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Low or Absent Sexual Desire & Aversion
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The range of issues concerning sexual desire is wide (Table 32-8). As the etiology is multi-factorial, the approach to treatment will also need to be broad, ranging from counseling on basic sexual and possibly lifestyle issues, to consideration of pharmacotherapies including hormones.
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It must be respected that some people normally put a low priority on sex or choose to not have any active sexual life. Others may be inhibited or find sex aversive, and some are clinically phobic. These problems can be of recent origin or reflect a long-standing pattern. Lack of desire may pertain situationally only to certain sexual partners or practices (such as oral sex). Couples with different levels of desire may disagree as to which partner’s level is “abnormal.” In this situation, each side has valid feelings, and it is important not to stigmatize the patient with the lower level of desire. Most couples occasionally deal with periods of discrepancy in desire or mutually low desire and feel they should have sex more often than they do. Demands of family, career, and friends often take precedence over sex.
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Problems with desire or sexual aversion can derive from deeper relational power struggles or reflect childhood sexual, physical, or emotional abuse that requires couple counseling or individual psychotherapy for resolution. The following case example, however, demonstrates how permission and encouragement to talk about sex directly, together with specific suggestions, can have a powerful positive influence.
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CASE ILLUSTRATION 3 LOSS OF SEXUAL DESIRE
Alice, a healthy 33-year-old primary school teacher, reported having lost her desire for sex. Her sex problem history established that although she had enjoyed sexual activity with her husband for the first 2 years of their marriage, in the past year it had become a chore that she never put on her extensive “to do” list. Because sex was seen as a bedtime activity, when she was usually tired, their sexual frequency dropped from weekly to once every several months. They did not address the problem directly, and Alice and her husband’s feelings of estrangement from each other continued to grow.
When asked what steps they had taken to address these problems, Alice disclosed that she and her husband had never had an open discussion about sex. Her primary care physician validated that this was common among couples and that most people have to learn to talk more comfortably about their sexual needs (Permission and Limited Information). The physician also explained that everyone has certain conditions that need to be met to be interested in sexual activity (P and LI) and encouraged Alice to think about her conditions and then, with her husband, to “set some private time aside outside of the bedroom to let yourselves have a discussion about this, even if it is awkward” (Specific Suggestions).
Doctor: It can be good for relationships when people risk being a little uneasy. You don’t have to have the same perspective. You are each entitled to your own separate feelings about the situation, but together you can talk it out, try to understand each other, and see what other choices you have (P, LI, and SS).
At her 1-month follow-up appointment, Alice reported significant progress. When the couple set time aside to discuss their sex life, they had a very meaningful and tender talk. The husband was relieved to learn about the major sources of Alice’s lack of desire and she acknowledged feeling resentful that he seemed unresponsive to her needs. He admitted that he had taken her lack of desire very personally, secretly and painfully interpreting the problem as her lack of desire for him. With these hidden resentments expressed, they could set aside their power struggles and cooperate in addressing these issues. Recognizing how they had both felt lonely and uncared for allowed them to take specific actions, such as planning a regular evening each week just for the two of them to talk and nurture their intimacy.
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The physician also recommended a self-help book and offered to refer the couple to a therapist who treats couples, should their attempts to communicate falter.
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Permission & Limited Information
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For many individuals and couples, not being sexually active can be a choice and, if acceptable to the people involved, should not be judged by others to be dysfunctional.
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Others may learn to accept that low desire may be understandable given their immediate circumstances (e.g., the months prior to and after childbirth, recovering from illness) and that their previous levels of desire can be expected to return over time. Validate the patient’s right to say “no” to sex.
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When a person presents diminished or lacking sex drive as a problem, questions can explore the conditions under which the person has previously felt the desire for sexual contact and release, and help her or him think about ways to reestablish some of those circumstances.
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People raised within traditional sex roles can be helped to identify issues arising from sexual “suppression,” wherein neither women nor men experience their sexual potentials. Questions about desire open the door to sexual fantasies and scripts, and can form reference points for reestablishing desire where it is low or absent. For example, if a woman has experienced desire and excitement during courtship, but none after marriage, the doctor might help her understand why these changes have occurred and suggest potentially simple solutions.
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A “prescription” to go away on a weekend or to arrange a sleepover for children with relatives may help couples “break the ice” and reexperience intimacy. Suggest that the patient and their partner set time aside to talk about each other’s feelings and discuss conditions for more enjoyable sex, with each taking an uninterrupted amount of time for self-expression. Self-help books may also be recommended.
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An assessment for couples or individual psychotherapy may be indicated when simpler discussions and behavioral changes have been unsuccessful.
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Other Medical Interventions
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Clearly, comorbid conditions should be excluded and, consideration given to readjusting current medications, if appropriate. Positive results in several domains have been obtained in some studies of postmenopausal women with sexual problems, treated with transdermal testosterone, usually in addition to menopausal hormone therapy (i.e., estrogen ± progestin).
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Since none of the studied testosterone preparations has been approved by the Food and Drug Administration (FDA) for use in the United States (nor by Health Canada in that country), there are no approved testosterone products for women in North America. However, the transdermal preparations have been approved by regulatory agencies in Europe and South America where they are available and in use.
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Testosterone products are sometimes used “off label” and may be helpful for select individuals, for example women postoophorectomy or those with premature menopause whose testosterone levels may be virtually undetectable. Vaginal or clitoral application of testosterone cream has been suggested for women who seek treatment for a troubling loss of desire following chemotherapy for breast cancer. However, this treatment is NOT universally accepted in the medical community.
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DHEA vaginal preparations, currently still in clinical trials, have shown promising results and may prove useful in the future.
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Sexual Arousal Problems
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Problems with female arousal are primarily manifested as vaginal dryness and may be reported separately from or together with lack of desire, difficulty reaching orgasm, or pain experienced during intercourse. The most common medical cause in older women is estrogen deficiency with resulting signs of vulvar irritation and atrophic vaginitis. Arousal may be inhibited by anxiety and depression, or shame resulting from early conditioning; it may also be a side effect of antidepressant medication. These possibilities should be explored (see Table 32-5).
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Male arousal problems are manifested by erectile problems physically, but also include subjective inhibitions and performance anxiety as well.
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CASE ILLUSTRATION 4
Betty, a 78-year-old patient, had an appointment with her female physician. She brought along her 82-year-old husband because she wanted to discuss what she called her “sexual problems.” Betty said she did not care about sex, that her husband was often angry with her lack of enthusiasm, and that this pattern had existed throughout the 50 years of their marriage. She believed she was not “a sexual person” because she had never been very excited by intercourse. She did enjoy kissing and caressing and mentioned that on several occasions she had been able to have orgasm when he stroked her labia and clitoris, but that she had never had orgasm from the “real sex” (intercourse) that he preferred. The physician responded that there really is no one way to be a “sexual person,” that many people cherish the sensual and emotional aspects of sex, and that Betty did not need to consider herself asexual just because she preferred different aspects of sexual intimacy than her husband (P and LI). The physician further explained that the majority of women reach orgasm more often from manual caressing than from coitus, and that many couples enjoy bringing each other to orgasm without intercourse (P and LI). The couple was relieved and admitted to having curiosity about trying this petting more. They were given brief instructions to take turns at home touching and stroking each other without the goal of orgasm (sensate focus), to get reacquainted with each other’s body, and to refrain from any attempts at intercourse for 2 weeks (SS).
A follow-up telephone call confirmed that they were enjoying taking turns caressing each other, that orgasm often happened for each, and that they occasionally progressed to intercourse. A 1½-year follow-up was especially poignant—the husband reported that Betty had recently died from a stroke, and, although grieving her loss, he expressed profound appreciation for having gotten help for their sexual conflicts from the physician.
Husband: Settling those old battles over sex made our last year together more loving and caring than ever before in our marriage.
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Permission & Limited Information
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Is the patient getting stimulation in the way that works best for her? Feeling distant from or angry with a partner can inhibit sexual arousal, and such relationship concerns need to be addressed.
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Homework may be suggested for her to identify what stimulation works best. The goal is to experience the pleasure of arousal in that mode—not to reach orgasm. Inquiry should be made into the quality of the patient’s relationship. Commercial lubricants (Astroglide, KY Jelly, and so on) and vaginal moisturizers (such as Replens) can be suggested and, if vaginal atrophy is present, a low-dose intravaginal estrogen preparation (cream, pill, or suppository) should be prescribed unless contraindicated.
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As has been mentioned, an intravaginal DHEA preparation is undergoing further evaluation as a hormone replacement alternative without the usual contraindications. Labrie et al. (2009) have published extensively on DHEA use. The premise for safety of this cream for patients is that of “intracrinology,” a term coined to describe the fact that DHEA, a relatively inert precursor substance (“a prehormone”) inserted into the vagina, is absorbed and there transformed/converted “on site” in specific cells to active steroids (testosterone, estradiol) which act locally. The DHEA is then locally also deactivated, never entering the circulation, and thus not reaching other tissues. The endometrium which is close by remains unaffected, because it does not possess the necessary converting enzymes to act on the DHEA.
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Self-help books also can be recommended, such as ones by Barbach (2000) and Johnson (2008, 2013).
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Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).
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Other Medical Interventions
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Referral to an ob–gyn or other women’s health specialist.
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There have been more than a dozen studies in the past 12 years or so showing a growing link between erectile problems and cardiovascular disease in men, including younger populations. If a man presents in primary care setting with erectile complaints, the physician should always assess cardiovascular risk factors as potential contributing factors, and recommend aggressive risk factor reduction (e.g., weight loss, exercise) if relevant.
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Generally, a man with a significant psychological component is aware of nocturnal or morning erections, is able to maintain his erection for a reasonable time and then ejaculate with masturbation, or has good erections in some situations but not in others. He may be able to get a firm erection but lose it after penetration or may not get an erection with a partner at any time. The original cause of the problem is often distinct from the maintaining variable, which is generally anxiety. Consider possibilities such as performance anxiety, lack of direct physical stimulation of the penis, conscious or unconscious guilt (e.g., “widower’s syndrome”), anger at his partner or other relationship issues, or childhood issues such as sexual abuse.
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CASE ILLUSTRATION 5
Carl, a 58-year-old HIV-negative gay male, confided to his physician that he had been “impotent” since the death of his partner of 17 years, with whom he had had an active and monogamous sexual life. Attributing this problem to aging and worries about HIV infection, Carl nonetheless asked for any help the primary care physician could provide. A full session was scheduled for talking only. His partner had died suddenly from cardiac arrest a year before. In the past month, Carl had attempted sex on four occasions with two different men and was unable to get an erection. After a thorough socio-sexual history, Carl was seen to fit the “widowers’ syndrome.” Clearly, he was still grieving the loss of his partner but attempted to control his tears with statements such as “I should be over this by now” and “Life has to go on; he wanted me to go on.” Carl then revealed that he was very afraid of feeling such loss, fearing that he would never be able to come out of the sadness. His grieving was acknowledged and validated (P), and it was explained to him that temporary sexual problems were common after such loss because of a number of factors: performance pressure of being with a new partner, continuing feelings of loyalty to a deceased partner, subsequent guilt at having sex with new people, and concerns about HIV infection with a new partner (LI). The physician encouraged Carl to join a grief support group or to contact a psychotherapist comfortable with gay sexuality (SS). In addition, the doctor referred Carl to a book on male sexuality, with suggestions on how to talk to a potential partner about both safer sex practices and ways they could reduce the pressure to have erections (LI and SS). At a follow-up visit 4 months later, Carl reported he had been able to cry more about his loss and was enjoying sex and intimacy with a new friend who had also lost a partner.
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Permission & Limited Information
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Many patients over 40 years old report previous successful sexual encounters when they were younger in which they became erect without direct physical stimulation of the penis. If their pattern for sexual interaction has rarely or never included direct touching by a partner, it might help them to learn that such touching becomes more necessary as men age, and that it can be an enjoyable part of sex.
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Institute a temporary ban on penetration and suggest sensate focus, progressive relaxation, and Kegel exercises. The couple should agree not to attempt penetration or intercourse even if the patient gets an improved erection.
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Doctor: For every minute you are relaxing with your partner and have an erection, your body is remembering just what it needs to do to get and maintain an erection. Your mind can be free to enjoy the pleasurable feelings and sensations of being caressed and kissing your partner. You might even allow your erection to go away. If you stay relaxed, it likely will return again with resumed stimulation.
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Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).
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Other Medical Interventions
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Referral to a urologist interested in male sexual functioning.
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PDE5 inhibitors. Tadalafil (Cialis), sildenafil (Viagra), and vardenafil (Levitra) are three oral medications popularly known to have revolutionized the medical treatment of male erectile problems. Although contraindicated in men taking organic nitrate medication for angina, these medications have been found to have broad-spectrum effectiveness across men of all ages and medical conditions, including diabetes, hypertension, neuropathy, postprostatectomy, and depression.
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An important caveat is that, in spite of the evidence of PDE5 medications’ demonstrated safety and efficacy, approximately 50% of men do not refill their prescriptions. Underlying psychological and interpersonal factors may need to be explored with these patients at follow-up visits.
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Testosterone replacement therapy. For men with demonstrated low levels of serum testosterone, hormone replacement therapy may be helpful. This does not seem to benefit men whose serum testosterone is within normal limits, although recent work suggests there may be more subtleties to this. Side effects can be serious, including increase of any existing prostatic cancer, enlargement of the prostate, retention of fluids, and liver damage. Careful monitoring and follow-up prostate-specific antigen (PSA) screening and prostate examinations are necessary.
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Antidepressant medication. Antidepressants, especially bupropion-SR (Wellbutrin-SR), can be effective treatment for some, but other patients may find that SSRI antidepressants hinder erection and ejaculation.
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External penile vacuum device. With the aid of a vacuum cylinder, a tension ring is placed around the base of the penis after it has become erect. This device may work better for men who clearly have a major organic component to their erectile problem, such as severe diabetes, multiple sclerosis, or spinal cord injury. Although this device can create erections functional for intercourse, men with a more psychogenic etiology may be disappointed when the erections are not as firm as they had been expecting. Side effects may include bruising of the penis.
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Intracorporeal penile injections or intraurethral delivery of prostaglandin E1 (PGE1). These methods were originally used diagnostically by urologists. However, patients can now be taught to inject themselves prior to sexual encounters, resulting in firmer erections that often do not disappear at orgasm or ejaculation and last about an hour. Side effects are priapism in less than 3% of patients and pain. In addition, scarring may be a concern with repeated injections over time.
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Penile implant surgery. Since the advent of effective oral medications, implants with semirigid silicone rods or inflatable cylinders are less commonly utilized. Total costs are high, usually over $20,000. Complications include device failure (requiring additional surgery) and infection. However, for some men, this has been an effective and helpful treatment.
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Rapid Ejaculation (Premature Ejaculation)
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Terms such as rapid or early ejaculation are clinically preferable to the established premature ejaculation, as they highlight the subjective nature of the problem and are less pejorative. No absolute measure—either in number of minutes or thrusts—is applicable to the diverse numbers of men presenting with this problem. Factors to be assessed include a patient’s subjective evaluation, degree of sexual satisfaction, and sense of control.
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CASE ILLUSTRATION 6
Donald, a 45-year-old divorced man, reported ejaculating after 1 minute or less of intercourse. This had been his pattern since becoming sexually active in his late teens. He reported proudly that he never masturbated but had a high sex drive, which led him to multiple sexual partners including prostitutes. His primary care physician gave Donald a supportive talk about how he could teach himself to last longer with certain physical exercises (P, LI, and SS). The patient was willing to do “self-stimulation” or “self-pleasuring” exercises for this “medical reason” and was comforted that as with the physical fitness regimen that he valued, he could tone up his PC muscles and learn to relax the pelvic muscles during sexual stimulation. Donald was advised to increase his frequency of ejaculation, was told about the importance of relaxation for maintaining erection, and was encouraged to read Zilbergeld’s (1999) self-help section on “stop–start” exercises for lasting longer (P, LI, and SS). As his confidence grew through the solo exercises, and as he increased the frequency of ejaculation, Donald was able to try the stop–start exercises with a partner with increasing success. He said that it also helped him to read about the experiences of other men (getting validation from the universality of sexual concerns) and about how many women enjoy a variety of forms of sexual stimulation in addition to intercourse.
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Permission & Limited Information
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Point out that early ejaculation is a very common problem—one study found that 35% of married males reported that they ejaculated too quickly. Tell the patient that men with this problem have a high success rate when they try one or more specific suggestions for this problem. Give a brief explanation of the psychophysiologic mechanism.
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Doctor: Men aren’t supposed to be able to have long-lasting erections if they are too nervous or distracted. The fight-or-flight response generally makes men more likely to ejaculate. Most men have trained themselves through rapid masturbation to get erect and ejaculate quickly; so it makes sense that they would continue to ejaculate quickly when they are with a partner.
Assure the patient that men often report more intense orgasms after they have learned to last longer and that it is highly likely that he will gain greater ejaculatory control by following these suggestions.
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The patient may need to increase his frequency of ejaculations, alone or with a partner, perhaps masturbating to orgasm earlier on a day that a sexual encounter with a partner is anticipated. Discuss other ways he can please his partner, so he does not feel pressure to do it all with an erect penis. Discuss the importance of muscle relaxation in achieving a prolonged erection. Suggest breathing exercises and progressive muscle relaxation exercises, targeting the PC muscles or those in the buttocks.
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In contrast to common attempts by men to diminish sensations in hope of lasting longer, they actually need to increase their tolerance for the good sensations and feelings and can best do this by concentrating on their feelings and getting more “turned on.” Focusing on these feelings in a relaxed “practice” atmosphere can increase the threshold of enjoyment before ejaculation and orgasm.
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He and his partner can read about and practice the “stop-start technique.” Encourage the patient to change positions and to go from intercourse to oral or manual stimulation of his partner, and then back to intercourse (following the desires of his partner); changing positions and pleasuring a partner to orgasm without intercourse helps many men last longer.
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Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).
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Other Medical Interventions
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Clomipramine (Anafranil, 25 mg as needed) or SSRI antidepressants help men prolong their erections prior to ejaculation.
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Prilocaine-lidocaine cream applied to the penis and then used with a condom has been recommended by some clinicians (although “numbing” of the genitals may detract from enjoyment for both partners).
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Many women do not learn to have orgasms until they are in their 20s, 30s, or even later. A primary anorgasmic or preorgasmic woman is not yet able to reach orgasm reliably either with a partner or by herself. A woman with secondary orgasmic problems was previously able to reach orgasm but is no longer able to do so. Situational orgasmic problem refers to a condition in which a woman can have orgasm with masturbation but not with a partner, or with one partner but not with another. She may reach moderate-to-high levels of arousal without experiencing the pleasure and release of climax. If no arousal or interest is present, she should be evaluated for a desire or arousal problem.
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Some males might report delayed or absent ejaculation despite prolonged intercourse or other stimulation. Some report ejaculation without the sensation of orgasm (see Table 32-8).
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CASE ILLUSTRATION 7
Ethyl’s complaint of low sexual desire and difficulty feeling aroused led the physician to do a brief sex problem interview. With this more open discussion, Ethyl revealed that she had never been able to climax, but had been highly aroused in the first year of her 5-year marriage. Their lovemaking style was focused on intercourse, and Ethyl’s husband did not seem to understand why she did not enjoy it as much as he did. She had not faked orgasm but had never told him about her feelings of frustration about not reaching orgasm. Ethyl had never masturbated and remembered vague attitudes conveyed by her parents and her church that masturbation was not a correct thing to do. The physician then validated that many women first learn about self-pleasuring as adults and that the information she could get about how her own body worked would then be useful in her sexual relationship with her husband. It was suggested that Ethyl read a self-help book for women who want to learn to have orgasms (P, LI, and SS). At a visit 3 months later, Ethyl reported that she had proudly experienced her first orgasm by herself and felt so encouraged by this that she was able to talk more openly with her husband, who then agreed to go with her to see a marital/sex therapist to discuss ways they could bring more pleasure into their own lovemaking.
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CASE ILLUSTRATION 8
Frank, a 24-year-old man, confided that he had never reached orgasm with a partner. A sex problem history revealed that he had never ejaculated during intercourse and that his partners had never tried to bring him to orgasm manually or orally. Frank was able to ejaculate with masturbation, describing a vivid sexual fantasy (which he did not allow himself to have when with a partner) and a lifelong pattern of stimulation in which he rubbed his penis back and forth against a pillow without using his hands. He was congratulated for bringing this problem to his physician’s attention (P) and was told that anxiety was often a cause of this problem, together with a masturbation pattern that did not simulate the type of sensations he would have during intercourse (LI). The physician encouraged Frank to take a stepwise approach to the problem by enlisting the help of a willing partner and starting with those elements that had been successful for him. He was also encouraged to expand on the kind of physical stimulation he received during masturbation by gripping his penis with his hand and stroking it. With his partner, Frank was to focus on the goal of having high arousal while his partner stimulated his penis manually and he was imagining his “tried-and-true” fantasy. The next step was to reach higher levels of arousal in this manner and to stimulate an orgasmic response (SS). Frank was also referred to a self-help book (P, LI, SS). Follow-up indicated that Frank had successfully reached orgasm with manual stimulation with a partner in 3 weeks and was following suggestions in the book on his goal toward ejaculation during intercourse.
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Permission, Limited Information, & Specific Suggestions
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Both men and women may present with difficulties in achieving orgasm because of a repeated pattern of masturbation that does not approximate the stimulation they receive from a partner. Although physical arousal may be apparent (erection or lubrication), these patients may not be feeling excited if they have to forego the fantasies or kinds of stimulation that had worked for them while masturbating. Encouraging them to incorporate the conditions under which they can reach orgasm when alone into their sexual play with a partner is the first step in their expanding their sexual enjoyment. In some instances, use of a vibrator may be recommended to provide the more intense stimulation needed for some people. Explicit communication with the patient’s partner should be encouraged about the need to have enough stimulation prior to ejaculation and orgasm.
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Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).
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Other Medical Interventions
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The usual treatment of problems related to female orgasm is a combination of a good sex and psychosocial history, demythologizing, educating, behavioral treatments, and couples work where needed. There is no medication treatment available, since anorgasmia is rarely a physically caused problem.
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As noted, Labrie et al. (2009) and the third author have had promising experience with intravaginal DHEA, whereas intranasal oxytocin (20–24 IU) is being studied as a potential stimulator of orgasm in women, and might hold promise for the treatment of delayed ejaculation.
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Sexual Pain: Dyspareunia and Vaginismus
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Dyspareunia—pain for women or men associated with genital sex of all kinds may be one of the most common and perhaps most underreported of the sexual dysfunctions. Vaginismus, a specific cause of female dyspareunia, involves the involuntary spasm of muscles around the vagina. Vaginismus can usually be treated by teaching the patient exercises to establish personal vaginal control and remove sources of contributing associated anxieties, such as conditioning to previous genital trauma, fear of penetration, anatomical ignorance, and others.
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A gentle, sensitive genital examination and demonstration should always be a part of the evaluation of vaginismus. The use of progressively sized vaginal dilators has been helpful in some cases, but treatment can often be successful without them.
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CASE ILLUSTRATION 9
Nineteen-year-old Gina complained to her primary care provider that she had dyspareunia, was losing interest in sex, and was worried that her boyfriend was becoming impatient with her avoidance of sex. The physician then encouraged her to describe this problem behaviorally and in detail (P). Gina said that she had enjoyed intercourse since the age of 17 years and always used latex condoms, but on one occasion 6 months ago she suddenly felt as if her vagina “was being rubbed with sandpaper” when her partner penetrated her. Although the physical pain had not actually returned in subsequent lovemaking sessions, Gina’s fear of the pain recurring diminished both her interest in and her enjoyment of sex. When asked what she would do if the pain happened again during intercourse, Gina replied that she “would have to ask him to hurry up, but sometimes he lasts longer then.” The physician asked how she would feel about telling him to stop all movement immediately and to withdraw when she felt discomfort or pain. Gina expressed concern that an abrupt withdrawal from intercourse might result in her boyfriend having testicular pain. She was reassured that this would create no lasting discomfort for him, and that there were alternatives for reaching ejaculation and orgasm, either with her or alone (P, LI, and SS). She was also offered some suggestions for reading about how couples learn to increase their enjoyment of sex (SS). The physician also praised Gina for having shown the courage to discuss this personal issue and encouraged her to bring up any future concerns (P, LI).
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These issues can be approached gradually, by encouraging the woman to speak with her partner about her needs and to be a full participant in the sexual encounter. She and her partner should be educated about the need for sufficient stimulation and arousal prior to attempted penetration, and about the importance of her being in control of the sexual movement, so that she can stop it instantly if pain is felt. Instruction in Kegel’s PC muscle exercises increases the woman’s awareness and control of her vaginal muscles. Vaginal self-dilatation can be accomplished with graduated cylinders or with fingers, from the little finger to multiple fingers, while practicing muscle relaxation and calming mental imagery. The patient should be encouraged to be the one in control by bearing down on the finger(s) or penis as if pushing something out of the vagina, then relaxing. It helps for some women to imagine “capturing” the penis or other object in this manner, instead of being “penetrated.”
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Other Medical Interventions
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Other medical suggestions include the use of artificial lubricants, such as Astroglide, Gyne-Moistrin, or KY Jelly (not good with latex); vaginal moisturizers, such as Replens; and vaginal and vulvar application of estrogen creams. Further evaluation of vaginismus includes assessment for developmental anatomical abnormalities; if deemed appropriate, surgical revision of the vulvovaginal region and/or excision of abnormal growths in the genital area may prove helpful. Diseases thought to cause the pain, such as vaginitis, condylomata, endometriosis, pelvic inflammatory disease, and other gynecologic or pelvic diseases, may all be treated directly. When painful intercourse has been a long-standing problem, however, medical intervention alone is seldom adequate and should be followed by sex therapy directed at the probable fear and expectation of pain that have been conditioned.