific network of centers and circuits. The behavioral correlate of neural activity in these centers is the experience of sexual desire. In the absence of such activity there is no libido. Like the other drives, sexual desire is organized so that it is kept in balance by inhibitory and activating mechanisms. When the inhibitory centers dominate, sexual desire is diminished; an increase of sexual desire is experienced when the circuits are under the influence of the activating centers. The centers have extensive anatomical connections to other parts of the brain, and by virtue of these connections, sexual desire can be enhanced and inhibited by a number of internal and external forces. The sex centers and sexual appetite are responsive to hormones, specifically testosterone and LH-RF. Without an adequate hormonal environment they cannot operate and libido vanishes. Also, external stimuli such as the aroma, sight, sound and touch that indicate that an attractive partner is at hand-influence the state of desire profoundly. The connections of the sex centers to the parts of the brain that process and store experience make sexual desire highly sensitive to the past. The suppression of sexual desire can be acquired. We learn to inhibit desire in situations that carry negative contingencies, and learn to allow desire to emerge in “safe” contexts. In fact, desire is the product of a Classification of sexual disorders 64 biologically rooted substrate that is shaped indirection and intensity by events of the past. Also important from a clinical vantage is the fact that the sex centers are profoundly influenced by emotion. The negative emotions that serve individual survival and motivate us to avoid and defend against danger-fear and anger-have priority over the urge to reproduce. This hierarchy has clear survival value. But this adaptive mechanism can go awry if the “dangers” are not accurately perceived. If an individual reacts to fantasy dangers, if he reacts with alarm to fears that have no basis in reality, his sex drive will become inhibited just as surely as if there was a real tiger in his bed. That is the psychophysiologic basis of the inhibition of sexual desire. Physiologic causes of HSD Depression Depression is perhaps the most common physiologic cause of HSD. Depression is marked by a diathesis of vegetative symptoms which includes sleep, eating and libido disturbances. It may be speculated that during a depressed state the activity of the centers and circuits that serve such vital function as eating and sex is diminished. The loss of sexual appetite may be an early symptom of depressive states and may appear even before the patient’s mood becomes perceptibly sad. Characteristically, during depression erection and orgasm are not impaired at all or not to the same extent as is libido. Again, sexual therapy is not an appropriate treatment modality when loss of libido is secondary to depression. The underlying depression should be treated first by appropriate means which may include medication and/or psychotherapy. Often, but not always, sexual desire returns spontaneously when the depression lifts. Stress Severe stress, such as is experienced on the battlefield, or during a traumatic divorce, or after a job loss or forced retirement, is often associated with a loss of sexual interest. Clinical observations suggest that crisis and stress are also Classification of sexual disorders 65 associated with a physiologic depression of the sexual apparatus. Drugs The sex centers depend for their proper functioning on a delicate balance of the neurotransmitters serotonin and dopamine, on a specific matrix of sex and pituitary hormones, and probably on yet undiscovered chemical ingredients as well. Anything that upsets these balances, which tinkers with the recipe, may result in a malfunctioning of the centers and so depress libido. While the specific mechanisms of action are not clear in all cases, clinical evidence suggests that some drugs may produce a diminution of sexual desire; these include narcotics, high doses of sedatives and alcohol, certain centrally acting antihypertensive agents such as those, for example, which contain reserpine and methyl dopa, and drugs which antagonize the action of testosterone. Hormones Because the activity of the sex centers depends on testosterone, insufficient levels of this hormone or its physiologic unavailability may produce a diminution of sexual interest in both males and females. This can result from any condition or drug or psychic state which impairs the production of androgens by the testes, ovaries and adrenals. Common factors in testosterone deficiency include the aging process, prolonged stress, surgical removal or disease of the testosterone-producing glands, and hormones and medication, such as provera and estrogen which antagonize the action of testosterone. A low testosterone level should always be ruled out when the evaluation points to a possible organic etiology for HSD. Recent evidence suggests that increased levels of the hormone prolactin may play some role in libido problems. Medical Illness Any medical illness or surgical procedure which disturbs the anatomy or physiology of the brain’s sex centers such as, for example, renal dialysis, can be associated with low libido states. Such conditions are rather rare, but they do play a role in some cases and should not be neglected. Also, some Classification of sexual disorders 66 medical, urological and gynecological disorders cause sexual activity to lose its pleasurable aspect or to become uncomfortable and even painful. Under such circumstances a secondary loss of interest and /or sexual avoidance may occur. Psychological causes of ISD When a patient’s sexual drive is constitutionally low, or he is deficient in testosterone, or he is depressed, i.e., when the sex centers are hypoactive on a physiologic basis, sexual appetite is low because it is not generated. But in ISD libido is diminished because it is actively, albeit unconsciously and involuntarily, suppressed on the basis of psychological conflict. In clinical practice psychogenic disturbances of libido are more prevalent than those that are secondary to physiologic factors. Some patients are so strongly defended against their sexual desire that they will actively avoid any situations which may evoke it. Such patients will not read erotic literature or look at erotic pictures. They will not discuss sexual topics and may even experience discomfort when a conversation or joke has sexual overtones. They may avoid socializing with a potential sexual partner and will go out of their way to avoid physical contact. Other patients have learned to control their sexual appetite so well they don’t need to avoid stimuli which would ordinary evoke it. They are able to suppress erotic appetite in the face of the most tantalizing stimulation. The “Turn Off” Mechanism Most of patients tend to suppress their desire by evoking negative thoughts or by allowing spontaneously emerging negative thoughts to intrude when they have a sexual opportunity. They have learned to put themselves into negative emotional states, by selectively focusing their attention on a perception or thought or by retrieving some memory or allowing an association to emerge that carries a negative emotional valence. In this manner they make themselves angry, fearful or distracted, and so tap into the natural physiologic inhibitory mechanisms which suppress sexual desire when this is appropriate and in the person’s best interest. In other words, sexual desire is normally inhibited Classification of sexual disorders 67 when the individual is in danger or in an emergency. In physiologic terms the sex circuits are blocked by the activity of the fear and “anger” circuits. Some patients have learned to activate these emergency circuits, evoking or permitting upsetting thoughts, and in this manner suppressing their sexual desire. A variety of evoked images, associations or perceptions are “selected” for their ability to serve as a “turn off” mechanism-there is no specificity in the content of these negatives. A patient will focus his/her attention selectively on one of the partner’s unattractive physical features-his pot belly, her unkempt hair, her fat thighs, the odor of his breath, or his genitals etc.-in the service of shutting down the sex centers. Or the memory of the partner’s unacceptable behavior or past injustices may be employed. Other persons choose sexual times to retrieve memories of non-erotic situations to control their erotic mood. Work, children and money are commonly used “turn offs.” It may be speculated that in patients who suffer from global ISD, all erotic feelings cause anxiety and evoke the attendant defenses against this. All sexual situations evoke negative thoughts and associations. When the desire inhibition is situational, only specific situations evoke sexual conflict and cause the patient to tap into the “turn off” mechanism. Such negative thoughts serve the opposite purpose as sexual fantasies, which are used to enhance the sexual desire and serve to diminish the anxieties that turn off desire. Erotic imagery buffers the sex circuits and protects them from the negative input which may shut them down. The negative focus described above does the exact opposite. It “opens the switch” which will suppress the sex centers. The person who is conflict-free about sex mentally does the opposite of the inhibited one, in the sense that he does not allow negative feelings or thoughts or distractions to intrude upon his sexual pleasure. Some persons have a very narrow range of requirements for sexual pleasure. Only partners with very specific characteristics “turn them on.” This is adaptive if they are with Classification of sexual disorders 68 such a desired partner, but if they never seem to find the right one, the clinician should be alert to the possibility that they are inhibiting themselves in the service of a hidden sexual conflict. Others can respond to a wide variety of partners; they are much more accepting, finding and relating to the partner’s positive attributes so that they are able to enjoy the relationship. The conflicts which cause the patient to be conflicted about wanting sex-seem to be multiple. On a deeper level, any and all of the countless reasons which make sex dangerous or undesirable to that individual may be operative. There seems to be no specific content, no special unconscious conflict or fantasy or developmental disturbance that produces this symptom. A variety of intrapsychic as well as interactional factors may contribute to the development of desire inhibition, although ultimately it is always fear or anger, most often but not always beyond the patient’s awareness, which makes desire undesirable. These underlying causes can be organized qualitatively, i.e., according to the depth or intensity of the underlying conflict. Mild Sources of Anxiety o performance anxiety, o the anticipation of lack of pleasure in the act, o mild residual gilt about sex and pleasure. “Mid-level” Sources of Anxiety o Unconscious Fear of Success and Intimacy o Power struggles o anger at contractual disappointments Deep Sources of Anxiety o unconscious fears of injury and/or castration Treatment of desire dysfunctions In the simplest terms, the objectives of treatment are to modify the patient’s tendency to inhibit his erotic impulses, and to allow these feelings to emerge naturally and without effort as they will in the healthy, conflict-free person. The patient must learn not to fight his natural tendency to “turn on.” Classification of sexual disorders 69 To implement this objective a combination of experiential tasks and psychotherapeutic sessions is employed. In the psychosexual therapy of desire phase disorders, behavioral experiences are employed together with psychotherapeutic exploration of resistances. ISD patients will seldom improve unless they gain some measure of insight into underlying conflicts, into why they do not want sex, and so therapeutic exploration of emotional conflicts with the aim of fostering insight becomes the primary treatment modality. HYPERACTIVE SEXUAL DESIRE Excessive sexual desire is so rare as to constitute a clinical curiosity when it is a primary symptom. An abnormally intense sexual appetite in females has been termed “nymphomania” and the corresponding condition in the male is “Don Juanism.” Primary hyperactive sexual desire must be differentiated from those high levels of sexual activity that are components of manic and hypomanic states. Compulsive and obsessive sexual states must also be differentiated from true excessive sexual desire. Sexual obsessions are highly prevalent. Many patients are constantly preoccupied with their sexuality and may masturbate to orgasm ten times a day or more. However, careful evaluation reveals that these patients really do not experience an excessive or constant desire for sex. Rather they are highly anxious and tense and seek to relieve their discomfort with sexual activity. In all compulsive states, anxiety rises when the compulsive act is prevented. And, indeed, these patients experience a flood of anxiety when they are not engaging in physical stimulation or in seduction. Sexual activity used in the service of tension relief is a compulsion and not truly overactive sexual desire. Female sexual arousal disorder Though its actual prevalence is not known, female sexual arousal disorder (FSAD) is believed to affect a significant Classification of sexual disorders 70 proportion of women in all age groups. Epidemiological survey conducted in 1994 in USA shows that 19% of women between the ages of 18 and 59 reported lubrication difficulties. Some authors surveyed 100 “normal” couples, finding that 48% of women reported “difficulty getting excited” and 33% reported difficulty “maintaining excitement.” However, despite the frequent difficulty in regard to sexual excitement/arousal, 86% of these women rated their sexual relations as “very satisfying” or “moderately satisfying”. This discrepancy may be attributed to the fact that intercourse may occur even though a women is minimally aroused while males require a sufficient rigid erection for intercourse to occur. In this regard, despite the 48% and 33% of women reporting difficulty getting excited and maintaining excitement, only 15% of the husbands thought their wives had this problem. In postmenopausal women, the rate of lubrication problems is even higher, reaching 44% in one study. Definition and diagnostic issues Female sexual arousal disorder specifically refers to the arousal phase of the sexual response cycle. Criteria for FSAD according to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) are following: A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. B. The disturbance causes marked distress or interpersonal difficulty C. The sexual dysfunction is not caused by a general medical condition or by direct physiological effects of a substance. The essential criteria of a deficient physiological response agree with the International Classification of Diseases (ICD-10; World Health Organization, 1992). Clinical description Women who meet the criteria for this syndrome feel the desire for sex and like lovemaking. Frequently they can have orgasms, especially when stimulated intensely with a vibrator. Classification of sexual disorders 71 However, they remain dry when they are stimulated in a manner which would be adequate for most women. Penetration without normal lubrication and swelling can result in painful and uncomfortable intercourse. This may result in secondary problems such as dyspareunia, Vaginismus, and loss of sexual desire. Partners of such patients often feel rejected and upset by what they take to be a personal sexual rejection or evidence that they are poor lovers. Differential diagnosis Like the male, the female’s lubrication-swelling response is mediated by the autonomic nervous system, principally by its parasympathetic divisions. This mechanism is ultimately under the control of the cortex; therefore, theoretically female excitement should be as sensitive to emotional factors as male excitement. In actual fact, however, the psychogenic form of this disorder is uncommon. Apparently, a woman with sexual conflicts is more likely to lose her interest in sex or to develop orgasm difficulties than to become inhibited in the excitement phase. Most women who have a normal desire for sex and can reach orgasm but fail to lubricate are menopausal. The vasocongestive phase of the female sexual response cycle is much more resistant to illness and drugs than male erection, because it involves simpler anatomic structures and does not depend on a complex hemodynamic high pressure system in the genitals. The increased pelvic vascularity which marks the female excitement phase merely causes a transudate to seep through the vaginal wall. The only factor that makes female excitement vulnerable to physical stressors at all is that for proper vasocongestion and lubrication the vagina must be supplied with adequate levels of estrogen. When estrogen is deficient the vaginal endothelium which transmits the fluid and its underlying network of blood vessels tend to atrophy. The most common cause of estrogen deficiency is menopause, due to the natural aging process or to the surgical removal of the ovaries. Although the senile ovary and the adrenal gland continue to make small amounts of estrogen in posmenopausal women, in most cases this is not sufficient to support the lubrication Classification of sexual disorders 72 function of the vagina. Therefore, all postmenopausal women, especially if they do not have regular intercourse, are likely to suffer from deficient vaginal lubrication. Estrogen deficiency is easily diagnosed. Normal menstruation is presumptive evidence of an adequate estrogen level and all patients who complain about vaginal dryness should be asked about the regularity and quality of their menses. In addition, all patients with this complaint should have a vaginal examination, which will reveal a dry and pale vaginal mucosa. Estrogen has a marked effect on the cells that line the vagina, and a microscopic examination of the patient’s vaginal smear that has been specially stained will give a rapid, but not highly reliable, indication of whether estrogen is deficient. Advanced laboratory techniques for the measure of estradiol levels in the blood are now available for a much more reliable measure of estrogen. The evaluator should inquire about any health problems that could be contributing to the sexual dysfunction. Although the following theoretically can interfere with the female excitement phase by causing a longer arousal time and, in some instances, by decreasing vaginal lubrication, it should be noted that they are, with rare exception, not the primary clinical complaint of excitement phase disturbance. Neurogenic disorders: disorders affecting the sex centers of the brain include head trauma or CVA (Cerebrovascular Accident). This may decrease excitement phase by direct injury to the sex centers and/or injury to the limbic system or parietal lobe. Hypothalamic lesions or chraniopharingoma result in the same from pressure on the cerebral structures, while chromophobe adenoma decreases excitement not only by pressure on the sex center and limbic system, but also by elevating the prolactin level. Psychomotor epilepsy may diminish female excitement phase by disturbance of the limbic system. Disorders affecting the lower neural structures associated with genital reflexes include the following: neurological conditions may cause diminished or even absent excitement phase due to patchy lesions in the spinal cord which interfere Classification of sexual disorders 73 with genital reflexes. Those which are most frequently responsible for such sexual difficulties are multiple sclerosis and alcoholic neuropathy. In fact, sexual difficulties are sometimes among the first manifestations of multiple sclerosis, with variable complaints such as diminished lubrication, diminished or absent clitoral sensitivity, and dyspareunia, all of which interfere with arousal. Patches of demyelinization in the spinal cord are responsible. Other disorders affecting the spinal cord, and possibly associated with decreased or absent arousal phase, are tabes dorsalis, amyotrophic lateral sclerosis, syringomyelia, myelitis, and severe malnutrition and vitamin deficiencies. Alcoholic neuropathy and herniated lumbar disc lead to diminished or absent phase by virtue of injury to somatic and autonomic nerves concerned with genital reflexes, as does primary autonomic degeneration (Shay-Drager syndrome). Traumatic injuries to the spinal cord resulting in paraplegia preclude sexual excitement since no sensations are perceived. The sensory pathways are interrupted and sympathetic fibers may also be disrupted. Vascular problems may result in diminished or absent excitement phase because of thrombotic injury and occlusion of pelvic blood vessels. The arousal phase is diminished in many patients suffering from coronary disease or severe hypertension. The reasons are probably predominantly psychological-including depression and anxiety about sudden death. Antihypertensive and beta adrenergic blocking drugs or possibly diseased pelvic blood vessels may contribute to diminished excitement on an organic basis. Endocrine and metabolic disorders: the following are most likely to impair the orgasm and desire phases rather than excitement; the effect on excitement is secondary. Diabetes mellitus may be associated with diminished or absent excitement due to neuropathy of the sensory nerves of the clitoris. Testosterone deficiency states in females result in diminished lubrication and interference with the functioning of the sex centers, which require testosterone. In addition, neural transmission and cellular response of the genitals may be Classification of sexual disorders 74 impaired. Thyroid deficiency states may interfere with arousal by mechanisms not clearly understood. Other endocrine disorders, such as Adison’s disease, Cushing’s syndrome, acromegaly and hypopituitarism may all diminish excitement because of various endocrine deficiencies which affect the sexual circuits of the brain or the cellular response of genitals. Other medical disorders which may diminish female excitement include liver disease, due to insufficient conjugation of estrogen and resulting neutralization of androgens. Such sexual dysfunction may also result from kidney diseases. A small number of young menstruating women do complain about vaginal dryness on a psychogenic basis. In some cases, this syndrome is clearly related to fear or conflict about intercourse or to poor lovemaking techniques that do not provide sufficient time and stimulation for an adequate response. But the clinical experience with these rare syndromes has been spare and a specific set of immediate psychological antecedents has not yet been revealed for this disorder. It is also necessary to determine whether sexual symptoms are secondary to a psychiatric disorder such as an affective disorder, or an anxiety disorder. A few screening questions that may be helpful are as follows: has substance abuse or mental illness ever been a problem? Has the woman ever received psychiatric treatment or been hospitalized for psychiatric reasons? Has she ever taken psychiatric medications? Has she ever experienced depression, phobias, or panic attacks? If a psychiatric disorder appears to be present, the diagnosis and treatment should be clarified. It is important to know whether any medications could be contributing to the sexual dysfunction. It is also informative to know which came first, the sexual symptoms or the psychiatric problems, and whether extreme stressors are present. As always, the patient should also be asked about suicidality. Patients with severe psychiatric illnesses may be too fragile to tolerate psychosexual therapy or otherwise unable to benefit from it. Classification of sexual disorders 75 The etiology of excitement phase disorders The excitement phase in females is accompanied by reflex vasodilatation with generalized swelling of the labia and the tissues surrounding the vagina, resulting in heightened labial coloring and increases lubrication or wetness, the latter transudes from the vessels in the vaginal barrel. Arteriolar dilation is caused by activation of two centers in the spinal cord, one at S2, S3, and S4, and the other at T11, L1, and L2. As with the male, excitement can be enhanced or inhibited by signals from the brain, which are in turn influenced by previous experiences. Estrogen plays the dominant role in vaginal lubrication. Its physiologic, cyclic effect upon cervical secretions is well known, that is, increased wetness during the midcyclic ovulatory phase and diminished secretions postovulatory, coincident with progesterone (anti-estrogen) release and diminished estrogen production. Estrogen also affects vaginal lubrication directly by enhancing the vascular bed beneath the epithelium, which results in improved lubrication. This effect upon the vaginal mucosa is not dependent upon ovulation and continues as long as sufficient estrogen is produced by the ovaries. Although estrogen production by the ovaries diminishes and eventually ceases beyond the menopause, estrogen levels in postmenopausal women can continue to be substantial, due primarily to the peripheral conversion of adrenal androstendione to estrone and, to a much lesser extent, of testosterone to estradiol. However, with increasing age such adrenal contribution to estrogen production becomes inadequate to sustain secondary sex tissues such as the vaginal mucosa and, indeed, even adjacent tissues such as the urethra and trigone Although excitement phase dysfunction in females can exist as a separate syndrome, the discomfort of intercourse with a dry vagina can easily lead to secondary inhibition of sexual desire, if not complete avoidance. In essence, then, female excitement phase disorders are due chiefly to impairment of the vasocongestive excitement phase response, Classification of sexual disorders 76 associated primarily with diminished or inhibited estrogen production. It should be emphasized that in the premenopausal woman such disorders are relatively uncommon. Estrogen Deficiency States Atrophic vulvo-vaginitis. This condition is by far the most common gynecological cause of excitement phase dysfunction that cause genital discomfort during the postmenopausal years. Gynecological examination reveals that the introitus is dry and often reddened. There may be less muscle tone and fascial strength (inelasticity) of introital and vaginal supports. The vaginal mucous membrane exhibits various degrees of dryness and thinning, sometimes to the point of minute mucosal hemorrhages. Laboratory findings will usually show the following: in the absence of other causes of vaginitis, the wet smear of vaginal secretions shows mainly parabasal cells. Blood levels of estrogen are low, while FSH and LH are typically elevated. Aside from physiological postmenopausal estrogen deficiency, other conditions which would produce atrophic vulvo-vaginitis include: Oophorectomy, particularly in younger women whose ovaries are still producing significant amounts of estrogen. The mechanism is, of course, by removal of the chief source of estrogen supply (“surgical menopause”) Radical pelvic surgery (as for cervical cancer), since it includes oophorectomy and also interferes with the parasympathetic and sympathetic sensory pathways To a lesser but sometimes significant degree, vaginal dryness may be induced by progesterone compounds such as medroxyprogesterone, which act as anti-estrogens and also anti-androgens. This would include certain oral contraceptives containing a high progestin ratio (hypoestrogenic). In such instances the gynecological examination reveals a noticeable vaginal dryness but no thinning of the mucosa or petechial spots, as in atrophic states. The vaginal smear reveals a preponderance of intermediate cells, rather than cornified or parabasal. Classification of sexual disorders 77 Treatment of arousal dysfunctions The treatment of FSAD may be carried out individually with the patient alone or in conjoint sessions with the patient and her partner, or through a combination of the two. In patients with impaired sexual arousal, treatment may proceed along medical or counseling sex therapy lines or with both in combination. Medical treatments are rarely considered for premenopausal women. Menopausal patients who are estrogen deficient and have impaired arousal and dyspareunia are often given hormone replacement therapy alone without specific counseling. This approach although it improves lubrication and discomfort, is often inadequate for the treatment of sexual dysfunction. The most effective approach for these cases would be specific sex therapy counseling for arousal deficiency, in addition to hormonal or other medical treatment. For patients with impaired sexual arousal that is psychogenic, the range of cognitive-behavioral sex therapy techniques may be employed. These techniques are integrated with psychodinamically oriented psychotherapy when deeper emotional issues and resistances to treatment become apparent. Female orgasmic disorder Orgasm phase disorders are highly prevalent. Among patients under 40, inhibition of the female orgasm and premature ejaculation in males are possibly the most common sexual complaints seen in clinical practice. Definition and diagnostic criteria DSM-III describes the following diagnostic criteria for Impaired Female Orgasm when this is due to psychological inhibition: “Recurrent and persistent inhibition of the female orgasm as manifested by a delay in or absence of orgasm following a normal sexual excitement phase during sexual activity that is judged by the clinician to be adequate in focus, intensity, and duration” Classification of sexual disorders 78 Patients in this diagnostic category are not “frigid” in any sense of that outdated term. They may be loving, care about men, be interested in sex, and have the capacity for erotic pleasure. During loveplay, they may feel sexual excitement and may lubricate. In other words, the desire and excitement phases of the sexual response are intact and their chief complaint is only that orgasm is difficult or impossible to achieve. The female orgasm threshold is distributed along a continuum. 1. At one extreme are those rare women who can have an orgasm without any physical contact with the clitoral area, merely by engaging in erotic fantasies, kissing or stimulation of the breasts. 2. Then there are the approximately 20 to 30% who are able to achieve orgasm through coitus alone without direct clitoral stimulation. 3. Next on the continuum are women who can climax together with their partner but only if coitus is “assisted” by clitoral stimulation. 4. Women who fall into the next segment of the distribution cannot reach orgasm in the presence of a partner, even if they receive clitoral stimulation. They can, however, stimulate themselves to orgasm when they are alone and employing erotic fantasies. 5. At the pathological extreme of the orgasm threshold continuum are the totally anorgasmic women who have never had an orgasm at all. These constitute approximately 8% of the U> S> female population (Fisher, 1973). The demarcation between normalcy and pathology is a matter of some controversy. There is little disagreement that the last two response patterns are clearly pathological and that treatment should be recommended for such patients and those with situational anorgasmia who reach climax only in certain circumstances or with certain partners and not with other desired partners. Some psychoanalytically oriented clinicians feel that all women who cannot reach a climax on penetration Classification of sexual disorders 79 unless by additional clitoral stimulation are abnormal and in need of treatment, even if they are orgastic with a partner. However, it is the consensus of current professional opinion that such a response pattern constitutes a normal variation of the female sexual response (DSM-III, 1980), and some therapists with a feminists orientation feel that such women should never be treated (Hite, 1976). It has been clinical experience that some coitally anorgasmic women can acquire a coital orgastic response and should be given the opportunity for treatment, while it makes no sense to treat others. The distinction between who should be offered a trial of treatment and who should be reassured should be made during the evaluation. The reaction of women and their partners to this dysfunction varies widely. In contrast to males, who are always distressed when sexual excitement does not lead to ejaculation, some women are perfectly content about not having orgasms and do not seem to suffer from tension or discomfort after sexual stimulation. In some cases this is denial, but there are women who simply find sex gratifying even if they do not experience a climax. This is not necessarily a sign of pathological passivity. The person’s point of view should be respected and that such women should not be pressured into treatment by husbands or by well meaning therapists. However, other anorgasmic women are desperate about their situation, sometimes to the point of obsession. They complain of tension, physical pelvic discomfort, and anger at their partner when the sex act always ends with a climax for him but never for her. Sometimes the partner is more upset about his mate’s orgasm problem than she is. The spouse may infers also some deficiency on his part. This is especially likely if a man misperceives female orgasm as a man’s responsibility, something a man “gives” to a woman. Partner reaction is always an important diagnostic issue because, even though he may not have caused the patient’s problem, his negative or pressuring response may create an Classification of sexual disorders 80 obstacle to her cure, while his cooperation and support are invaluable for the success of sex therapy. Primary anorgasmia-never having experienced orgasm by any means-is not uncommon. Secondary anorgasmia-the onset of anorgasmia in a woman who has been orgasmic in masturbation and coitus-is not uncommon, but the diagnosis is usually secondary to inhibition of desire, even though the inhibition of orgasm may have occurred first. The differential diagnosis and etiology Actually, only a few drugs and illnesses impair orgasm in women and this syndrome is usually psychogenic. Over half the women who complain of orgasm problems have a situational pattern, being able to have orgasm when they masturbate but not with a partner. It is not necessary to pursue physical causes in such cases. But for women who have no orgasms at all, medical causes must be ruled out. In otherwise healthy women, these include use of MAO inhibitors (antidepressants) and the alpha adrenergic blocking agents (used to treat hypertension), true phimosis of the clitoris, and very rare congenital abnormalities. Neurological degenerative diseases or injuries or tumors that destroy the spinal centers and nerves that mediate the orgasm reflex, severe damage to the genital organs (as in radical pelvic surgery for cancer), and advanced diabetes, which may injure the sensory nerve endings of the clitoris, can also produce an absence or delay of orgasm. But women with these conditions tend to be ill and have other medical signs or symptoms. The history of all totally anorgasmic women should include questions to rule out these drugs and diseases. A physical examination is also required to insure that the patient does not have one of the rare anatomic abnormalities of the genitals that can cause orgasm problems in women. The risks of organicity are so low in the primary form of this syndrome that, when the medical history rules out the specific illnesses and drugs and patient’s genitals are normal, a trial of sex therapy without any further medical workup is safe. However, when a previously orgastic woman loses her capacity Classification of sexual disorders 81 to climax, especially in the absence of a psychological crisis, there is a strong possibility that she has a medical problem, and the diseases and drugs that can cause orgasm impairment must be carefully ruled out, because serious and treatable illness, including diabetes, multiple sclerosis, spinal cord tumors and degenerative diseases, may otherwise be missed. The most common immediate psychological mechanism instrumental in the inhibition of the female orgasm is obsessive self-observation during lovemaking, which will effectively interfere with the release of the orgasm reflex. Another common simple cause is that the patient is not obtaining sufficient clitoral stimulation. This can happen when the couple has the unrealistic expectation that she should climax merely in response to rapid penile penetration without much foreplay and without clitoral contact. In other cases a woman will not let her partner know what she wants because of shame and insecurity. Some anorgastic women are unable to fantasize or to use sexual imagery. Some report obsessive phenomena, that unwelcome thoughts or meaningless phrases or parts of songs, etc., enter their minds during sex. Others feel only neutral or even irritating sensations when the clitoris is touched and/or they are simply not aroused by clitoral stimulation. It may be speculated that these women have erected perceptual defenses against erotic sensations and are afraid of letting themselves go in sexual abandonment (fear of the loss of control that occurs at climax and fear of closeness or fusion with the partner). Inability or unwillingness to communicate with the partner is associated with anorgasmia. The patient’s deeper intrapsychic problems in her relationship with her partner are inferred from her family and psychosexual history and from the assessment of the couple’s relationship. Conflicts due to strict childhood prohibitions against masturbation and other forms of sexual expression are often found in the histories of women with sexual problems. Most of these women did not masturbate in adolescence. A significant number had hostile or distant Classification of sexual disorders 82 relationships with their mothers, who did not encourage their emerging sexuality. Unconscious neurotic processes (oedipal conflicts), which cause the woman to develop a “father transference” towards her current partner, with attendant defenses against sexuality, are given a prominent place in the psychoanalytic literature on female sexual problems. In fact, overly close or ambivalent relationships with fathers are seen in some (but not all) women with sexual and relationship problems. Pleasure inhibitions and ambivalence about closeness and commitment to a man are often noted when reviewing these patient’s relationships with the men in their current life. Some women with sexual problems are competitive with all men and may experience fear, ambivalence, and mistrust towards their current partner. This often comes from a sense of outrage at what is perceived by the woman as unfair advantages accorded to men in our culture. An overcontrolling and compulsive personality style which makes it difficult for the patient to “let go” is commonly found among anorgastic women. Treatment and prognosis Treatment must be aimed at correcting fears and misconceptions. It must also help a woman increase her assertiveness and sexual initiative, and support her in realizing that her sexual activity is for her own enjoyment as much as her partner’s. Progressive exercises in masturbation and in sex play with her partner may help her to become more familiar with her desires and sexual responses and to achieve satisfaction. Orgasm inhibition of women has an excellent prognosis with sex therapy. Almost all totally anorgastic women can learn to have orgasms, even when the symptom is associated with deeper intrapsychic and relationship problems. Whether the woman will be able to have orgasms with her partner is not as easily predictable, since this depends on the nature of the couple’s system, and may require more complex conjoint therapy. Classification of sexual disorders 83 Vaginismus Diagnostic criteria and clinical features According to DSM-III, vaginismus is defined as follows: “There is a history of recurrent and persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with coutus”. It is usually evident at the start of a marriage, precluding consummation. Ordinarily, when woman is sexually aroused, the vaginal muscles relax and the introitus opens. But in vaginismic women the muscles snap together so tightly that penetration may be impossible. When the vaginal muscle spasm is somewhat less severe, entry may be forcibly attained but the experience is painful for the woman. The patient has no voluntary control over her response, and on a conscious level vaginismic patients are often extremely distressed by there inability to have intercourse and children. It is interesting to note that while some patients with this disorder also have other sexual problems, many have normal sexual desire, lubricate, and are orgasmic. It is only penetration which is difficult, painful, or impossible. In most cases, the vaginal muscles go into spasm in response to any attempt at vaginal penetration, so that the patient has great difficulty in undergoing a pelvic examination. A few patients have a specific vaginismus which only occurs during coital attempts and not at other attempts at vaginal penetrations. These patients can be examined without difficulty and this situational pattern rules out organic obstruction. The differential diagnosis Those patients who find vaginal penetration difficult in all situations must first have a vaginal examination to rule out organic obstruction and to establish that the vaginal muscles are in fact in spasm. The examiner can palpate the vaginal muscles and confirm that they are tightly closed. Patients with vaginismus may feel pain when examiner’s finger are first introduced, but if the examiner retains the examining finger in the vagina while she quietly reassures or distracts the patient, the vaginal muscles Classification of sexual disorders 84 of vaginismic patients will usually relax within 10 to 60 seconds. The patient then begins to feel comfortable with the speculum or the examiner’s finger inside her vagina. She has been confronted with the important fact that there is no structural abnormality and that the block was only due to her muscle spasm, which will diminish if she does not panic. If the vaginal muscles are found to be tight, the next diagnostic question is whether the cause of the spasm is psychogenic or physical, because both can result in muscle spasm. Any gynecological disorder that makes sex painful can evoke a conditioned guarding response and vaginismus. Endometriosis, PID, vaginitis, herpes, birth and surgical injuries of the genitals are among the many painful medical disorders which can result in this syndrome. For this reason, if the patient complains of pain during the vaginal examination, apart from that produced by the spastic vaginal muscle, a thorough gynecological evaluation is in order to insure that no treatable or dangerous gynecological conditions are missed. Behavioral analysis shows that the immediate psychological cause of vaginismus is a reflex involuntary spasm of the muscles that guard the vaginal introitus. At times the patient’s sexual history reveals a specific precipitating trauma, such as incest or rape or a painful attempt at intercourse. Some have or have had a painful gynecological condition. Others are guilty and conflicted about sex. In many cases, however, the patient remembers nothing that could explain her symptom. Analysis of the intrapsychic dynamics and of the couple’s system shows that the underlying psychological causes range from the trivial to the serious. Vaginismus may occur as an isolated symptom in a basically healthy woman who is in a good relationship. Other vaginismic patients have severe neurotic conflicts about sex. Some are ambivalent about their marriage and/or about pregnancy or motherhood. Some are passive-aggressively punishing their husbands. Some have a panic disorder. Classification of sexual disorders 85 When evaluating the vaginismic patient it is important to gauge the severity of the underlying emotional problem, because this will determine how difficult treatment will be. In the more complex cases the symbolic meaning of the symptom and/or the role that the closed vagina plays in the relationship should be assessed, so that the therapist knows what psychological issues will have to be confronted during the psychodynamic aspects of treatment. Many vaginismic patients develop a secondary phobic avoidance of vaginal penetration. This must be analyzed so it can be treated before the vaginal spasm, for one can hardly expect a patient to proceed with vaginal dilation if she panics at any approach to her vagina. Treatment and prognosis Regardless of the severity of the associated emotional problems, the symptom of vaginismus has an excellent prognosis with treatment that includes progressive vaginal dilation. Although patients with more complex problems may resist during therapy, it is the rare vaginismic woman whose symptom cannot be cured with brief, direct, behavioral treatment. Male orgasmic disorder There are three types of ejaculatory symptoms which may be either psychogenic or organic: absent or delayed (retarded) ejaculation, absence of orgastic sensation or partially retarded ejaculation, and rapid (premature) ejaculation. “Dry” orgasm is caused by retrograde ejaculation or by anejaculatory orgasm, which are always due to organic causes. Male orgasmic disorder (302.74) was formerly called retarded ejaculation. This ambiguity in diagnostic label refers to what is primarily stressed out-not ejaculating or not being coitally orgasmic. In some cases retarded ejaculation is seen because his partner wants to be impregnated and couple seeks treatment because the retarded ejaculation creates frustration over the consequent infertility. However, in actual practice, retarded ejaculation refers to male coital anorgasmia and Classification of sexual disorders 86 treatment strategies are directed at the inability to have specifically coital orgasms. Some men with this condition are proud of maintaining erection for a long time and repeatedly satisfying partners. Yet, clinical experience shows that this creates problems in relationships because man’s partner takes it as a personal rejection. Definition and diagnostic criteria DSM-IV describes the following criteria for male orgasmic disorder: “Recurrent and persistent delay in or absence of orgasm following an adequate excitement phase”. The diagnosis of retarded or absent ejaculation is not based on how long it takes to reach orgasm. The duration of all phases of the sexual response cycle varies among individuals and from one occasion to another. Many people vary the amount of time at any stage of the sexual response for their own satisfaction or their partners’. Retarded or inhibited ejaculation exists when a man wishes to pass from the plateau stage to ejaculation but cannot. With increased striving for ejaculation, his distress increases, ejaculation becomes more difficult, and pleasure diminishes. If ejaculation does occur, it is relatively unsatisfying. Men with this condition usually do not have the same problem with masturbation but do have it with genital contact with partners. Differential diagnosis The differential diagnosis between organic and psychogenic RE is simple in the majority of cases. Most retarded ejaculators below the age of 50 can climax without difficulty on masturbation and organic factors do not have to be considered in these cases. In older men, the ejaculatory delay often occurs in all situations; then medical causes must be ruled out. Ejaculation may be delayed or blocked by any physiologic stressors that impair the sex drive, including testosterone deficiencies, depression, and drugs which depress the central nervous system, such as alcohol, sedatives, and narcotics. The aging process, which increases the refractory period of the male orgasm, alpha adrenergic blocking drugs and also thioridazine are virtually the only organic causes which Classification of sexual disorders 87 selectively impair the orgasm phase of the male sexual response cycle and produce no other sexual or medical disabilities. Primary RE is usually psychogenic, secondary ejaculation problems carry a significant risk of organicity. When a man whose orgasms have previously been normal complains of delayed ejaculations, unless this is clearly the product of the normal aging process, a thorough medical history and neurological workup is requires because serious neurological disease states may be associated with this symptom. Surgical and traumatic injuries, tumors, disease of the spinal cord and of the pelvic nerves that mediate ejaculation, and advanced diabetes which injures the peripheral nerves can certainly cause ejaculatory difficulties. However, in such cases the patient either has a history of radical pelvic or abdominal surgery or spinal cord injury or will probably have other neurological signs and symptoms. These are likely to affect the motor and sensory functions of the lower extremities. And, since the spinal cord centers which control these reflexes are in close proximity, impairment of urinary and/or bowel control is often seen together with ejaculatory symptoms that are caused by neurological impairment. When a patient complains that he experience normal orgastic sensations but no fluid emerges from his penis, anejaculatory orgasm must be differentiated from retrograde ejaculation. This differential is not difficult, since the two syndromes are produced by different states and drugs. The most common cause of retrograde ejaculation is transurethral prostatectomy. Anejaculatory orgasm is caused by the failure to produce semen or by a blockage of the tubus which conduct semen from the testicles to the urethra. Vasectomy is currently the most common cause of anejaculatory orgasm. The differential diagnosis between these two syndromes is made by examining a post orgasm urinary specimen under the microscope. Sperm cells will have entered the bladder and will be found in the urine of men with retrograde ejaculation, while the urine of anejaculatory patients will contain no sperm. Classification of sexual disorders 88 Etiology The etiology of retarded or inhibited ejaculation remains controversial, but it often involves internal conflicts over coitus and ejaculation that the man finds unacceptable. Often the problem is lifelong, but it sometimes develops after a traumatic incident (such as discovering a partner’s infidelity), after the onset of represses or suppressed anger toward the wife following a period of good sexual functioning. The most common immediate psychological antecedent that blocks ejaculatory release is the same as in female orgasm inhibition-obsessive self-observation. The patient obsessively wonders: “Will I come? When will I come? IS she getting tired? Is she really enjoying this? IS she making love to me because she has to?” he is free of theses obsessions when he masturbates and immerses himself in his sexual fantasies, and therefore has no trouble ejaculating in that situation. Deeper psychological problems include all the neurotic conflicts about sex and all the relationship difficulties that have been implicated in the other sexual disorders of males. Ambivalence and rage towards women, which derive from unresolved childhood problems with mother, are particularly prevalent in this group. Fears of intimacy, commitment and pleasure are also common and related to the same dynamics. Exploration of the patient’s feelings towards women and a detailed analysis of his relationship with his mother, as well as with his current partner, often reveal neurotic processes that must be dealt with in treatment. Retarded ejaculators are frequently very angry at their current wives and lovers and involved in sadomasochistic system with them. They “hold back” their orgasms along with their rage. A rigid, compulsive, and overcontrolling personality with difficulty in handling anger is often seen in this patient population. Treatment Treating retarded ejaculation is usually very difficult, and success may be followed by relapse. Sometimes the emotional dynamics of the couple are involved with the relapse, so treatment requires cooperation and motivation by both partners. Progressive behavioral therapy is used over a period Classification of sexual disorders 89 of weeks; vigorous manual stimulation to orgasm by the partner is followed by vigorous manual stimulation and insertion just as ejaculation is about to occur. Premature Ejaculation (PE) (302.75) is the most common sexual problem for men. Almost all men ejaculate rapidly in their first-partner sexual experiences. Such response, with or without distress, is normal in adolescence; this is not PE, as control has not yet been learned-something that will come with experience, i.e. with time many men are able to teach themselves how to achieve control that is gratifying and satisfactory. However, ejaculatory control is elusive for many men, and their sexual experience becomes defined by it. The figures vary by author, with the range being between 30% and 75%. Obtaining an accurate figure of incidence is complicated by the lack of agreement as to definition. Many men who have PE may develop a secondary erectile disorder and may therefore present to the clinician with a different chief complaint. Definition and diagnostic criteria DSM-IV defines premature ejaculation as follows: A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity. B. The disturbance causes marked distress or interpersonal difficulty. C. The premature ejaculation is not due exclusively to the direct effects of a substance Defining this condition has always been a source of controversy. Vasilchenko finds that ejaculation is premature if it occurs within 60 seconds after penetration or by 20 penile thrusts. He defines this condition as ejaculatio praecox absoluta-EPA. Masters and Johnson (1970) diagnosed premature ejaculation (PE) when the male would have an Classification of sexual disorders 90 orgasm before his partner more than 50% of the time, i.e. when a man cannot control his ejaculation after vaginal penetration so that a fully orgasmic partner fails to reach orgasm at least half the time. The DSM-IV definition quoted above depends on a person’s subjective sense of regulation, not on limits of time, thrusts or even personal satisfaction. This seems more practical, since some men and their partners are not distressed by rapid ejaculation. They are able to develop mutually enjoyable lovemaking patterns despite lacking control. Men who ask for help feel sexual dissatisfaction because ejaculation occurs before the individual wishes it. This often (though not always) has an impact on the individual’s partner, resulting in distress or interpersonal difficulty. The individual feels a reinforced sense of shame, dread, humiliation, and inadequacy with painful consequences. The partner initially maybe confused and may feel responsible, but the more usual response in a partner who has some sexual understanding is to feel frustrated, impatient, and angry. This in turn is perceived by the individual, which only intensifies his anxiety and distress and distorts even further the nature of the sexual experience. Most cases of PE are primary, in that the condition has always existed. In the rare cases on which it is secondary, it is usually associated with a specific psychosexual stress. Long, enforced sexual abstinence may produce rapid ejaculation when sexual activity is resumed; most men rapidly regain voluntary control, but, in some, PE apparently becomes established with increasing anxiety. All men with PE experience anxiety, which is central to the dysfunction. The initiation of sexual activity is viewed by both partners with apprehension, and completion of sexual activity is associated with a decreasing level of satisfaction. As a secondary phenomenon, sexual desire becomes inhibited, and in some men, erectile capacity is also impaired. They may develop a secondary pattern of sexual avoidance. Etiology There have been many attempts to explain the cause or causes of PE. The sexual status examination of premature Classification of sexual disorders 91 ejaculators indicates that they are frequently not aware of the state of their sexual excitement or of their level of tension. These patients may obsessively focus on trying to control their ejaculation. Their excitement rises rapidly and they are not conscious of the sensations premonitory to orgasm. It has been postulated that this perceptual failure is the key to this syndrome. Sensory awareness is necessary for acquiring control of all voluntary reflexes, including ejaculation. On a deeper level, many premature ejaculators are conflicted about sexual gratification and pleasure and seem to suppress or deny their erotic sensations when these become “too” intensely pleasurable or last “too” long. The premature ejaculator’s perceptual defenses thus interfere with this learning process. Unconscious intrapsychic conflict seems to appear less often in PE than inmost sexual dysfunctions. PE is often isolated symptom, and no other psychological problem can be detected on the evaluation. In such cases the syndrome can be conceptualized as a sexual learning disability. In other cases, prematurity is associated with deeper psychological problems and difficulties in the marital relationship. It has been postulated that premature ejaculators are hostile to women and that their symptom serves the unconscious purpose of depriving their partner of pleasure. Another view has been that PE is an expression of castration anxiety. The vagina is seen as frightening and dangerous, and the PE serves to “get the penis out of their” as rapidly as possible. Clinical evidence shows that psychological problems of these patients are not specific. One finds loving and kind as well as hostile men in this population; the partners also vary from loving to demanding. For this reason, the psychodynamics and relationship system of each patient must be carefully and individually evaluated. Differential diagnosis The excellent response of this syndrome to psychotherapy indicates that primary prematurity is rarely organic. However, there are some congenital conditions of the urinary tract and spinal cord which can cause ejaculatory control difficulties on a physical basis. The most common of these is spina bifida. Such conditions are extraordinarily rare and tend to be associated Classification of sexual disorders 92 with other signs and symptoms of medical and neurological disability. Therefore, when a healthy young man who has a negative medical history complains that he has always come too rapidly, a syndrome of lobuli paracentralis should be ruled out. This syndrome is triggered by the affected cortical centers that are responsible for regulation of urogenital functioning. The syndrome marked by PE, nocturnal enuresis, pollakiuria and premature puberty. Neurologic symptoms are associated with integrating in the process of pyramid innervation. Secondary prematurity is much more likely to be caused by an underlying medical disorder, especially when the loss of control is not associated with significant stress or a change in the patient’s sexual relationship. A frequent case of late occurring PE is organic erectile dysfunction. The man, who is progressively becoming impotent for a medical reason may “learn” to ejaculate rapidly before he loses his tenuous erection. Some surgical procedures and spinal cord disorders can cause secondary PE by impairing the nerves and neural center that govern the ejaculatory reflex. Therefore, when a man who had enjoyed good control complains that he is now coming rapidly, it is mandatory that he receive a careful Neurologic or urologic evaluation. Treatment and prognosis Ejaculation is a matter of control. Not surprisingly, the most common method for treating PE is the behavioral approach. PE has an excellent prognosis with sex therapy that uses either the “squeeze” or the “stop-start” methods. The symptom can often be cured with these behavioral measures, even if it serves unconscious defensive functions. However, when prematurity plays a role in the patient’s intrapsychic dynamics and/or the couple’s neurotic system, treatment is likely to be more complex. In such cases rapid improvement in sexual adequacy is apt to evoke anxiety and resistances to treatment that require psychotherapeutic interventions. Surprisingly, the SSRI medications, such as Prozac, Paxil, and Zoloft, whose negative side effects include decreased sexual desire and less intense orgasm, can be a good Classification of sexual disorders 93 treatment for PE. Phosphodyesteras inhibitors help a man sustain his erection even after the orgasmic release, making these medications also helpful in assisting men with PE. Male erectile dysfunction Erections difficulties are found in all ages. They become more common with age. While any problem with sex is upsetting to a man, nothing generates as much concern, anxiety, shame and even terror as an inability to get or maintain erections. This can make a man feel less of a man. The primary meaning of impotence, the term traditionally applied to erection difficulties, is “a lack of power, strength and vigor”-the negation of all that is considered to be masculine. Sexual excitement in both males and females is caused by reflex vasodilatation and congestion of the genital organs. This influx of blood changes them from the quiescent state and prepares them for their reproductive functioning. The excitement phase in males marked by penile erection and in females by vaginal lubrication and swelling. Definition Erectile Dysfunction (ED) or Inhibited Sexual Excitement in the male is defined in the DSM-IV as “Recurrent and persistent inhibition of sexual excitement during sexual activity, manifested by partial or complete failure to attain or maintain erection until completion of the sexual act”. This definition assumes that sexual desire is present, that the environment is suitable. This definition includes the rare cases of male erectile difficulty during masturbation. Most patients with ED find kissing, touching and even genital contact pleasurable, but the arousal component of these behaviors is blocked either continuously or intermittently. If this blocking occurs frequently, it can lead to diminished desire, in which case inhibited sexual desire is a secondary diagnosis. Some of these men develop a secondary avoidance of sex, so that it may look as though they are completely asexual. Classification of sexual disorders 94 ED is always obvious and causes concern, even though its occasional occurrence is a natural part of most men’s experience. The outcome depends on how a man interprets it. Most men accept it enough to be able to go on to further sexual experiences unimpeded. Their partners are usually even less concerned. However, some men, after even one episode of impotence, approach sexual activity with dread and monitor their performance. This fear may well be confirmed: the man’s attention shifts from his pleasure to the degree of his penis’ tumescence or flaccidity. Treatment must focus on eliminating spectatoring and the underlying anxiety. Careful and meticulous questioning is often necessary to elicit the precise and detailed information about the specific circumstances under which the erectile difficulty appears that is needed to differentiate between organic and psychologically impotent men. Some patients have morning erections, or can masturbate without difficulty when they are alone, but are impotent with a partner. Some complain they cannot attain an erection. Others lose it-when they take their clothes off, or are about to penetrate, or are inside the vagina or when there is a demand for performance, or when they are with certain types of women, or in an intimate or committed situation. Still others complain that their erections are not completely firm. The partner’s reports are frequently helpful in clarifying these important diagnostic issues. Women vary greatly in their reaction to their partner’s ED. Some are marvelously supportive and convey to the man the massage that he is important to her-not his erect penis. Such loving attitudes rule out partner pressure as an etiological factor. At the other extreme are partners who are sexually demanding and critical and carry on when their man does not perform to their satisfaction. Some women insist on penetration as their only means of gratification, or object to their partner’s use of erotica, or do not wish to stimulate his genitals. The pressure created for a man when he knows that his partner expects him to attain an erection rapidly and maintain it until she is satisfied heightens his performance anxiety and is likely to create or aggravate his potency Classification of sexual disorders 95 problems. Sometimes partner may be supportive, but he may be so consumed with self-loathing that he can’t accept what she offers. Many men distance themselves from their partners after such “failures” and engage in orgies of self-flagellation. Etiology The highly complex erectile system depends on the integrity of the delicate penile anatomy, the pelvic blood vessels and nerves, the correct balance of neurotransmitters in the brain, a functional autonomic nervous system, an adequate hormonal environment, and last but not least, a calm and erotically focused psyche. It is not wonder that erection is the most vulnerable part of the male sexual response and that impotence can be caused by a variety of drugs and disease states and emotional stressors. Psychological factors play a role in almost all cases of ED, whether primarily organic or psychogenic. The patient who is partially impotent because of a mild circulatory deficiency frequently reacts to his diminished erectile capacity with panic, thereby worsening the physical disability. For this reason, the psychological aspects of the problem should be evaluated in all cases of erectile difficulty, even when the problem is clearly organic. Here is an outline of the issues that should be considered while evaluating a patient with erectile dysfunction: I. Psychogenically caused erectile dysfunction A. Anxiety There are many presentations of anxiety, from performance issues to insecurity about a man’s sense of masculinity. B. Depression Depression is one of the most common causes of impotence. Sometimes the sexual dysfunction is the presenting symptom of a man who denies his emotion and says he is not depressed. C. Unconscious sexual conflict II. Organically caused erectile dysfunction A. Disease of or injury to the nervous system 1. The brain-strokes, tumor, trauma, Parkinson’s disease, dementia, surgery Classification of sexual disorders 96 2. Spinal cord-trauma, tumor, surgery, multiple sclerosis 3. Prostate and rectal surgery, trauma B. Disease of or injury to the circulatory system 1. Arteries-arteriosclerosis, diabetes, hypertension, trauma, aneurism, surgery 2. Veins-venous leaks, incompetent veins 3. Blood-severe anemia, sickle-cell anemia C. Disease of the endocrine system 1. Hyperprolactinemia The hormone prolactin, which controls the production of milk in a nursing mother, is usually present only in minimal amounts in the male. One of its secondary effects is to diminish sexual interest and arousal. Tumors of the pituitary gland can cause an abnormal increase in the production of prolactin, leading to impotence in man. 2. Hypergonadotropic hypogonadism: testicular The testicles manufacture androgens, which are necessary for sexual desire and function. When the testis do not function properly, as sometimes happens after mumps, trauma, or abnormalities of fetal development, the pituitary sends out more gonadotropic hormone to try to “turn on” the underfunctioning testes. Blood tests diagnose this condition. 3. Hypogonadotropic hypogonadism: pituitary Like the aforementioned condition, this disease is marked by insufficient androgens in the man’s system. This time it is caused by a malfunctioning pituitary gland, so that the gonadotropic hormones that “turn on” the testes are low or absent. Again, blood tests are necessary to make this diagnosis. 4. Thyroid disease Thyroxin, the major hormone produced by the thyroid gland, regulates the metabolic rate of the entire body. Both too little (hypothyroidism) and too much (hyperthyroidism) can lead to impotence. Physical examination and blood tests are the means to diagnosis. 5. Adrenal disease Classification of sexual disorders 97 The hormones of the adrenal gland-steroids and adrenaline-regulate a wide variety of bodily functions. Again, too much or too little can cause erectile problems. D. Local conditions 1. Peyronie’s disease-fibrosis of penis, which can cause the penis to bend to one side or other 2. Phimosis- a condition in which the foreskin is contracted and cannot be retracted. E. Drugs There are a variety of medications and street drugs that can lead to erectile problems. The most common are antidepressants, antihypertensives, antiandrogens, estrogen, cimetidine, marijuana, and cocaine. Alcohol and smoking tobacco are risk factors to ED. Social drinking or having “just a few drinks to relax” may inflame desire but kill erections. Long-term alcoholism-which can destroy testicular cells, lower testosterone production, and increase the production of female hormones-has serious negative effects on penises and sexual desire. Smoking contributes to the hardening and clogging of arteries, including the ones that supply blood to the penis. Smokers have far more potency problems than nonsmokers. Most patients have more than one factor causing their erectile dysfunction. In a man with diabetes, for example, vascular, neural, and psychological factors may combine to cause erectile dysfunction. In most cases, the currently operating immediate psychological cause of psychogenic ED is performance anxiety. An examination of the patient’s mental processes when he attempts to make love will reveal this mechanism: “I wonder if it will work,” or “I’m afraid I might not be able to have an erection,” or “I don’t think I can keep this erection until she comes,” etc. Because of his obsessive concern about his erections, he is very likely to experience difficulty. The focus on performance to the exclusion of pleasure is threatening and, since the erectile response is very sensitive to emotion, the physiologic concomitants of the patient’s performance anxiety Classification of sexual disorders 98 will trigger the reflexes that drain the penis of the extra blood required for erection. Sometimes performance anxiety is “pure” and the psychological assessment of the couple reveals that the patient is free of emotional problems and that his relationship is good. In other cases the symptom serves as a defense against unconscious sexual conflict or plays a dynamic role in relationship difficulties. Such issues must be detected during the evaluation. The psychopathology of the impotent patient is not specifically different from that of men with other sexual symptoms. Psychoanalytic theory postulates that unresolved oedipal problems and “castration anxiety” play a role in male sexual disorders and it is not uncommon to see evidence of ambivalence towards women and excessive sexual fears in impotent men. “Oedipal” problems are recognized by investigating the patient’s family dynamics and also by analyzing his adult sexual relationships. Was he overly close to or ambivalent toward his mother? Is he still too involved with her? Does he make “mothers” out of his current lovers or does he phobically avoid women who remind him of his mother? Is he overly competitive with or fearful of other men? Is his anxiety about sex excessive and impervious to realistic reassurance? The evaluation of impotent men frequently reveals that they are ambivalent about or openly hostile towards women and that they are still overly involved with their mothers. Many men with erectile difficulties have received negative messages about sexual pleasure. For this reason, it is important to assess the attitudes about sex and pleasure that prevailed in the patient’s family of origin. Partner’s aggressive sexual demands and critical attitudes play a causal role in impotence. An aggressive, nonsupportive partner who uses sex as a pawn in the marital struggle is often the critical element in impotence and the success of treatment may depend on the improvement of the partner’s attitudes. Therefore, the assessment of the couple’s sexual system and of the partner’s emotional characteristics is important in the evaluation of men with erectile problems. Classification of sexual disorders 99 Diagnosis and differential diagnosis Since the physical manifestations of psychogenic and organic impotence are identical, unless the symptom is clearly situational, organic factors must always be investigated and ruled out during the evaluation. In men under the age of 40, psychogenic impotence is more common, while in older men there is a higher risk of organicity because of the greater incidence of circulatory problems and diabetes, as well as the more common usage of medications with sexual side-effects. So, the fact that erectile dysfunction increases progressively with age does not mean that it is an inevitable consequence of aging: other age-related conditions increase the likelihood of its occurrence. Essentially, the diagnostic procedure consists of systematically ruling out the few disease states, such as diabetes and testosterone deficiency, that are known to cause obvious neurogenic, vasculogenic, and endocrine problems- a complex, costly, and far from precise procedure. Actually only a small proportion of impotent patients require a complete urological workup. A skillful examiner who is knowledgeable about sexual medicine can probably rule out organicity in over 90% of psychologically impotent patients on the basis of the interview alone, simply by establishing that the difficulty fluctuates with the patient’s emotional state. Patients whose erectile impairment has an organic basis do not have full erection at any time, while men whose problem is psychogenic may experience erectile difficulty only under emotionally demanding circumstances. For this reason impotent patients must be carefully questioned about spontaneous erections, erections on masturbation, as well as a.m. and nocturnal erections. If the patient or his partner recalls normal erections that are undiminished in quality and firm enough for penetration in any circumstance, organic factors do not have to be investigated further. Treatment and prognosis Maltifactorial nature of erectile dysfunction requires a multidisciplinary approach to its management. Classification of sexual disorders 100 If there are physical problems influencing the patient’s sexual function, there are a variety of treatment options that can be used in conjunction with psychotherapy. Oral medication. There are several oral medications that operate to increase the likelihood of obtaining and maintaining an erection. They operate in slightly different ways, but basically they all function to increase the blood flow into the cavernous areas of the penis and to retard outflow. Success with these agents is variable. They include yohimbine, alpha 2 blockers, trazodone, vasodilan, L-arginin, and phosphodyesteras type V inhibitors (sildenafil citrate [Viagra], tadalafil [Cialis], vardenafil hydrochloride [Levitra]). The agents of the latest group specifically inhibit phosphodiesterase type V, the class of enzymes that are responsible for the breakdown of cGMP. The type V isoform is expressed in reproductive tissues and the lung. Inhibition of the breakdown of cGMP enhances the vasodilatory action of NO in the corpus cavernosum and in the pulmonary vasculature. Nowadays sildenafil citrate is approved for treatment of pulmonary hypertension and does not prescribed to ED patients due to its severe adverse effects. Phosphodiesterase type V inhibitors are contraindicated in patients taking nitrates, because a sharp blood-pressure drop might occur, resulting in a heart attack. Patients whose ED is the product of mild performance anxieties growing out of a lack of sexual confidence and partner pressure that is only due to ignorance and not a product of rooted hostility have an excellent and rapid response to sex therapy. Those whose symptoms reflect profound psychopathology and marital difficulties are, of course, more difficult to treat. It is important to assess the severity of the underlying problems during the evaluation in order to be able to give the patient a realistic estimate of his prognosis. Classification of sexual disorders 101 Ejaculatory Pain Due to Muscle Spasm of the Male Genitals This rather rare syndrome is analogous to vaginismus in the sense that it is caused by a painful and involuntary spasm of the muscles of the reproductive and sexual organs. In the male the cremasteric muscles and/or the smooth muscles of the internal male reproductive organs and/or the perineal muscles react with painful spasm as the man ejaculates or immediately thereafter. Patients typically experience a sharp cramp-like pain immediately upon ejaculation. this may be mild but can be excruciating and disabling. The pain is experienced in the perineum and in the shaft of the penis. It may be transient or last for hours ad even days. The physical examination between episodes is normal and may also be normal while the patient is in pain. Sometimes, however, the scrotum is red, swollen, tender and tense during an attack. Patients tend to be extremely distressed by this symptom and develop a fear of and avoidance of orgasm, which creates an intense conflict when they feel sexual tension. Some patients always experience the pain whenever they ejaculate, on masturbation as well as with a partner. In other cases the symptom is situational and is experienced only when they are ambivalent about ejaculating. Differential Diagnosis Organic disorders, such as prostatitis, epididymitis, vesiculitis, diseases of the urethra and referred pain from other areas can theoretically cause ejaculatory pain, and evidence of these should be pursued during the medical history. Actually, organic ejaculatory pain is rare, but must nevertheless always be ruled out as it can be associated with dangerous disease states including penile cancer. The diagnosis of ejaculatory muscle spasm is made by the typical history of pain, by exclusion of organic causes, and by a trial of sexual therapy. There is some evidence to suggest that the painful ejaculation syndrome lies on a continuum of ejaculatory inhibition which results from ambivalence about orgasm. At one Classification of sexual disorders 102 extreme is retarded ejaculation, then partially retarded ejaculation, next is the syndrome of functional ejaculatory pain, while the orgastic experience of the least conflicted men merely lacks gratification and pleasure. This syndrome may explain some of those puzzling cases of ejaculatory pain that remain undiagnosed and unimproved after repeated urological examinations. Sexual Phobias and Avoidance The avoidance of sex because of irrational fears and phobias is not, strictly speaking, a sexual disorder, because there may be nothing wrong with the phobic patient’s sexual response. For this reason it is not included in DSM under the psychosexual disorders. However, sexual phobias are discussed here because these disabling syndromes are very common among patients with sexual complaints and are frequently amenable to sex therapy. Actually, some elements of sexual avoidance is present in almost all sexual disorders, but it is the essential feature of sexual phobias. The detection and analysis of a phobic component in any sexual problem are important aspects of the evaluation, because the patient’s avoidance of sex must be resolved before the other aspects of the difficulty can be treated. According to DSM-IV, sexual phobias are classified under the term “Psychosexual Disorder Not Elsewhere Classified.” Diagnostic Criteria and Clinical Features The essential feature of a sexual phobia is the persistent and irrational fear of and compelling desire to avoid sexual feelings and/or experiences. The fear is recognized by the individual as excessive and unreasonable. Phobic patients may avoid sex altogether or their anxiety and avoidance may be confined to specific aspects of sex: sexual failure, the genitals, sexual secretions and odors, sexual fantasies, various erotic activities such as kissing, masturbation, orgasm, undressing before the partner, seeing the partner nude, pregnancy, etc. Classification of sexual disorders 103 Fear and avoidance of sex are often highly distressing and may seriously interfere with the development of a normal sex life, romantic attachments, and marriage. The social and emotional life of such patients may become progressively constricted as a result of their avoidance of sexual situations. Some patients with sexual phobias remain virgins all their lives; many do not marry and some become socially isolated. Other phobic patients manage to marry despite their phobias, but their lives are never easy. During the evaluation it is important to gain an understanding of the emotional damage which has resulted from the patient’s phobic avoidance of sex, as this usually requires additional therapeutic intervention. When the phobic person is “trapped” into a situation where sex can no longer be avoided on the pain of losing a valued partner or feeling guilt about frustrating a beloved one, the experience is extremely unpleasant. Phobic patients report that they feel panic or revulsion and sometimes rage during sex. A common experience is trying “to get it over with as quickly as possible.” Some partners of phobic patients are amazingly understanding, patient, and protective. Others are furious and threatened and try to manipulate and pressure the phobic patient for sex. The partner’s reaction is a significant variable in planning therapy and in estimating the prognosis, because the cooperation of a gentle, nonpressuring partner is extremely helpful in treatment. Sexual phobias must be differentiated from other kinds of problems which result in sexual avoidance. Some patients with ISD avoid sex because it gives them no pleasure. Others with anxiety about their sexual performance are afraid to face the humiliation and frustration of failure. Still other patients avoid intercourse because it is physically painful or uncomfortable, while some deliberately withhold sex to punish their partner. Again, the differential diagnosis between these different causes of low sexual frequency is important because in each entirely different treatment approaches are required. Paraphilias 104 Chapter 5 Paraphilias The word paraphilia describes a variety of sexually intense experiences that differ from the standard pattern. Formed by the prefix para (meaning “beside” or “alongside of”) and philia (“love”), a paraphilia then was originally conceived of as a sexual act or fantasy lying “alongside” or “outside” the normal experience of love. The most recent Diagnostic and Statistical Manual (DSMIV) considers a paraphilia to have basic characteristics: 1. An intense, recurrent sexual experience existing for at least six months that involves fantasy, urges, or behavior. 2. A particular object of the sexual experience-nonhuman things, individuals who suffer or are humiliated, children or other nonconsenting persons. 3. A particular result of the sexual experience-clinically significant distress or significant impairment in social, occupational, or other important areas of function. The DSM-IV classifies perversions into eight categories: 1. Exhibitionism. The exhibitionist is usually thought of as a man who exposes his genitals to a stranger. It is unusual for an exhibitionist to do more than show himself and perhaps masturbate. Most men anticipate the viewer’s shocked response, though some imagine that the surprised woman will find them sexually desirable. In general, exhibitionists are younger men who began their activity prior to the age of eighteen. 2. Fetishism. Fetishism is the preference for nonliving objects as the exclusive means of attaining sexual excitement. The fetishist prefers the fetish rather than the human being associated with it. Such behavior is “safe” in that it avoids the dangers of a real human experience. Not all fetishists require the fetish for gratification, but without it sexual excitement tends to be much less intense. The most common fetish is an article of clothing. Minor Paraphilias 3. 4. 5. 6. 105 fetishistic behavior should not be considered aberrant; however, when the fetishistic behavior becomes acute, relationship problems occur and normal sexual relations tend to be avoided. There is evidence that in some fetishists a biogenic factor is present, namely, abnormal electrical activity in the temporal lobes indicative of temporal lobe epilepsy. Pedophilia. Pedophilia is a preference for repetitive sexual activity with prepubertal children. Twice as many pedophiles prefer opposite-sex children. Heterosexually oriented males prefer 8to 10-year-old girls. Homosexually oriented males prefer a partner 10 to 13 years of age. Adults who have no sexual preference choose children under age 8. Incestuous pedophilia is found in only 15 per cent of cases. On the other hand, the victim is a total stranger to the pedophile in only 10 per cent of cases. While in general the pedophiles are males, it is well known that there are women who have sexual relations with young boys. However, they are almost never charged with the crime of pedophilia. Mothers are occasionally involved in incest with their preadolescent daughters, as well as sons. Masochism. True sexual masochism involves sexual excitement generated by one’s own humiliation, pain, or suffering. It can involve being spanked, whipped, tied up, or made to say humiliating things. Sexual asphyxiation, a form of masochism that involves becoming oxygen deprived-often by a rope around the neck-is a particularly dangerous form of sexual arousal that leads to a number of deaths. Sadism. Sadism exists in a spectrum from mild fantasies of dominance all the way to lust murder. The sadist is more likely to be a man, is likely to have known about his predilection as an adolescent or young adult, and is likely to maintain this form of sexual interest for many years. Transvestic fetishism. A man who wears women’s clothes because he believes he is a woman in a man’s body is a transsexual. A man who wears women’s clothes because Paraphilias 106 he gets sexually aroused while doing it is a Transvestic fetishist. This disorder is limited to males, most of whom are heterosexual, though some may report homosexual experiences. Their preferred sexual release is masturbation, and their desire is stimulated by the clothes they wear. A gender identity disorder (transsexualism) may appear in these individuals depending on their degree of satisfaction with their maleness. 7. Voyeurism. A voyeur is someone who seeks out situations where he can secretly observe another person undressing, naked, or engaging in sexual activity. The voyeur masturbates while peeking, or afterwards while the memory is still fresh. Interest in sexual looking begins in early adolescence and to some extent is normal. It becomes a paraphilia when it persists, becomes an individual’s main form of sexual gratification, and causes him distress or leads to social problems, the most common of which is getting caught. Other Parafilias. This category includes rare types of nonstandard sexual behavior, such as zoophilia in which sexual excitement is produced by the act or fantasy of engaging in sexual activity with animals. Animals are the preferred form of sexual outlet, even when other forms are available. Coprophilia (the love of feces), frotteurism (sexual excitement produced by by rubbing against an unsuspecting stranger), klismaphilia (autoeroticism produced by a self-administered enema), mysophilia (sexual excitement created by filthy surroundings), necrophilia (sexual excitement produced by sexual activity with a corpse), telephone scatalogia (obscene telephone calls) and urophilia (sexual excitement produced by urination on a victim) are other types of nonstandard sexual behavior. Not all persons who exhibit paraphiliac behavior are distressed. Many come to the physician’s attention because the behavior distresses the spouse, usually the wife (paraphiliac disorders affect males far more frequently than females), or because the behavior has become a criminal offense and the Paraphilias 107 patient a “sex offender”, who is referred by some agency of the criminal justice system. Within the range of paraphiliac behavior, paraphiliacs are a heterogenous group engaging in diverse sexual activity. Their degree of psychopathology varies from mild to severe and the degree of danger to the public ranges from nonexistent to grave. Moreover, there is no direct correlation between any of the paraphilias and character structure or personality trait. These are also heterogeneous and very diverse. The primary-care physician has only to retain his equanimity and detached concern long enough to obtain a reasonably accurate history that will enable him to make an appropriate referral to a psychiatrist. The primary-care physician should empasize to the patient the inherent dangers of the paraphiliac behavior, both legal and social, and stresses the importance of psychiatric care. The physician should be considerate and compassionate while indicating willingness to continue medical care during and after psychiatric treatment. Understanding the psychodynamics of perversion Sigmund Freud’s View of Perversion Freud thought a perversion was the “inverse of a neurosis.” To understand his vision, we must understand neurosis. A neurotic symptom is the result of a compromise between a wish and the anxiety that the wish generates. The symptom, for example impotence, serves to hide knowledge and expression of a forbidden thought or action. We can say that the symptom expresses the wish and fear simultaneously, and does this while keeping both out of the awareness of the individual with the symptom. Thus, a neurotic symptom is the mixing together of a wish and a fear. It is a displaced, often symbolized expression of a forbidden sexual or aggressive wish. In a perversion this situation is reversed. Instead of feeling threatened by the open expression of forbidden desires, the perverse individual clings to them, is excited by them, and wishes to enact them. Instead of the disgust or anxiety most of us would feel when confronted with the fantasy of being sexual Paraphilias 108 with a child, the pedophile finds the notion arousing. Thus, the perverse individual enacts a forbidden sexual wish in fantasy and perhaps realty. In a healthy individual, anxiety functions as a signal that some desires are unacceptable because they will cause trouble either in realty or in the inner world of prohibitions against incestuous, rapacious desire. The signal is recognized, and behavior is inhibited, rerouted. Defenses come into play to manage the impulse. Healthy defenses allow the energy behind the impulse to be used in socially acceptable, positive ways. In the neurotic, defenses also come into play, but they are less adequate to the task. Instead of rerouting behavior into positive channels, a neurotic symptom appears. The man who (unconsciously) wants women to admire his erect penis is unable to speak in public. The woman who (unconsciously) desires to seduce the thirteen-year-old boy who lives next door is unable to go over and borrow a cup of sugar. Freud noticed that children naturally enjoy and do many of the things we think of as perverse. However, as the child grows up and matures he leaves behind “polymorphous perverse” sexuality and replaces it with adult, genital sexuality. The perverse individual is neither concerned with giving speeches nor unable to borrow sugar. The perverse sexual act serves to protect an individual from the anxieties involved in separating and individuating. In a sense, Freud was suggesting that perverse patients are desperately holding on to sexualized, childhood ways of experiencing and feeling and are unable to grow up and face the realities of adult sexual life. Robert Stoller’s Model of Perverse Sexual Excitement Stoller considers that a particular kind of hostility drives all forms of sexually exciting fantasy. The more hostility, the more perverse the fantasy or action. Stoller wrote: “...hostility, overt or hidden, is what generates and enhances sexual excitement, and its absence leads to sexual indifference and boredom. This dominance of hostility in eroticism attempts to undo childhood traumas and frustrations that threaten the development of masculinity and femininity (gender indentity). The same sort of Paraphilias 109 dynamics, though in different mixes and degrees, is found in almost everyone, those labeled perverse and those not so labeled.” What does this mean? It means there is a spectrum of childhood trauma ranging from minor and unavoidable to severe and unusual sexual, physical, and emotional abuse. It means that when the child experiences these traumas as aimed at his or her developing sexual self, the child attempts to cope with the threat by the creation of fantasy stories that are sexualized. The themes of these stories eventually coalesce to form a core masturbation fantasy, which becomes the center around which adult sexual experiences are organized. Many victims of child abuse are so overwhelmed that they avoid sexual experience all together, but some are pervesely drawn to it. It is a well-Known fact that individuals who sexually abuse have often been sexually abused. If they have not been sexually or physically molested, they have been subjected to repeated hostile, humiliating emotional abuse that was experienced as an attack on their gender identity. Perverse sexual fantasy and action are attempts to change the past in order to prove to the individual that he is no longer the small, powerless, frightened little person that he once was. Treatment and Prognosis Treatment of the paraphilias should not be undertaken by a nonpsychiatric physician. All cases should be referred to a psychiatrist. Patients with paraphilias are difficult to treat, and the results of therapy are often disappointing. Seldom do patients seek treatment on their own. More often they are referred by their wives or by the courts. Occasionally they request treatment because of threat of legal action or of divorce. The prognosis is much more optimistic if the patient’s concern about his deviant behavior is sufficient to cause him to seek help on his own., If motivation is not inadequate, the patient will skip therapy sessions, avoid “homework” assignments, resist revealing his fantasies or dreams, and use passive-aggressive maneuvers with the therapist, such as arriving late, forgetting sessions and diverting the attention of the therapist to irrelevant issues. Paraphilias 110 The principal objectives of any therapy are to increase heterosexual responsiveness and decrease paraphiliac behavior. Within this framework, the therapist attempts to help the patient establish a rewarding sexual relationship and to improve sexual functioning within that relationship. The therapist usually tries to help the patient control his undesirable sexual behavior rather than to reduce his interest in it. If this proves to be impossible, the therapist helps the patient adapt to his deviant role. Gender identity disorders 111 Chapter 6 Gender identity disorders The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders has five criteria that must be met before a diagnosis of gender identity disorder can be given: 1. There must be evidence of strong and persistent crossgender identification. 2. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. 3. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex. 4. The individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia). 5. There must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning. The current edition of the ICD-10 (International Statistical Classification of Diseases and Related Health Problems) has five different diagnoses for gender identity disorder: transsexualism, Dual-role Transvestism, Gender Identity Disorder of Childhood, Other Gender Identity Disorders, and Gender Identity Disorder Unspecified. Transsexualism has the following criteria: The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment. The transsexual identity has been present persistently for at least two years. The disorder is not a symptom of another mental disorder or a chromosomal abnormality. Gender identity disorders 112 Dual-role transvestism has the following criteria: The individual wears clothes of the opposite sex in order to experience temporary membership in the opposite sex. There is no sexual motivation for the cross-dressing. The individual has no desire for a permanent change to the opposite sex. Gender Identity Disorder of Childhood has essentially four criteria, which may be summarized as: The individual is persistently and intensely distressed about being a girl/boy, and desires (or claims) to be of the opposite gender. The individual is preoccupied with the clothing, roles or anatomy of the opposite sex/gender, or rejects the clothing, roles, or anatomy of his/her birth sex/gender. The individual has not yet reached puberty. The disorder must have been present for at least 6 months. The remaining two classifications have no specific criteria. This chapter discusses gender identity problems in terms of age-related developmental stages, because this approach seems to be of most practical value to physicians. At each stage beyond infancy, problems representing normal developmental conflicts are differentiated from those considered pathological. Childhood During infancy (birth to 18 months) core gender identity is already being learned. The most severe gender identity disorder, transsexualism, is already manifests in this period. This early onset has led to speculation that a disorder of fetal sex hormone is etiologically significant in transsexualism. In any event, physicians not consulted about transsexualism at this early stage. Some organic and intersex conditions that often cause sexual identity problems later in life are evident at birth, but Gender identity disorders 113 only those that produce ambiguous or anomalous external genitalia usually are recognized. The ambiguous genitalia in girls are enlarged clitoris with or without some degree of labial fusion. This is noticed in infants with hyperadrenocorticism or whose mothers were exposed to androgenic substances in the first trimester. Ambiguous genitalia in male are microphallus and hypospadias or epispadias. Extremely rare is the condition of true hermaphroditism. Definitive medical or surgical intervention can be undertaken ad completed immediately for some of these problems, such as progestin-induced female pseudohermaphroditism. Crucial decisions affecting sexual identity must be made immediately after birth to prevent sexual identity problems. This process often involves complex determinations of chromosomal, gonadal, hormonal and anatomical sex, and sometimes delicate decisions about the appropriate sex of assignment and rearing. During toddlerhood and preschool period (1 ½ years through 5 years), many aspects of normal development can become the basis of sexual identity problems. The first object of identification for both boys and girls is a mothering female; it is entirely normal for children of this age to show both samesex and cross-sex identification. As they explore their identities, they magically assume that they can be whichever sex they wish. Intermittent (but not predominant or preferred) cross-sex identification or behavior in boys and girls does not indicate sexual identity problems. If parents or other important adults misinterpret such manifestations, however problems may ensue. For example, a father who sees his son playing with dolls or wanting to wear an apron and help mother cook may think he is effeminate or potential homosexual. The father may withdraw and reject, ridicule and disturb the boy’s masculine development by becoming unavailable as a role model and by convincing the child that he must, indeed, be unmasculine. Such conflicts can be induced by either parent in children of either sex, although in this culture, at least, cross gender behavior is usually more censured in boys than in girls by parents of both sexes, and Gender identity disorders 114 fathers tend to be more concerned with clear sex differentiation than mothers. Both envy and fear of the opposite sex occur normally in preschool children. Girls may envy male genitals as something they do not have and may fear them as potentially damaging. Boys may fear female genitals as something to confirm the possibility of castration and may envy females’ capacity for creativity and their dominance in the world of the toddler. These normal internal struggles can become pathological, with the child rejecting his or her own sex, when parents and other adults fail to value the sexes equally. During this period, Oedipal conflicts are most intense. The conflict caused by fear of the fantasized retaliation by the “rival” same-sex parent may cause the unconscious wish to submit to that rival as a love object to retain his love and appease him. Also, some parents render heterosexuality genuinely unattractive or fearsome through their relationship with one another or with the child. Obligatory or preferential homosexuality may sometimes have such a background. Organic conditions, such as genital malformations, begin to produce subjectively perceived sex identity problems in this period. During these years, most children become clearly aware of anatomic sex differences. Body image formation, especially with respect to the genitals, is a major component of sexual identity. Toddlers begin to compare themselves with others. More important, those whose genitals remains ambiguous may continue to suffer from ambiguous gender identity messages in their rearing by parents, older siblings and others. Any delay in correcting remediable conditions should be discouraged. However, correction carries risks of its own. Whether surgery is performed mainly to prevent further emotional damage due to genital ambiguity , or whether it is medically unavoidable, as in some cases of second – or laterstage repair of hypospadias, careful psychological counseling and follow-up for the child are imperative. Precocious puberty, whether idiopathic or organic, can occur even before age 5. Cases with specific pathology demand Gender identity disorders 115 immediate treatment. When treated early enough, these conditions need not cause a child serious sexual identity problem unless the reactions of others make the child believe he is sexually abnormal. Even conditions that virilize as well as cause precocious puberty in girls, such as hyperadrenocorticism, need not disturb normal core gender identity if the girls are treated early and raised unambiguously. A possible parallel has been noted in boys exposed to excessive levels of female hormones in utero. They are less aggressive, less assertive and less athletic than controls. Disturbances in core gender identity become set and behaviorally obvious during this period. Transsexuals already are firmly set in their cross-sex behavior and preferences. These children cross-dress whenever possible, they hate and avoid all activities and interests of their own biological sex and they are interested only in those of the opposite sex. Boys are extremely feminine in appearance and behavior, girls are very masculine. These children are already aware of intense gender dysphoria. Their parents either foster their cross-gender identity or make no effective efforts to interfere with it. Disturbances in sex-appropriate behavior are a separate entity, both clinically and conceptually. The younger the child, the more difficult it is to distinguish such disturbances from those of core gender identity, and to differentiate disturbances from normal variations. Cross-sex role preference may reflect not problems of core gender identity or sexual orientation, but a child’s observation of, or belief that there is, preferential treatment of the opposite sex or denigration of his own sex within the family. Sometimes the same-sex parent or, less frequently, an older sibling or other important relative displays behavior or a personality that makes him or her unacceptable to the child as someone with whom to identify. Parents, siblings or other relatives may systematically negate and demean the child’s sex-appropriate behavior. Cross-sex interests and behavior-effeminacy in boys and tomboyism in girls-is common in sexual identity problems observed during this period. These are temporary or intermittent in normal children. When persistent (especially Gender identity disorders 116 effeminacy in boys), they announce significant conflict. By age 5, a boy who consistently prefers to play with dolls and girls and is indifferent to trucks, fire engines and strenuous noisy play with other boys is probably expressing a sexual identity problem. During the period of early school years (6 years to puberty) there is increased interaction with the environment during this time, when the child in moving out of the parental cocoon into the wider world of peers and teachers. This process heightens the possibility that masculine and feminine stereotypes may distort atypical but normal interests and attitudes onto conflicted or pathological sexual identity. School children can be very cruel, and they may place a normal but studious boy who is not interested in sports in the same category as effeminate boys who have serious sexual identity conflicts. Some athletic coaches even exceed children in shattering the sense of masculinity in normal boys if they are not as competitive as the coaches expect them to be. Tomboyism is not as stigmatized as effeminacy, but girls too can be made to doubt their femininity if they deviate from the stereotypes of the community. Toward the latter part of this period, homoerotic play begins to increase. For the vast majority of youngsters this is not prognostic of homosexuality and they are seldom disturbed about it. However, the parents may be horrified and, by their actions and attitudes, may convince the child he is abnormal. They often seek medical advice, although they may find it difficult to accept even the most knowledgeable reassurance that such play is usually just part of growing up. When visible body or genital abnormalities have been repaired or may not be fully correctable, they become particularly troublesome to a child because of the emotional and ego development characteristics of latency. Body and genital comparison is ubiquitous in the showers and toilets of schools-perhaps less so among girls than among boys, but this difference is diminishing. Children with uncorrected conditions respond intensely to their own perceptions of their pathology, as well as to the real or imagined reactions of others. Gender identity disorders 117 Girls whose mothers were exposed to androgenic substances during the sixth to twelfth week of pregnancy and who developed progestin-induced hermaphroditism constitute one group of children who have no active organic pathology, but who, in this period, show behavioral consequences of fetal androgenization. Even if this condition is recognized at birth, the anomalous genitalia immediately repaired and the girls assigned and reared unambiguously as females, they show more tomboyism than average. However, there is no disturbance of core gender identity or, so far as is known, of later sexual orientation. There is the same possibility of analogous behavioral shifts in fatally estrogenized boys. Transsexualism is evident in this age period to anyone who pays attention to the child. Typically, the child’s crossgender identity has been fostered at home; now the child confronts the full community and for the first time feels the weight of social disapproval and rejection. This makes the child miserable without modifying his inappropriate identity in the least. It is usually in this period that true transsexuals first come to medical attention because the parents also cannot ignore the pressure from others, the diagnosis of transsexualism in females at this age is often less clear than that in males because of society’s greater tolerance of crosssex preferences in girls. Persistent effeminacy and tomboyism are common in sexual identity problems that appear in childhood. In a comparative study of markedly effeminate boys and their families and of a control group of noneffeminate boys and families, it had been found that the early life experiences of the effeminates include: 1. Parental fostering of, or unconcern about, effeminate behavior during the earliest years. 2. Lack of psychological separation from the mother, caused in part by excessive holding of the baby. 3. Maternal overprotection and inhibition of rough-tumble play with other boys. 4. Greater availability of female than male companions and playmates in the early years. Gender identity disorders 118 5. Actual or emotional unavailability of a consistent adult male role model. 6. Strong paternal rejection of the young boy. 7. Unusual physical beauty, which may influence adults to treat the boy as a girl. There is expert consensus that markedly effeminate boys are at higher risk of developing one of these-three gender identity disorders: transsexualism, transvestism, and homosexuality. Preadolescence and adolescence Normal developmental behavior in this period that most likely gives rise to sexual identity problems is homoerotic play. Mutual masturbation is the most common homoerotic act of both sexes, but any homosexual behavior, e. g., fellatio, cunnilingus, may occur normally at this phase. Puberty and early adolescence bring to light several organic and intersex conditions that usually are not evident in childhood. Turner’s syndrome is finally diagnosed because of the complete absence of puberty. Exogenous estrogen will produce the external physical changes of puberty and feminine appearance. These girls need serious, repeated reassurance that their sexual function can be entirely normal and that they can be mothers by adoption. Failure to menstruate, even though other pubertal changes have taken place, can have many causes; one is vaginal agenesis. In some girls, this is a relatively simple consequence of incomplete Mullerian ducts development, and the girl has normal ovaries, tubes and uterus; in others there is faulty development of the other internal sex organs as well. Whether reproductive capacity can be established depends on many factors, but vaginal agenesis is relatively simple in terms of healthy sexual identity. These patients have been reared as girls and, in the absence of sexually pathogenic influences, have a normal female core gender identity, heterosexual orientation and feminine sex role preferences. Vaginoplasty is usually safe and successful and permits full sexual function, includig orgasm. Gender identity disorders 119 A more striking intersex condition that is sometimes revealed when menarcheal failure and vaginal agenesis are investigated is the androgen insensitivity (testicular feminizing) syndrome. In the fully developed form of this familial disorder, the body cells of a genotypic male are completely insensitive to androgen. Because of cellular insensitivity to androgen, the external genitaliadifferentiate as female, the normal result of a lack of fetal androgen during the sixth to fourteenth weeks, the infant is born with normal looking female external genitalia and is assigned and reared as a girl. There are no ovaries or other female reproductive organs, and abdominal testes produce normal amounts of androgens. At puberty the estrogen normally produced by the testes and the adrenal glands cause breast growth and other female body characteristics-a phenotypically normal looking pubescent girl. Only laparotomy prompted by lack of a vagina reveals the absence of other female structures and the presence of testes. Although medically dramatic, this condition causes few major problems of sexual identity. The patient will be infertile and will require vaginoplasty with administration of exogenous estrogens after the testes are removed. However, normal female sexual identity has already occurred, and if the patient can be helped to resolve the emotional trauma of discovering her lack of reproductive potential, sexual identity problems generally do not occur. Because body preoccupation is painfully intense in early adolescence, anomalous genitalia or atypical secondary sex characteristics can cause not only sexual identity problems but even psychotic depression and suicide. That is why in cases of true hermaphroditism, all organs of the sex opposite to the sex of rearing should be surgically extirpated, so that the physician can honestly assure the adolescent that no contradictory sex organs exist. The gender dysphoria of transsexualism reaches a peak of painful intensity in early adolescence. Adult body configuration and genitalia intensify the rejection of what the individual considers to be the ''wrong'' anatomy. Adult sex drive coupled with the impossibility of functioning as members of the sex to Gender identity disorders 120 which they feel they ''really'' belong are deeply frustrating realities that transsexuals cannot deny. Some early-adolescent boys surreptitiously obtain and use estrogens to effect body changes. Some already begin to press for sex-reassignment surgery. Request for sex reassignment surgery increase in late adolescence and are sometimes desperate. Delayed or absent puberty caused by organic pathology, especially in boys, is commonly not discovered until late teens. The etiology varies, it is often untreatable and it sometimes is life compromising. As in other conditions not evident in childhood, normal rearing can protect the child from major disorders of sexual identity, but not from the trauma to his sense of male adequacy caused by failure to achieve puberty or to look like or function sexually as a man. Of course any treatable condition should be treated immediately, but diagnosis and treatment of delayed sexual maturation is highly complex and still experimental. Therapy Education and explanation often remain the physician's most helpful tools in treating sexual identity problems. Helping the child or adolescent and the adults in his life to understand what is happening, and why, often makes therapy unnecessary if the problem has not yet become internalized or fixed. The younger the child, the more necessary it is to involve the entire family in therapie for a sexual identity problem. The principle of earliest intervention is axiomatic in medicine and nowhere more so than in intersex conditions. Because many components of sexual identity are fixed or most strongly influenced early in life, the sooner that ambiguities can be resolved, especially in the parent's minds, and decisions made about sexual assignment and rearing, the more troublefree will be the development of the child's sexual identity. Ego-dystonic homosexuality 121 Chapter 7 Ego-dystonic homosexuality Egodystonic sexual orientation is an egodystonic condition. The World Health Organization lists egodystonic sexual orientation in the ICD-10, under "Psychological and behavioral disorders associated with sexual development and orientation". The WHO describes it thus: The gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioral disorders, and may seek treatment in order to change it. (F66.1) The WHO applies the following note to the entirety of part F66: "Sexual orientation by itself is not to be regarded as a disorder." Ego-dystonic homosexuality was included in the American Psychiatric Association's DSM-III but it was removed from DSM-III-R in 1987, because "almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic". But psychically distressing ("ego-dystonic") homosexuality appears in DSM-IV. Under "Sexual Disorder Not Otherwise Specified," there is the diagnosis "Persistent and marked distress about sexual orientation". This category includes distressing homosexuality and distressing heterosexuality.6 DSM-IV doesn't use "egodystonic" to name distressing homosexuality; indeed, it doesn't even use "homosexuality" to name it. Probably 1 to 3 per cent of female, and 3 to 6 per cent of male, adults are predominately or exclusively homosexual, and perhaps as many as 33 per cent of all people will have had some kind of homosexual activity during their lives. Available evidence indicates that the biologically normal newborn infant probably has an innate neuropsychological and neuroendocrinological bias toward an eventual heterosexual orientation. If this point of view is accurate, it means that, in Ego-dystonic homosexuality 122 the absence of biological abnormality, various kinds of unnatural influences are necessary to disrupt heterosexual orientation permanently. Probably adult homosexuality can result from many different influences-some known, some speculated, some still unknown. One possibility is that there is an alteration or aberration in the fetal hormonal influences that organize the embryonic central nervous system for ultimate heterosexual arousal and responsivety. The altered developmental biology could reverse that bias or diminish or neutralize its strength. Although there is no direct empirical evidence for this as a basis of homosexuality in man, experimental evidence on primates and other mammals, and clinical evidence from studies on human endocrinopathies and genetic disorders suggest that some such altered biology during fetal development may play a significant role in some or all gender role and orientation deviation. A known cause of homosexuality in some adults is unconscious conflict arising from postnatal rearing influences that make heterosexuality unappealing or unattainable. The causes and psychodynamics of such conflicts are varied. There is no doubt that such conflicts are etiologic in homosexual psychiatric patients who are unhappy with their homosexuality. It is not known whether or what extent they are etiologic in the much larger nonpatient homosexual population, although several researchers typical conflicts in nonpatient research population also. If aberrant fetal biology plays no role, fairly powerful and chronic influences are probably necessary to deflect the innate heterosexual bias. If fetal biology is aberrant, a child may have less resistance to relatively minor pathogenic experiences of the sort that might also be found in the histories of many heterosexuals. Homosexuality that arises from interpersonal ad intrapsychic conflict may be considered an adaptive response to the psychological repudiation or avoidance of heterosexuality. There are many social learning theories that explain preferential adult homosexuality on the basis of various Ego-dystonic homosexuality 123 postnatal learning and socializing influences and that minimize the importance of unconscious conflict. But as general explanation, these theories lack credibility because of the onesided position they take in the nature/nurture interaction, neither extreme of which is scientifically tenable. Homosexuality does not necessarily imply diminished function in other areas of life or even an impoverished sex life. There are more homosexuals who feel satisfied and are productive or creative in all walks of life than homosexuals who cannot function effectively because of emotional conflict over their sex orientation. If aberrant fetal biological development is found to be the basis of some homosexuality, such cases could possibly be considered one of the sexual anomalies. Perhaps only that unknown proportion of cases of homosexuality that are traceable to identifiable interpersonal and intrapsychic disturbances of psychosexual development can be assumed to follow the medical psychiatric model of illness. Even in these cases, determining what to do about the problem is the sole right and choice of the individual, except in specific instances of misuse against others. A broad range of homosexual persons and homosexual behaviors, perhaps a majority, probably fall outside such a model of illness and reflect a wide variety of motives, origins, and individual and cultural meanings. Varieties of homosexual expression Preferential or obligatory homosexuality – elicits the most interest and is subject to the most bias and misunderstanding, even though only minority of persons who have ever had any homosexual experiences fall into this category. These people can respond erotically only to members of the same sex, or they are more readily and pleasurably aroused by members of the same sex even when opposite sex partners are available and willing. Ego-dystonic homosexuality 124 Developmental homoerotic activity is homosexual in terms of object choice, but it is usually not prognostic of adult homosexuality. It may occur at any or all immature developmental stages in both boys and girls, Kinsey found that 33 per cent of women and 50 per cent of men recalled preadolescent or adolescent homoerotic play. Pseudohomosexuality – has been described primarily in males but complementary motivation may operate in females. The primary conflicts of pseudohmosexuals concern dependency and power, which they associate respectively with femininity and masculinity. If they perceive themselves as week or inadequate compared to other men, they unconsciously assume that they are nonmasculine, which equals feminine, which equals homosexual. The most common symptom of this condition is pseudohomosexual anxiety or panic, often when the man finds himself in an all-male environment or when some life situation, such as rejection by a sex partner or losing out to another man in the competitive job market, is perceived as a blow to masculine self-esteem. Sometimes these men may act out these conflicts in occasional homosexual behavior, either to test out their perceptions of themselves or in passive resignation to what they perceive as their fate. These experiences are usually not satisfying and are often severely anxiety-producing. But pseudohomosexuality sometimes develops into a pattern of exclusive behavior through restricted learning and socialization and through the absence of emotional freedom to explore heterosexuality. The childhoods of these men may have been characterized by passivity and isolation from peers, but few remember wishing to be girls or feeling early erotic attraction to males. Pseudohomosexuality is a risk for people of either sex whose developmental conflicts gave them an inadequate sense of masculinity or femininity. Ego-dystonic homosexuality 125 Situational homosexuality – is that which occurs among preferential heterosexuals in enforced single-sex envirenment, such as some armed forces assignments. Usually these people revert later to their heterosexual patterns and no problem is presented to the physician unless the experience precipitates a pseudohomosexual panic. Exploitative homosexuality – is that in which people with physical and social power, as in an inmate subculture, force weaker or more submissive people to be sexual objects, usually through anal intercourse but also through fellatio. While there may be unconscious sexual identity conflicts in the exploiters, these are essentially acts of violence in which the penis is used as a weapon or symbol of dominance, as in heterosexual rape. Sexual exploitation motivated by power, dominance and underlying rage also occurs in women’s prisons. Male exploiters typically do not consider themselves homosexual and would rarely seek therapy for a sexual conflict. Enforced homosexuality – is the complement of exploitative homosexuality. While there is a general and probably accurate consensus that primarily erotic homosexual preference cannot be induced in anyone in the absence of pre-existing sexual orientation conflicts, there is one report of preferential homosexuals who claim never to have had homosexual tendencies before being forced in prison to be regular sexual objects. Treatment More professionals consider treatment in appropriate for homosexuals who are content with their preference. However, some homosexuals are very distressed about their homosexual feelings and seek treatment with the aim of acquiring the capacity to love a woman, to experience heterosexual gratification, and to enjoy a normal family life. Many clinicians Ego-dystonic homosexuality 126 consider these persons eminently deserving of a trial of treatment. The published data on shift in orientation among homosexuals of both sexes after psychoanalysis or psychoanalytically-oriented psychotherapy are remarkably consistent: about one-third or more of those patients who wish to change and who remain in treatment become exclusively heterosexual, and about one-third more become bisexual or preferentially heterosexual. A somewhat higher reversal rate has been reported with the use of psychoanalytic group therapy in groups composed entirely of homosexuals. Evaluation of sexual disorders 127 Chapter 8 Evaluation of sexual disorders The first step in the treatment of sexual disorders is a thorough evaluation. The physician must clarify the chief complaint, establish an accurate diagnosis and determine the etiology of the problem. The latter requires two kinds of data: the differential diagnosis between organic and psychological causes and an analysis of the psychological elements of the problem. Not all patients whose chief complaint is of a sexual nature should undergo an immediate evaluation and assessment of their sexual lives. Sometimes sexual problem is in fact a sign of a serious mental disorder. Patients with psychosis, mania, and borderline conflicts may present with sexual symptom. That is why it is important to evaluate entire person when looking at sexual issues. When a major psychiatric illness is suspected, it is vital to address it before limiting attention to sexual issues. An important early step in the evaluation of every sexual complaint is to take a thorough drug and alcohol history. Although alcohol is the most commonly abused substance that interferes with sexual performance, most of the “street drugs” (cocaine, heroin, amphetamines, sedatives) can have a deleterious effect on sexual performance. Further, there are a variety of legitimately prescribed medications that influence sexual physiology. Here are some of these medicaments (Table 1): Conditions that suggest that a patient’s sexual disorder is not substance related-even though the patient may be using a potentially problematic drug-include symptoms whose onset precedes the use of the drug, symptoms that persist over a month after completely stopping use of the drug, and a prior history of sexual dysfunction while not using the substance in question. Evaluation of sexual disorders 128 Table 1 Drug name Paroxietine (Paxil) Perphenazine (Trilafon) Phenelzine (Nardil) Prazosin (Minipress) Propranolol (Inderal) Protriptyline (Vivactil) Ranitidine (Zantac) Reserpine Sertraline (Zoloft) Spironolactone (Aldactone) Sulfasalazine (Azulfidine) Tamoxifen (Nolvadex) Testosterone Thiazide diuretics Thioridazine Thiothixene Trazodone (Desyrel) Potential effect Decreased desire; delayed or no orgasm Decreased or no ejaculation Impotence; retarded or no ejaculation; delayed or no orgasm; priapism Impotence; priapism Loss of desire; impotence Loss of desire; impotence; painful ejaculation Loss of desire; impotence Decreased desire; impotence; decreased or no ejaculation Decreased desire; retarded or no orgasm Decreased desire; impotence Impotence Priapism Priapism Impotence Impotence; retrograde, painful, or no ejaculation; priapism, anorgasmia Spontaneous ejaculations; impotence; priapism Priapism; clitoral priapism; increased desire; retrograde or no ejaculation; anorgasmia The following lists of the main areas of inquiry in a sexual evaluation cover all the bases. Basic information Nature and development of the sexual difficulty Evaluation of sexual disorders 129 Emotional reaction to the problem Understanding of its genesis Attempts to resolve it Psychiatric history Previous illness, therapy, hospitalization Previous psychological testing Physical health Medical history, illnesses, disabilities Medicines taken Drug and alcohol use Motivation for treatment History specific to couples How they met, what attracted them to each other Initial sexual experience together Changes in the nature of their sexual experience, wanted or unwanted, over the course of the relationship Method of and satisfaction with birth control What can not be talked about in the relationship Sexual history Family, cultural, religious background concerning sex Early sex play, education Discovery of arousal Initial shared experiences, same and opposite sex Abuse, sexual or physical Adolescence Dating Sexual experiences: petting, mutual orgasm, intercourse Body image, eating disorders Masturbation How often, how done Fantasies Other sexual partners Before present relationship (if any) During present relationship (if any) Feelings about sex not already discussed Evaluation of sexual disorders 130 Likes and dislikes Wishes and fears What is important about sex Orgasm Closeness Verbal, nonverbal communication Feelings about partner(s) not already discussed Once the basic information has been gathered, it is time to consider medical examination and psychological testing. A medical examination should be done in the vast majority of sexual dysfunction cases regardless of the general state of the patient’s health. There are variety of medical conditions, from diabetes to sickle-cell anemia, that can cause alteration of sexual function, and it is only through a thorough medical examination that some of them can be diagnosed. Medical illness can influence each and every stage of sexual function. One of most serious errors is to overlook a medical condition that causes a sexual disorder. Not only would any psychological treatment the patient receives be limited in its effect, but there is also the possibility that an unrecognized illness would progress and cause irreversible harm to the patient in a situation where it could have been diagnosed and treated. There are two important clues that would suggest that a medical condition might be causally related to a sexual dysfunction. First is a temporal association between the onset or exacerbation of an illness and the appearance or exacerbation of a sexual dysfunction. Second is an alteration in sexual function that goes against usual physiological function, as when a twenty-year-old man develops impotence without any stressors that might argue for psychological etiology. Some sexual disorders are more likely to be caused by medical conditions than others. For example, pain with sexual interaction is a symptom that especially requires a complete physical examination. Vaginismus can also be related to variety of physical abnormalities of the female genitourinary tract. Withdrawal from alcohol or opioids is known to be related to Evaluation of sexual disorders 131 the sudden appearance of premature ejaculation. Other sexual disorders frequently associated with organic causes are impotence, low or absent libido, secondary anorgasmia in males and females, seconadary retarded ejaculation. Illness and drugs must be carefully ruled out when evaluating patients, especially those over the age of 40, with complaint that carry a high risk of organicity. If the symptom is clearly situational, psychogenecity is established and, conversely, drugs and illness are ruled out as causative factors. Since sexual symptoms frequently result from interplay between organic and psychological factors, an attempt must be made to sort out the relative contributions of each. Organic disease can occur in people with previous psychological problems and their anxious response to even mild organic deficiencies will complicate the clinical picture enormously. Therefore, for the management and rehabilitation of patients with organic or partial organic problems, the assessment of psychological reactions is extremely important. The partners responses and attitudes are of equal importance in determining the ultimate clinical picture and must be carefully noted during the evaluation. Psychological testing is very helpful in the evaluation of patients with sexual symptoms. This is particularly true for those individuals with dual diagnoses, personality disorders, potentially factitious disorders, and the paraphilias. The personality structure of such patients is often complicated, and it is consequently difficult to evaluate their capacity to engage in therapy. Psychological testing can help sort out the degree of psychopathology, the motivation to get better, and the nature of hidden conflicts. Further, psych testing is useful with those individuals who have difficulty communicating verbally because of depression, shyness, or anxiety. When making diagnosis of a sexual problem, it is important to remember that notions of what is sexually “normal” vary from culture to culture and family to family. Socioeconomic, educational, and religious background strongly Evaluation of sexual disorders 132 influence an individual’s notions of sexual deviance, standards of performance, and gender role behavior. Sexual mores change from generation to generation. Sexual symptoms can appear in a variety of situations. As we have already mentioned, sexual apathy and even anhedonia (lack of any pleasurable feelings) can accompany severe depression. Inappropriate sexual behavior can be seen in acute manic episodes. When making a diagnosis of a sexual disorder, you must first determine that the sexual symptoms are not better accounted for as an aspect of another psychiatric disorder. Furthermore, for a problem to classify as a diagnosable sexual dysfunction it must cause marked distress or interpersonal difficulty. Thus individual who tells you that he is not at all interested in sex and is perfectly content with his celibate, abstinent state, does not have a diagnosable disorder of desire. Formal DSM diagnoses are only the first step in understanding the nature of a problem. An understanding of patients with sexual difficulties should include a formulation of the psychodynamics of each individual and a description of the nature of the relationship between the partners. We must try to understand not only how the disorder got to be the way it is but also what function it serves in the psychic and interpersonal economy of the patient, what other conflicts and problems trouble the patient, and the ways in which the patient habitually solves or fails to solve problems both in the inner and the outer worlds. Male infertility Causes of male infertility are divided into three main groups: 1. Pre-testicular 2. Testicular 3. Post-testicular 1. Pre-testicular – disorders of hypothalamuses and hypophysis (congenital or occurred): Hypogonadotropic hypogonadism, prolactinome, isolated deficiency of FSH, isolated deficiency of Evaluation of sexual disorders 133 LH etc. This disorders result in impairment of spermatogenesis regulation. 2. Testicular - two types are distinguished: a) Chromosomal (Kline Felter syndrome Noonan syndrome, digenesis of gonads, y-chromosome mycrodeletion syndrome) b) No chromosomal (varicocele, hydrocele, cryptorchysm, trauma of testis, orchitis, Sertoli-cell-only syndrome, chemiotherapy, radiotherapy). These disorders result in the impairment of spermatozoa production. 3. Post-testicular common disorders, urinogenital inflammatory processes, being passed on from infections (STI) and immunological impairments. These disorders lead to disturbance of motility of spermatozoa and seminal duct opturation. Treatment of sexual disorders 134 Chapter 9 Treatment of sexual disorders Treatment of sexual disorders should be directed to their causes, including deep seated sexual conflicts developed during psychosexual development. It is necessary to take into account that sexual inferiority affects the psyche of person, and vicious circle is formed which deepens the pathological process. Interpersonal relations between sexual partners worsen and conflict situations become more frequent. All this proves that the psychotherapy plays a central role in correction of sexual disorders. If necessary psychotherapy combines with other forms of treatment: pharmacotherapy, physiotherapy. The important part of treatment is the elimination of bad habits: alcohol abuse, smoking, formation of a normal dietary ration, normalization of sleep. It is desirable to distract patient’s compulsive thoughts about own sexual inferiority towards other essential interests, mental and physical job. Psychotherapy of sexual disorders Following forms of psychotherapy are common in treating sexual dysfunctions: 1. Hypnosis The purpose of the hypnosis is to expose the patient to conforming suggestion during a hypnotic sleep. 2. Adlerian therapy Adlerian Therapy is a growth model. It stresses a positive view of human nature and that we are in control of our own fate and not a victim to it. We start at an early age in creating our own unique style of life and that style stays relatively constant through the remained of our life. We are motivated by Treatment of sexual disorders 135 our setting of goals; how we deal with the tasks we face in life, and our social interest. The therapist will gather as much family history as he could. He will get an idea of the clients' past performance. These data will be used in setting goals for the client. This will help make certain the goal is not to low or high, and that the client has the means to reach it. The goal of Adlerian therapy is to challenge and encourage the clients' premises and goals. To encourage goals that are useful socially, and to help them feel equal. These goals include any component of life, parenting skills, marital skills, ending substance-abuse, and most anything else. The therapist will focus on and examine the clients' lifestyle and the therapist will try to form a mutual respect and trust for each other. They will then mutually set goals and the therapist will provided encouragement to the client in reaching their goals. The therapist may also assign homework, setup contracts between them and the client, and make suggestions on how the client can reach their goals. 3. Behavior therapy Behavior therapy is always undergoing refinement and uses learning to overcome specific behavioral problems. In this type of therapy it is believed that behaviors are learned, that we are a product of our environment. Focus will be on present and overt behavior. In this type of therapy it is believed that reinforcement and imitation teaches normal behavior and that abnormal behavior is a direct result of defective learning. Therapy will be based on learning theory. The therapy will include a treatment plan, the goals of the treatment will be laid out up front, and the outcome expected from the therapy will be set right up front too. To eliminate unwanted behaviors you need to learn new behaviors. This may include assertion, behavioral rehearsal, coaching, cognitive restructuring, desensitization, modeling, reinforcement, relaxation methods, self-management, or new social skills. Both client and therapist need to take an active role in learning the more desired behavior. Treatment of sexual disorders 136 4. Existential therapy Focuses on freedom of choice in shaping one's own life. Teaches one is responsible to shape his / her own life and a need for self-determination and self-awareness. The uniqueness of each individual forms his / her own unique personality, starting from infancy. Existential therapy focuses on the present and on the future. The therapist try's to help the client see they are free and to see the possibilities for their future. They will challenge the client to recognize that he / she themselves were responsible for the events in their life. This type of therapy is well suited in helping the client to make good choices or in dealing with life. 5. Gestalt therapy Gestalt therapy integrates the body and mind factors, by stressing awareness and integration. Integration of behaving, feelings, and thinking is the main goal in Gestalt therapy. Client's are viewed as having the ability to recognize how earlier life influences may have changed their life's. The client is made aware of personal responsibility, how to avoid problems, to finish unfinished matters, to experience thing in a positive light, and in the awareness of now. It is up to the therapist to help lead the client to awareness of moment by moment experiencing of life. Then to challenge the client to accept the responsibility of taking care of themselves rather then excepting others to do it. The therapist may use confrontation, dream analysis, dialogue with polarities, or role playing to reach their goals. This may include treatment of crisis intervention, marital / family therapy, problem in children's behavior, psychosomatic disorders, or the training of mental health professionals. 6. Person-centered therapy Person-centered therapy gives more responsibility to the client in their own treatment and views humans in a positive manner. Founded by Carl Rogers in the 1940's. Rogers had Treatment of sexual disorders 137 great faith that we could and would work out our own problems. The therapist will move the client towards self awareness, helping the client to experience previously denied feelings. They will teach the client to trust in themselves and to use this trust to find their direction in life. The person-centered therapist makes the client aware of their problems and then guilds them to a means of resolve them. The therapist and client must have faith that the client can and will find selfdirection. The therapy focus on the here and how. They motivate the client in experiencing and expressing feelings. The person-centered therapist believes that good mental health is a balance between the ideal self and real self. This is where the problem lies, the result of difference between what we are and what we wish to be causes maladjusted behavior. 7. Psychoanalytic therapy Psychotherapy focuses on the unconscious and believes it influences human behavior. It is believed that a person is driven by aggressive and sexual impulses. It focuses mainly on the first six years of human life and how the events of this time period determine later personality. Repressed conflicts from childhood lead to personality problems later in life. Anxiety is a direct result of the repression of conflicts. Psychotherapist believes that the unconscious motives along with unresolved conflicts lead to maladapted behavior. They believe that to develop a normal personality, a person successful go through five psychosexual stages: Oral - Birth to 1 year: Sucking. Anal - 1 to 3 years: Holding and releasing urine and feces. Phallic - 3 to 6 years: Pleasure in genital stimulation. Latency - 6 to 11 years: Sexual instincts develop. Genital - Adolescence: Sexual impulses return. Inadequate resolution of any of these stages leads to flawed personality development. The client with the therapist help will make repressed conflicts conscious, making the Treatment of sexual disorders 138 unconscious conscious. Making these conflicts conscious to the client will help them in working through them, awareness. Psychotherapy is not useful in clients that are selfcentered, impulsive, or severely psychotic. The therapist should have extensive training and expense. The therapist when working with minorities should focus on the client’s family dynamics. Treatment will be long term. 8. Rational-emotive and Cognitive-behavioral Therapy Rational-emotive therapy is a highly action-oriented and deals with the client's cognitive and moral state. This therapy stresses the client’s ability of thinking on their own and in their ability to change. The rational-emotive therapist believes that we are born with the ability of rational thinking but that my fall victim to irrational thinking. They stress the clients ability to think, in making good judgments, and in taking action. The therapist will use directed therapy. The therapist believes that a neurosis is a result of irrational behavior and irrational thinking. The Rational-emotive and Cognitive-behavioral therapist believe the clients problems are rooted in childhood and in their belief system, that was formed in childhood. Therapy will include method is solving and dealing with emotional or behavior problems. The therapist will help the client to eliminate any self-defeating outlooks they may have and to view life in a rational way. The therapist will never have a personal relationship with the client. The therapist will think of the client as a student and themselves as the teacher. Male reproductive function Access Throughout spermatogenesis multiplication, maturation and differentiation of germ cells results in the formation of the male gamete. The understanding of spermatogenesis needs detailed information about the organization of the germinal epithelium, the structure and function of different types of germ cells, endocrine and paracrine cells and mechanisms, Treatment of sexual disorders intratesticular and spermatogenesis. 139 extratesticular regulation of Introduction Starting from a self-renewing stem cell pool, male germ cells develop in the seminiferous tubules of the testes throughout life from puberty to old age. The complete process of germ cell development is called spermatogenesis. The products of spermatogenesis are the mature male gametes, namely the spermatozoa. Spermatogenesis depends on intratesticular and extratesticular hormonal regulatory processes and functions of the intertubular microvasculature, the Leydig cells and other cellular components of the intertubular space. Organization of the testis The human testes are two organs of the shape of rotation ellipsoids with diameters of 2.5 × 4 cm engulfed by a capsule (tunica albuginea) of strong connective tissue. Thin septula testis divide the parenchyma of the testis in about 370 conical lobules. The lobules consist of the seminiferous tubules and intertubular tissue, containing groups of endocrine Leydig cells and additional cellular elements. The seminiferous tubules are coiled loops . Their both ends open into the spaces of the rete testis . The fluid secreted by the seminiferous tubules is collected in the rete testis and delivered to the excurrent ductal system of the epididymis. Structure of the seminiferous tubule The seminiferous tubule consists of the germinal epithelium and the peritubular tissue.The germinal epithelium consists of cells that include different developmental stages of germ cells, namely spermatogonia, primary and secondary spermatocytes and spermatids. These are located within invaginations of Sertoli cells. The prismatic Sertoli cells are connected by specialized zones of tight junctions of cellular membranes separating the germinal epithelium . Sertoli cells, Treatment of sexual disorders 140 investigated in histological sections, exhibit increasing amounts of lipid droplets in correlation to advanced age being an indicator of the "biological clock" of the testis. Further functions are attributed to Sertoli cells: 1. Sustentacular and nutritive functions for the germ cells. 2. Organization of the delivery of mature spermatids into the tubular lumen (spermiation). 3. Production of endocrine and paracrine substances for the regulation of spermatogenesis. 4. Secretion of androgen binding protein (ABP) for the maintenance of epithelia of the excurrent duct system. 5. Interaction with the intertubular endocrine Leydig cells. Spermatogenesis Spermatogenesis is the process by which a complex, interdependent population of germ cells produces spermatozoa. Spermatogenesis begins at puberty after a long preparatory period of "prespermatogenesis" in the fetus and the infant. Three major stages can be distinguished: spermatogoniogenesis, maturation of spermatocytes and spermiogenesis, which is the cytodifferentiation of spermatids. Spermatogonia multiplicate continuously in successive Mitoses in to spermatocyt. Spermatocytes divide in meiosis to spermatids. Mature spermatids are released from the serminal epithelium and the free cells are called spermatozoa. The delivery of mature spermatids from the germinal epithelium is managed by the Sertoli cells . Components of the intertubular space The intertubular space of the human testis contains the microvasculature, the endocrine Leydig cells, nerve fibres, macrophages, fibroblasts, further connective tissue cells and lymph vessels. Leydig cellsare prominent cells of the intertubular space. They constitute groups surrounding the capillaries. Leydig cells produce and secrete among others androgens, the male sex hormone, the most well known of which is Treatment of sexual disorders 141 testosterone. Testosterone activates the hypophyseal-testicular axis, the masculinization of the brain and sexual behaviuor, the initiation, processing and maintenance of spermatogenesis, the differentiation of the male genital organs and secondary sex characteristics. Recent investigations elucidated that the Leydig cells possess neuroendocrine properties in addition to their endocrine functions. There is evidence that Leydig cells express serotonin, different antigens characteristic for nerve cells as well as neurohormones, neuropeptides and numerous growth factors and their receptors. Kinetics of spermatogenesis Spermatogenesis commences during puberty and continues throughout life and until old age because of the inexhaustible stem cell reservoir. An abundance of germ cells are developed and delivered from the seminiferous tubules. The process of spermatogenesis is highly organized: Spermatogonia divide continuously, in part remaining spermatogonia, in part giving rise to spermatogenesis. Originating from dividing spermatogonia, cell groups migrate from the basal to the adluminal position of the germinal epithelium. Cell groups of different development are met in a section of a seminiferous tubule and contribute to the typical aspect of the germinal epithelium. Six of these typical aspects were described in the human testis as "stages of spermatogenesis". The development of an A type spermatogonium up to mature spermatids requires 4,6 cycles, e.g. 74 days. The mature spermatids delivered from the germinal epithelium as spermatozoa are transported through the epididymal duct system during additional 12 days. Therefore, 86 days at the minimum must be calculated for a complete spermatogenetic cycle from spermatogonium to mature spermatozoa. Spermatozoa with their unique shape are suitable for the transport to the female gamete. For this reason the nucleus of the spermatozoon is condensed, covered by an acrosome for Treatment of sexual disorders 142 establishing contact to the female gamete and connected with a flagellum for progressive motility. The diameter of the head of spermatozoon is 4–5 μm, the diameter of the flagellum is of 1–2 μm and the length of the spermatozoon measures 60 μm. Spermatozoa acquire their competence of motility during the transport throughout the epididymal ducts. Only 25% of the germ cells reach the ejaculate and more than half of them are malformed. Therefore, only 12% of the spermatogenetic potential is available for reproduction. Regulation of spermatogenesis The process of spermatogenesis in the seminiferous tubules is maintained by different internal and external influences. The Leydig cells in the intertubular space secrete testosterone and additional neuroendocrine substances and growth factors. These hormones, transmitters and growth factors are directed to neighbouring Leydig cells, to blood vessels, to the lamina propria of the seminiferous tubules and to Sertoli cells. They are involved in maintenance of the trophic of Sertoli cells and the cells of peritubular tissue; they influence the contractility of myofibroblasts and in that way regulate the peristaltic movements of seminiferous tubules and the transport of spermatozoa. They also contribute to the regulation of blood flow in the intertubular microvasculature. The local regulation of spermatogenesis in the testis requires the well known extratesticular stimuli provided by the hypothalamus and hypophysis. Pulsatile secretion of gonadotropin releasing hormone (GnRH) of the hypothalamus initiates the release of luteinizing hormone (LH) of the hypophysis. As a result of this stimulus Leydig cells produce testosterone. Testosterone influences not only spermatogenesis in the seminiferous tubules of the testis but is also distributed throughout the body and provides feedback to the hypophysis related to the secretory activity of Leydig cells. Stimulation of Sertoli cells by the pituitary follicle stimulating hormone (FSH) Treatment of sexual disorders 143 is necessary for the maturation of germ cells. The Sertoli cells itself Secrete inhibin in the feedback mechanism directed to the hypophysis. The extratesticular influences are a necessary basis for the function of intratesticular regulations. Disturbances of spermatogenesis Proliferation and differentiation of the male germ cells and the intratesticular and extratesticular mechanisms of regulation of spermatogenesis can be disturbed at every level. This may occur as a result of environmental influences or may be due to diseases that directly or indirectly affect spermatogenesis. In addition, different nutrive substances, therapeutics, drugs, hormones and their metabolites, different toxic substances or x-radiation may reduce or destroy spermatogenesis. Finally, also a rather simple noxe as increased temperature reduces the spermatogenetic activity of the testis. Under these negative influences the testis answer rather monotonuous by reduction of spermatogenesis. This may be expressed in the reduced number of mature spermatids, in malformation of spermatids, missing spermiation, disturbance of meiosis, arrest of spermatogenesis at the stage of primary spermatocytes, reduced multiplication or apoptosis of spermatogonia. If spermatogonia survive then spermatogenesis may be rescued. Otherwise spermatogenesis ceases and shadows of seminiferous tubules remain. 9. Transactional Analysis Transactional analysis focus on the clients cognitive and behavior functioning. The therapist helps the client evaluate their past decisions and how those decisions affect their present life. They believe self-defeating behavior and feelings can be overcome by an awareness of them.The therapist believes that the clients personality is made up of the parent, adult, and child. They believe that it is important for the client Treatment of sexual disorders 144 to examine past decisions to help their make new and better decisions. 10. Sex therapy The sex-therapy combines methods of behavioral psychotherapy, psychodynamic analysis and interpersonal attitudes. Pharmacological therapy of sexual disorders Pharmacotherapy has a large appliance in treatment of sexual disorders both in men and in female. CNS stimulators, psychotropic drugs, biogenic stimulators, prostaglandins, vitamin therapy, immunomodulators, local anesthetics, hormonal preparations such as gonadotropins, androgens and their synthetic analogues, anabolic steroids and specialized sexological drugs are used. The choice of medicine at sexual disorders is linked to the cause of disease, its duration, age of the patient, presence of concomitant somatic or psychic diseases, etc. According to this all medicinal treatment can be etiological, pathogenetic or somatic. In the treatment of sexual disorders sanatorium-and-spa treatment plays the great role. The physiotherapeutic treatment: the electrophototherapy, taking baths, fangotherapy, therapeutic massage, exercise therapy have salutary effect on organism particularly on the nervous, psychic and sexual systems. Acupuncture is also efficient. It is wrong to neglect methods of non-traditional medicine. Erectorotherapy is used in erectile dysfunction (outer prothetics), therapy by local negative pressure are often used. In the case of ineffective conservative therapy of an erection’s disorder resort to surgical methods which, as a rule, have three directions: 1. Revascularization of cavernous bodies of the penis, 2. Decrease of venous flow of cavernous bodies Treatment of sexual disorders 145 3. Endoprosthesis replacement of the penis (endofaloprosthesis): The results of treatment of sexual disorders are satisfactory in the case when the complex of regulating and therapeutic methods is used including also the partner. Tests 146 Tests 1. The stage of sexual libido defined as a) forming sexual identity b) striving for being in the focus attention c) striving for erotic contacts such as hugging and kissing d) forming sexual fantasies enhance with sexual intercourse scenes 2. Criteria of definition males’ sexual constitution is without a) index of trochanter b) maximal excesses c) the age of first masturbation d) becoming pubic hairy e) the age of first ejaculation 3. The type of Obsessive-Compulsive masturbation define as a) obsessive character b) beginning before arising sexual libido c) beginning after the period of mature sexuality d) manipulations on sexual organs which arise erection 4. Sort out three methodological approaches of sexology by order of priority a) monodisciplinary b) multidisciplinary c) interdisciplinary a) a,b,c b) c,a,b c) c,b,a 5. Particularity of sexual organs’ blood vessels a) one a. dorsales penis is accompanied by two vv. dorsales penis b) one v. dorsales penis is accompanied by two aa. dorsales penis c) small smooth structures (pollsters) located only on the penile vessels walls 6. The main male desire’s hormone is a) prolactine b) estrogens c) testosterone d) thyroxine Tests 7. Which is typical for dispareunia a) sensation of itching b) sensation of burning c) recurrent and persistent pain feeling during sexual intercourse d) spasm of the musculature of the outer third of the vagina e) insufficient lubrication 8. Contractions of the striated muscles are a) 0.8 per second b) 0.6 per second c) 0.3 per second 9. The organic causes of erection dysfunction are without a) diabetes Mellitus b) hypogonadismus c) alcohol polineuropathia d) asthenisation 10. Which of followed disorders can’t be cause of retrograde ejaculation a) diabetes Mellitus b) the state after prostatectomy c) mental disorders 11. The brain center’s of ejaculation are a) frontals lobes b) temporally lobes c) paracentral lobes 12. Ejaculation before emission called a) ejaculation preccox b) ejaculation ante portas c) ejaculation tarda 13. When is chlorethile blockade using a) retrograde ejaculation b) premature ejaculation c) syndrome of unejaculation 147 Tests 14. Man who exposes his genitals to a strangers called a) voyeurism b) exhitionism c) fetishism 15. What is the fetishism a) preference for sexual activity with animals b) preference for nonliving objects of opposite sex c) a man who wears opposite sex’s clothes d) man who exposes his genitals to a strangers e) preference for repetitive sexual activity with prepubertal children 16. The age of menstrual cycle of the middle constitutions’ women a) before 11 year b) 12-14 years c) 14-16 years d) 16-18 years 17. What is the oligozoospermia a) absence of spermatozoa b) akinesia of spermatozoa c) high level of degenerative spermatozoa d) hypokinesia of spermatozoa e) low concentration 18. Transsexualism is a) inhibition of sexual desire b) disorder of sexual orientation c) disorder of sexual identity d) transformation of socialization in sex roles 19. Sort out sexual response cycles’ phases by order of priority a) plateau b) excitement c) orgasm d) resolution a) a,c,b,d b) a,b,c,d c) b,a,c,d 148 Tests 20. During the lubrication: a) the vaginal walls begin a sweating like process transudation b) turns the vagina from its normal pink color to red c) develops orgasmic platform d) occurs rhythmic contraction a) a,b,c b) a,b c) a,d d) b,d 21. The stage of platonic libido is characterized a) forming sexual identity b) striving for being in the focus attention c) striving for erotic contacts such as hugging and kissing d) forming sexual fantasies enhance with sexual intercourse scenes 22. According to the progress Female orgasm is without a) transitory b) delayed c) clitoral 23. Involuntary election is: a) developing immediately during sexual organ's stimulation b) developing within sleep c) morning erection d) developing immediately during sexual organ's stimulation with participation of brain centers a) a,b,c,d b) b,c,d c) b,c 24. Emission consists of the reflex contraction of a) prostate glands and tubuli epididymides b) vas deferens and the seminal vesicles c) small pelvic muscles 25. At the period of puberty is the formation of a) socialization in sex roles b) psychosexual orientation c) sexual life with its excesses and abstinences d) sexual identity e) physiologic rhythm called conditional physiologic rhythm (CPR) 149 Tests 150 26. The stage of sexual orientation forming takes place a) in puberty b) in the period of mature sexuality c) in Prepuberty d) in Transitional period to mature sexuality 27. Psychogenically caused erectile dysfunction is a) anxiety b) spinal cord-trauma c) depression d) unconscious sexual conflict a) a,b b) a,c,d c) b,c,d d) a,b,c 28. The criteria of female sexual constitution are the following besides a) the age of first menstruation b) trochanter index c) pubic hair d) the age of first sexual intercourse e) the age of forming erotic libido 29. Exhibicionism is a) touching or rubbing against a nonconsenting person b) usе of nonliving objects for sexual gratification c) expose of one's genitals to an unsuspecting stranger d) sexual arousal at watching an unsuspecting person who is naked or having sex. 30. The lower level of spermatozoa in sperm is a) 100million/ml b) 50million/ml c) 20 million /ml d) 80 million /ml 31. The criteria of transsexualism are the following besides a) the desire to live and be accepted as a member of opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex Tests 151 b) the transsexual identity has been present persistently for at least two years c) the disorder is not a symptom of another mental disorder d) expose of one's genitals to an unsuspecting stranger 32. Organically caused erectile dysfunction is following besides a) the brain-strokes, trauma, dementia b) anxiety c) spinal cord-trauma d) arteries-arteriosclerosis, diabetes e) hyperprolactinemia 33. At the period of prepuberty is the formation of a) sexual identity b) socialization in sex roles c) sexual orientation 34. At the period of puberty masturbation called a) obsessive b) masturbation due to frustration c) vicarial masturbation d) masturbation is determined by hypersexual period 35. Transvestic Fetishism is a) heterosexual male aroused by cross dressing b) expose of one's genitals to an unsuspecting stranger c) us of nonliving objects for sexual gratification d) sexual arousal at watching an unsuspecting person who is naked or having sex 36. The following group of medication can be cause of erectile dysfunction besides a) neuroleptic medication b) sedative medication c) antihypertensive medication d) antibacterial medication Tests 37. a) b) c) d) 152 Sexual pain disorders are dyspareunia premature ejaculation erectile dysfunction vaginismus a) a,b b) a,d c) b,c d) c,d 38. Criteria for female sexual arousal disorder according to DSM-IV are following besides a) persistent or recurrent inability to attain, or to maintain adequate lubrication-swelling b) the disturbance cause marked distress or interpersonal difficulty c) deficiency or absence of sexual fantasies and desire for sexual activity d) it is not caused by a general medical condition 39. The vaginismus is a) ejaculation, immediately after coitus b) recurrent and persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with coitus c) recurrent genital pain with sexual intercourse in a man or a woman 40. Teratospermia is a) absence of spermatozoa b) akinesia of spermatozoa c) high level of degenerative spermatozoa d) low concentration of spermatozoa 41. The main manifestations of male sexuality are the following besides a) libido b) erection c) erogenous reactivity d) ejaculation e) orgasm 42. The main manifestations of female sexuality are the following besides a) libido b) erogenous reactivity c) lubrication Tests d) orgiastic platform e) orgasm a) d b) c,d 153 c) a,b d) d 43. Sexual manifestations according to age differences a) Prepuberty 1) sexual orientation b) Puberty 2) excesses c) Transitional period 3) socialization in sex roles d) Mature sexuality 4) CPR 44. Spinal center of erection a) Th2-th4 b) L2-L4 c) S2-S4 d) Th12-L4 45. Spinal center of ejaculation a) L1-L3 b) L4-L5 c) Th1-Th2 d) Th11-L5 46. The vesicular mechanism of the erection a) increasing penile flow b) decreasing penile outflow c) contraction of small smooth structures located only on the penile blood vessels walls a) a,c b) b,c c) a,b,c d) c 47. The libido is: a) The penis distends and becomes rigid b) Specific sensations which move the individual to seek out sexual experiences c) Emissia of sperma 48. Female sexual desire's hormone is a) prolactine b) estrogen c) testosterone d) thiroxin Tests 154 49. What is the ejaculation ante portas a) becomes after 20 friction b) more than 20 friction, but before partner having orgasm c) less than 50 friction d) before introitus e) before 5 min a) b,e b) a c) c d) e 50. Forming genetical sex a) 7-10 weeks of embryonal period b) 10-12 weeks of embryonal period c) conception d) puberty e) 12-20 weeks of embryional period 51. The male of middle constitution has the first ejaculation a) before 10 year b) 11-13 years c) 13-15 years d) 15-17 years e) above 18 year 52. The female orgasmic manifestation is a) erogenous reactivity b) ejaculation c) lubrication d) libido a) b b) d c) no one d) c 53. During orgasm a) female Orgasmic contraction is longer (20-30 sec) than male's b) some females are capable of multiple orgasm without refractor period c) force of the contraction is diminished d) male orgasmic contraction is longer (20-30 sec) than female's e) force of the contraction is increased a) a,b,c,d,e b) a,b,c c) a,b,e d) b,c,d 54. Bartholin' s glands are located a) major vulvar lipes Tests 155 b) minor vulvar lipes c) urinary d) vagina 55. Orgasm is a) the climax of pleasurable sensations b) the penis distends and becomes rigid c) specific sensations which move the individual to seek out sexual experiences d) emissia of sperma 56. Parapuberty is characterized a) socialization in sex roles b) forming psychosexual orientation c) first sexual intercourse, with excesses and abstinences d) forming sexual identity e) forming certain physiologic rhythm (CPR) 57. Vicarial masturbation is characterized a) obsessive b) premature onset, before arising sexual libido c) later onset, at the transitional period to mature sexuality d) after onset libido, during puberty e) activity on sexual organs which accompanied with erection 58. The stage of puberty is characterized a) forming psychosexual orientation b) forming sexual identity c) socialization in sex roles 59. The transitional period to mature sexuality is characterized the following besides a) sexual excesses b) socialization in sex roles c) sexual abstinences d) the realization of the sexual libido 60. The erectile response is primarily a) parasympathetic one b) sympathetic one Tests 156 Keys 1. d 11. c 21. b 31. d 41. c 49. d 59. b 2. d 12. b 22. c 32. b 42. d 50. c 60. a 3. a 4. a 5. b 13. b 14. b 15. c 23. c 24. b 25. b 33. b 34. d 35. c 43. a-3, b-1, c-2, d-4 51. c 52. c 53. b 6. c 16. b 26. a 36. d 44. c 54. a 7. c 17. e 27. b 37. b 45. d 55. a 8. a 18. c 28. d 38. d 46. c 56. d 9. d 19. c 29. c 39. b 47. b 57. c 10. c 20. a 30. c 40. c 48. c 58. a References 157 References 1. Հ ակ ո բ յ ան Ա.Է ., Նե ր ս ի ս յ ան Ն.Ռ., «Կլ ի ն ի կ ակ ան Սե ք ս ո լ ո գ ի ա», Եր և ան 2006 2. Васильченко Г.С., “Общая сексопатология” Руководство для врачей, Москва: Медицина 2005 3. Васильченко Г.С. “Сексология. Справочник”, Москва: Медицина 1990 4. Гери Ф. Келли, “Основы современной сексологии”, СaнктПетербург 2002 5. Кратохвил С., “Психотерапия семейно-сексуальных дисгармоний’, Москва: Медицина 1991 6. Кон И.С., “Сексология”, Москва: Академия 2004 7. Кришталь В.В., Григорян С.Р., “Сексология”, Москва: ПерСе 2002 8. Masters William H., Virginia E. Johnson and Robert C. Kolodny, “Human Sexuality”, New York: HarperCollins 1998 9. Kaplan H.S., “The new sex therapy”, New York: Quadrangle 1995 10. John H. Harvey, Amy Wenzel, Susan Sprecher, “The Handbook of Sexuality in Close Relationships”, Place of Publication: Mahwah, NJ 2004 11. Bergin A.E., & Garfield S.L., “Handbook of psychotherapy and behavior change”, New York 1994 12. Myra J., “Hard Sex”, Gender and Science Department of sociology: Kingston, Ontario, Canada 2004 13. Alcira Mariam Alizade, “Feminine Sensuality”, London 1999 14. Janice W. Lee, “Gender Roles”, New York 2005 15. Tony Ward, D. Richard Laws, Stephen M. Hundson, “Thousand”, Oaks-London-New Delhi 2003 16. Judith Halberstam, “Female Masculinity”, London 1998.