25-09: Psychosexual Disorders

The stages of sexual activity include excitement (arousal), orgasm, and resolution. The precipitating excitement or arousal is psychologically determined. Arousal response leading to orgasm is a physiologic and psychological phenomenon of vasocongestion, a parasympathetic reaction causing erection in men and labial-clitoral congestion in women. The orgasmic response includes emission in men and clonic contractions of the analogous striated perineal muscles of both men and women. Resolution is a gradual return to normal physiologic status.

While the arousal stimuli—vasocongestive and orgasmic responses—constitute a single response in a well-adjusted person, they can be considered as separate stages that can produce different syndromes responding to different treatment procedures.

There are three major groups of sexual disorders.

A. Paraphilias

In these conditions, formerly called “deviations” or “variations,” the excitement stage of sexual activity is associated with sexual objects or orientations different from those usually associated with adult sexual stimulation. The stimulus may be a woman’s shoe, a child, animals, instruments of torture, or incidents of aggression. The pattern of sexual stimulation is usually one that has early psychological roots. When paraphilias are associated with distress, impairment, or risk of harm, they become paraphilic disorders. Some paraphilias or paraphilic disorders include exhibitionism, transvestism, voyeurism, pedophilia, incest, sexual sadism, and sexual masochism.

Exhibitionism is the impulsive behavior of exposing the genitalia to unsuspecting strangers in order to achieve sexual excitation. It is a childhood sexual behavior carried into adult life.

Transvestism consists of recurrent cross-dressing behavior for the purpose of sexual excitation. Such fetishistic behavior can be part of masturbation foreplay.

Voyeurism involves the achievement of sexual arousal by watching the activities of an unsuspecting person, usually in various stages of undress or sexual activity. In both exhibitionism and voyeurism, excitation leads to masturbation as a replacement for sexual activity.

Pedophilia is the use of a child of either sex to achieve sexual arousal and, in many cases, gratification. Contact is frequently oral, with either participant being dominant, but pedophilia includes intercourse of any type. Adults of both sexes engage in this behavior, with exact prevalences unknown, but likely far less common among females.

Incest involves a sexual relationship with a person in the immediate family, most frequently a child. In many ways it is similar to pedophilia (intrafamilial pedophilia). Incestuous feelings are fairly common, but cultural mores are usually sufficiently strong to act as a barrier to the expression of sexual feelings.

Sexual sadism is the attainment of sexual arousal by inflicting pain upon the sexual object. Much sexual activity has aggressive components (eg, biting, scratching). However, forced sexual acquiescence (eg, rape) is an act of aggression.

Sexual masochism is the achievement of erotic pleasure by being humiliated, enslaved, physically bound, and restrained. It may be life-threatening, since neck binding or partial asphyxiation usually forms part of the ritual. The practice is much more common in men than in women.

B. Gender Dysphoria

Gender dysphoria is distress associated with the incongruence between one’s experienced or expressed gender and one’s assigned gender. As a disorder, it is defined by significant distress or impairment; those experiencing this incongruence but without the distress would not meet criteria for having gender dysphoria. Screening should be done for conditions related to the oppression and stigmatization that transgender people face, including a high risk of suicide.

C. Sexual Dysfunctions

This category includes a large group of vasocongestive and orgasmic disorders. Often, they involve problems of sexual adaptation, education, and technique that are often initially discussed with, diagnosed by, and treated by the primary care provider.

There are two conditions common in men: erectile dysfunction and ejaculation disturbances.

Erectile dysfunction is inability to achieve or maintain an erection firm enough for satisfactory intercourse; patients sometimes use the term incorrectly to mean premature ejaculation. Careful questioning is necessary, since causes of this vasocongestive disorder can be psychological, physiologic, or both. The majority are pathophysiologic and, to varying degrees, treatable. After onset of the problem, a history of occasional erections—especially nocturnal penile tumescence, which may be evaluated by a simple monitoring device, or a sleep study in the sleep laboratory—is usually evidence that the dysfunction is psychological in origin. Decreased nocturnal penile tumescence occurs in some depressed patients. Psychological erectile dysfunction is caused by interpersonal or intrapsychic factors (eg, partner disharmony, depression). Organic factors are discussed in Chapter 23.

Ejaculation disturbances include premature ejaculation, inability to ejaculate, and retrograde ejaculation. (Ejaculation is possible in patients with erectile dysfunction.) Ejaculation is usually connected with orgasm, and ejaculatory control is an acquired behavior that is minimal in adolescence and increases with experience. Pathogenic factors are those that interfere with learning control, most frequently sexual ignorance. Intrapsychic factors (anxiety, guilt, depression) and interpersonal maladaptation (partner problems, unresponsiveness of mate, power struggles) are also common. Organic causes include interference with sympathetic nerve distribution (often due to surgery or radiation) and the effects of pharmacologic agents (eg, SSRIs or sympatholytics).

In women, the most common forms of sexual dysfunction are orgasmic disorder and hypoactive sexual desire disorder.

Orgasmic disorder is a complex condition in which there is a general lack of sexual responsiveness. The woman has difficulty in experiencing erotic sensation and does not have the vasocongestive response. Sexual activity varies from active avoidance of sex to an occasional orgasm. Orgasmic dysfunction—in which a woman has a vasocongestive response but varying degrees of difficulty in reaching orgasm—is sometimes differentiated from anorgasmia. Causes for the dysfunctions include poor sexual techniques, early traumatic sexual experiences, interpersonal disharmony (partner struggles, use of sex as a means of control), and intrapsychic problems (anxiety, fear, guilt). Organic causes include any conditions that might cause pain in intercourse, pelvic pathology, mechanical obstruction, and neurologic deficits.

Hypoactive sexual desire disorder consists of diminished or absent libido in either sex and may be a function of organic or psychological difficulties (eg, anxiety, phobic avoidance). Any chronic illness can reduce desire as can aging. Hormonal disorders, including hypogonadism or use of antiandrogen compounds such as cyproterone acetate, and chronic kidney disease contribute to deterioration in sexual desire. Alcohol, sedatives, opioids, marijuana, and some medications may affect sexual drive and performance. Menopause may lead to diminution of sexual desire in some women, and testosterone therapy is sometimes warranted as treatment.

A. Paraphilias

1. Psychological

Paraphilias, particularly those of a more superficial nature (eg, voyeurism) and those of recent onset, are responsive to psychotherapy in some cases. The prognosis is much better if the motivation comes from the individual rather than the legal system; unfortunately, judicial intervention is frequently the only stimulus to treatment because the condition persists and is reinforced until conflict with the law occurs. Therapies frequently focus on barriers to normal arousal response; the expectation is that the variant behavior will decrease as normal behavior increases.

2. Behavioral

In some cases, paraphilic disorders improve with modeling, role-playing, and conditioning procedures.

3. Social

Although they do not produce a change in sexual arousal patterns or gender role, self-help groups have facilitated adjustment to an often hostile society. Attention to the family is particularly important in helping people in such groups to accept their situation and alleviate their guilt about the role they think they had in creating the problem.

4. Pharmacologic

Medroxyprogesterone acetate, a suppressor of libidinal drive, can be used to mute disruptive sexual behavior in men. Onset of action is usually within 3 weeks, and the effects are generally reversible. Fluoxetine or other SSRIs at depression doses may reduce some of the compulsive sexual behaviors including the paraphilias. A focus of study in the treatment of severe paraphilia has been agonists of luteinizing hormone–releasing hormone (LHRH). Case reports and open label studies suggest that LHRH-agonists may play a role in preventing relapse in some patients with paraphilia.

B. Gender Dysphoria

1. Psychological

Individuals with gender dysphoria often find benefit from psychotherapy, providing them with a safe place to explore and understand their thoughts and feelings, and to identify their own specific needs and desires and adjust to a changing life.

2. Social

Peer support groups, parent psychoeducation and support, and community empowerment are important social components of treatment.

3. Medical

Some individuals with gender dysphoria choose to pursue surgery or hormone therapy or both. Most recommendations prior to surgery include that the individual spends significant time prior living as their desired gender. Rates of suicide fall significantly after surgery but still remain much higher than the general population.

C. Sexual Dysfunction

1. Psychological

The use of psychotherapy by itself is best suited for those cases in which interpersonal difficulties or intrapsychic problems predominate. Anxiety and guilt about parental injunctions against sex may contribute to sexual dysfunction. Even in these cases, however, a combined behavioral-psychological approach usually produces results most quickly.

2. Behavioral

Syndromes resulting from conditioned responses have been treated by conditioning techniques, with excellent results. Masters and Johnson have used behavioral approaches in all of the sexual dysfunctions, with concomitant supportive psychotherapy and with improvement of the communication patterns of the couple.

3. Social

The proximity of other people (eg, a mother-in-law) in a household is frequently an inhibiting factor in sexual relationships. In such cases, some social engineering may alleviate the problem.

4. Medical

Even if the condition is not reversible, identification of the specific cause helps the patient to accept the condition. Partner disharmony, with its exacerbating effects, may thus be avoided. Of all the sexual dysfunctions, erectile dysfunction is the condition most likely to have an organic basis. Sildenafil, tadalafil, and vardenafil are phosphodiesterase type 5 inhibitors that are effective oral agents for the treatment of penile erectile dysfunction (eg, sildenafil 25–100 mg orally 1 hour prior to intercourse). These agents are effective for SSRI-induced erectile dysfunction in men and in some cases for SSRI-associated sexual dysfunction in women. Use of the medications in conjunction with any nitrates can have significant hypotensive effects leading to death in rare cases. Because of their common effect in delaying ejaculation, the SSRIs have been effective in premature ejaculation.

Flibanserin is a 5-HT_1A-agonist/5-HT₂-antagonist that is FDA approved for the treatment of female hypoactive sexual desire disorder. Women treated with flibanserin have a marginally higher number of sexual events. The medication interacts with alcohol, causing hypotensive events, so patients need to be educated about this risk. Flibanserin is taken 100 mg orally at bedtime to circumvent the side effects of dizziness, sleepiness, and nausea.

In addition to flibanserin, a second medication was approved by the FDA in 2019 for the treatment of hypoactive sexual desire disorder in premenopausal women. Bremelanotide activates melanocortin receptors, although the mechanism of action in hypoactive sexual desire disorder is unclear. It is self-administered by injection to the thigh or abdomen about 45 minutes before anticipated sexual activity. In the registration trials, about 25% of women had a clinically significant increase in libido compared to 17% of controls. While the response rates appear low, bremelanotide was generally well tolerated and does represent another option for some women with hypoactive sexual desire disorder.