Manual of Sexual Disorders

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Background-sexual disorders

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First heterosexual intercourse

fallen in the last four decades from 21 to 17 for both men and women
fewer than 1% of women aged 55 or over report heterosexual intercourse before the age of 16, compared with 20% of those in their teens
early intercourse is associated with:
lower social class
lower educational level
less likely to use contraception

Heterosexual partnerships

age and marital status are associated with multiple partnerships
increasing partner change with increasing social class
serial monogamy is more common in those aged 16-34, concurrent partnerships are more common in those over 35

Heterosexual practices

age related to number of acts, with frequency peaking in mid-twenties, then gradually declining
highest frequency in married and cohabiting groups of all ages
strong association in all age groups between length of relationship and frequency of sex – lower frequency in longer relationships
type of intercourse:

• vaginal intercourse predominates
• 75% have experience of non-penetrative sex
• 70% have experience of oral sex
• 14% of men, and 13% of women report experience of anal sex

those not married have wider repertoire of sexual practice
prevalence of oral, anal and non-penetrative sex increases with increasing numbers of partners

Sexual diversity and homosexual behaviour

no sexual attraction of any kind is reported by 0.4% of men, and 0.5% of women
90% of men, and 92% of women are exclusively heterosexual
1% of men, and 0.25% of women are mostly or exclusively homosexual
6% of men and 3% of women report some form of homosexual experience
lifetime experience of homosexuality is higher in higher social classes
the majority of those with homosexual experience have had sex with both men and women
men reporting anal sex do so usually as both the receptive and insertive partner
highest levels of homosexual activity reported by 25-34-year-olds

Physical health

multiple sexual partners are significantly associated with:
smoking
increasing levels of alcohol consumption
attendance at STD clinic is associated with:
number of heterosexual partners
history of homosexual partnership
likelihood of termination increases with the numbers of heterosexual partners

The sexual response cycle

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1. desire
2. arousal, mediated by the parasympathetic nervous system
3. plateau
4. orgasm, mediated by the sympathetic nervous system
5. resolution, longer in males and increases with age

Sensate focus: Masters and Johnson (1970)

behavioural psychotherapy involving the couple in graded assignments which may be modified according to the particular problem
divided into six stages:

touching partner without genital contact for subject’s own pleasure
touching partner without genital contact for both partners’ pleasure
touching partner with genital contact, but intercourse not permitted
simultaneous touching of partner and being touched by partner with genital contact, but intercourse not permitted
intercourse, but without male thrusting; initial containment brief, with lengthening periods of containment with each session
vaginal containment with movement; couple practice stopping before climax

Sexual dysfunction

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Lack or loss of sexual desire

• not secondary to other sexual difficulties
• does not preclude sexual enjoyment or arousal, but makes initiation of sexual activity less likely

Sexual aversion

• sexual interaction is associated with strong negative feelings of sufficient intensity that sexual activity is avoided

Lack of sexual enjoyment

• sexual responses and orgasm occur normally but there is lack of pleasure
• more common in women

Failure of genital response (erectile dysfunction)

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• in men, primarily erectile dysfunction
• in women, primarily vaginal dryness

Biology

erection depends on:

intact arterial supply
intact venous valves
vascular changes caused by parasympathetic nervous system
psychic erections are mediated by thoracic sympathetic outflow
reflex erections result from sacral parasympathetic outflow
androgens also influence erection, particularly those during sleep, via the limbic system

Epidemiology

prevalence of 4-9%
makes up 50% of male cases presenting to sexual problems service
incidence rises with age (1.3% at 35 years, to 55% at 75 years)

Aetiology

• organic in 50%

1. Local:

a) Peyronie’s disease – progressive fibrosis in the tunica albuginea, resulting in curvature of the penis upon erection
b) Congenital abnormalities, such as hypospadias, epispadias, absence of suspensory ligaments
c) Priapism – may result in impotence if not properly treated within 24 hours

2. Endocrine:

a) Diabetes – causes a combination of arteriopathy and neuropathy
i) 2/3 of diabetic males are impotent
b) Hypogonadism – nocturnal erections are androgen dependent
c) Hyperprolactinaemia secondary to hypothalamic/ pituitary disease, phenothiazines, sometimes in alcoholics
d) Endorphins – naltrexone can improve impotence

3. Neurological:

a) Peripheral or autonomic neuropathy, e.g. diabetes, alcoholism
b) Radical pelvic surgery causing autonomic disruption
c) Spinal cord lesion, e.g. transection, multiple sclerosis

4. Vascular:

a) arterial disease interfering with blood supply to pelvic organs
b) incompetent venous valves

5. Pharmacological:

a) alcohol
b) antihypertensives – ganglion blockers interfere with both sympathetic and parasympathetic systems and cause both impotence and ejaculatory failure

6. Psychological:

a) classical history of lack of sexual interest, but continued morning erections suggests psychological cause

7. Psychoanalytical:

a) anxiety about the persecutory object
b) unresolved Oedipal conflict
i) in younger men with primary impotence
c) deep ambivalence about the intimate object leading to fear of sexual failure
d) narcissistic crisis
i) in middle-aged men with secondary impotence

8. Cognitive:

a) due to negative self-image within a depressive view of the relationship, and is linked to abandonment fear
b) anxiety plays a key role
c) fear of hurting female/ fear of pregnancy/ distaste for female genitalia/ trying too hard

Management Failure of genital response (erectile dysfunction)

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Management

1. Assessment

full sexual history
physical examination
penile-brachial artery pressure index of less than 0.6 is indicative of arterial disease to penis; angiography may be necessary in younger patients
nocturnal penile tumescence monitoring can distinguish organic (no nocturnal erections) from psychogenic causes
dynamic cavernometry (normal saline infused into corpus cavernosum) can detect venous incompetence
intracorporeal injection of PAPAVERINE or PHENTOLAMINE can be diagnostic to establish the capacity for erection

2. Treatment

a) Physical

i) intra-cavernosal injection of vasoactive drugs:

PAPAVERINE, self-injected can give an erection lasting about an hour, and can be used up to twice a week
complications include priapism, fibrosis, haematomas, and bruising

ii) suction devices:

provide a safe method of obtaining an erection in up to 90% of patients
problems include lack of spontaneity, decreased sensation, and delayed or absent ejaculation

iii) vascular surgery

iv) penile prosthetic implants:

three types – malleable, self-contained inflatable, and multipart inflatable
few problems with those with organic cause, but for those with psychogenic impotence, it can exacerbate pre-existing marital difficulties

b) Psychological

i) counselling

ii) psychotherapy

CBT reports success rates of 70%
couple therapy seems more effective than surrogate or individual therapies
factors associated with better outcome include:

(a) good marriage
(b) better pre-treatment communication
(c) better general sexual adjustment
(d) female partners interest and enjoyment of sex
(e) absence of psychiatric history in female partner
(f) early engagement in homework assignments

Orgasmic dysfunction (anorgasmia)

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orgasm does not occur or is delayed
more common in women

Biology

orgasm involves local spinal mechanisms as well as CNS activity
EEG shows changes akin to epileptic seizures
orgasm is similar in both sexes:
HR and blood pressure increase
sudden increase in skeletal muscle activity involving almost all parts of the body
in females, there is transient rhythmical contraction of the uterus and vagina

Epidemiology

prevalence = 5-10% in females, 4-10% in males
in females, the prevalence of anorgasmia reduces with increasing age

Aetiology

1. Physical

in both sexes, the bulbocavernosus reflex has been reported to be absent in some people – this is strongly correlated with treatment failure
sometimes, local pain can create fear of orgasm
Drugs:

opiates have a direct inhibitory effect
antiserotonergic drugs inhibit orgasm
SSRIs
MAOIs
TCAs are all associated with female anorgasmia

2. Psychological

anxiety inhibits orgasm in females, but hastens it in men
there may be fear of pregnancy or STDs

Management

direct masturbation training is the treatment of choice
tasks include relaxation, fantasizing, and masturbation

Premature ejaculation (PE)

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the inability to control ejaculation sufficiently for both partners to enjoy sex
primary premature ejaculation is always present
secondary premature ejaculation develops after a period of satisfactory sexual functioning

Biology

if semen is released from the urethra without force, it is termed emission
ejaculation and emission are mediated by the alpha-adrenergic sympathetic nervous system
androgens have a role

Epidemiology

prevalence = 36-38%
13% of attendees and sexual disorders clinic have premature ejaculation

Aetiology

1. Psychological

anxiety promotes emission but inhibits orgasm
those with primary PE are more impaired in sexual functioning and are more anxious
those with secondary PE are more likely to have coexisting erectile dysfunction, and reduction in sex drive, and a reduction in arousal

2. Learning

many factors may interfere with the learning of the ability to identify the point of impending ejaculation

3. Physical

drugs do not cause PE
those with PE do not have penile hypersensitivity

Management

education in ejaculatory control using the ‘pause’ technique
sensate focus therapy
if difficulty is experienced with these methods, the ‘squeeze technique’ can be used
some antidepressants (e.g. FLUOXETINE) have a beneficial effect on PE

Non-organic vaginismus

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occlusion of the vaginal opening caused by spasm of the surrounding muscles
penile entry is impossible or painful

Biology

•when sexually aroused the upper 2/3 of the vagina are lax and capacious, whereas the lower 1/3 is closely invested by the surrounding musculature of the pelvic floor – the strongest is the levator ani
if these muscles are too tense then penile entry is occluded
pain or anticipation of pain can cause further muscle contraction

Epidemiology

prevalence is around 10%

Aetiology

the majority are primary
onset can sometimes be related to a traumatic episode (painful examination, rape)
sometimes vaginismus results from ambivalence about the relationship, or it may be due to reluctance to assume the mature adult’s role

Management

exploration of own genitalia – finger insertion, combined with sensate focus techniques
additional dilatation may be required using graded dilators

Non-organic dyspareunia

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• pain during intercourse may occur in both sexes

Excessive sexual drive

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• usually occurs in men or women during late teenage or early adult years
• if secondary to mental illness (e.g. mania) the underlying disorder is coded

Disorders of Gender Identity

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Transsexualism

the desire to live as a member of the opposite sex
there is discomfort with anatomical sex, and a wish to change the body into that of the preferred sex
it must have been persistently present for at least 2 years, and not due to another mental disorder (such as schizophrenia) or intersex, genetic, or sex-chromosomal abnormality
the majority of transsexuals experience a successful outcome after sex-reassignment treatment

Dual role transvestism

includes the wearing of clothes of the opposite sex for part of the time to enjoy the temporary experience of membership of the opposite sex
there is no desire for permanent sex change
no sexual excitement accompanies this cross-dressing, distinguishing it from fetishistic transvestism

Gender identity disorder of childhood

persistent, intense distress about assigned sex, together with the desire to be of the other sex – there is a profound disturbance of the sense of maleness or femaleness
usually manifest during early childhood, and always before puberty
more common in boys
between 1/3-2/3 of boys show homosexual orientation during and after adolescence – very few exhibit transsexualism in later life
some girls show homosexual tendencies in later life, and retain male gender identification, although most do not

Sexual Deviation

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Fetishism

sexual preoccupation and excitement with non-living objects, which take central importance in achieving orgasm
• to be regarded as deviant, fetishism must be essential for orgasm, and causing problems

Exhibitionism

sexual pleasure and gratification is derived from exposure of the genitals to a person of the opposite sex
predominantly male, aged 15-25
the victim is usually female, and there is often an intention to surprise, shock, or insult – a reaction in the victim heightens the excitement in the perpetrator
the victim is usually unknown
often compulsive in nature
often passive, inadequate men with problems in relationships and low self-esteem
may show personality disorder of asthenic or inadequate type

Voyeurism

• no sexual contact is attempted, though masturbation may occur during or after
• the voyeur often has fantasies of humiliating or embarrassing the victims with the knowledge that they have been observed
• the victim is usually unaware

Paedophilia

where the child is an older girl (over 12), the offender is often a young male but is unlikely to be consistently deviant or psychiatrically ill
for younger children, the adult is likely to be substantially older and more likely to show psychiatric illness such as:

schizophrenia
hypomania
alcoholism
dementia
mental handicap

Sadomasochism

sexual arousal in response to the infliction of pain, psychological humiliation or ritualized dominance or submission
sadomasochistic fantasies occur during intercourse or masturbation in both sexes, often in stable relationships
more common in homosexuals

Polymorphously perverse

multiple disorders of sexual preference

Other disorders of sexual preference

obscene telephone calls
frotteurism
bestiality:
low intellect
restricted social outlets
access to animals
anoxophila
necrophilia

Antisocial Sexual Behavior

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Rape

• this is unlawful sexual intercourse with a woman by force or against her will
• Classification of rapists (Trick and Tennant 1981):

1. Situational stress rapist

otherwise sexually normal, these individuals commit rape when under extreme situational stress
there is much guilt and remorse afterwards

2. Sociopathic rapist

poor social adjustment with criminality, poor work record, substance abuse, unstable relationships
rape is often impulsive, with immediate gratification and little regard to the consequences
threats of violence are common

3. Sexually inadequate rapists

shy, timid, and insecure, lacking social skills
they often plan a rape against an attractive or sexually threatening woman

4. Sadistic rapist

deep-rooted hatred of women arising from early relationships
the object of the rape is the infliction of humiliation and suffering
the rape is often planned, with precautions to avoid detection

5. Psychotic rapist

the rape is often bizarre, violent, and terrifying for the victim

Indecent exposure

• an offence under the 1824 Vagrancy Act: ‘openly, lewdly and obscenely exposing his person with intent to insult any female’
• two main groups:

Type I

inhibited young men of relatively normal personality and good character who struggle against the impulse but find it irresistible
they expose with a flaccid penis and do not masturbate
the frequency of exposure is often related to other sexual stresses and anxieties, such as marital conflict or a pregnant spouse

Type II

less inhibited, more sociopathic
expose with an erect penis in a state of excitement, and may masturbate
obtain pleasure and show little guilt
more likely to expose to a group of women or girls, and may return repeatedly to the same place
associated with other psychosexual disorders and other types of offences
may lead on to more serious sexual offences
80% do not offend again if they are charged with the first offence
the chances of recidivism rise dramatically with the second offence
treatment:
antilibidinal drugs
psychotherapy – cognitive and behavioural