What are sexual problems? - Chapter 11

How can pathological sexual problems be defined?

Because opinions are divided about what is and what is not acceptable behaviour, it is difficult to define what is 'normal'. However, there are two factors that are important in identifying psychopathology in sexual behavior and gender identity:

• A sexual activity or gender problem is suitable for treatment if it is frequent, chronic, distressing to the individual and affecting interpersonal relationships
• Some direct their sexual activity at individuals who do not participate in the activity or cannot legally consent to it (e.g., paedophilia)

For the diagnostic criteria, it is not always necessary that only the individual with the sexual problem experiences distress. Sometimes, it is hard to determine whether sexual problems are psychopathological, or not.

What are sexual dysfunctions?

Since the 1960s and 1970s, there has been more openness about sex and sexual activity. This opened up the opportunity to do more research into this.

There are four phases in the normal sexual cycle:

1. Desire
2. Arousal
3. Orgasm
4. Resolution

Sexual dysfunctions can occur in all these phases, except for the last phase, no specific disorders have been described. There are the sexual pain disorders that can occur at any stage.

How can sexual dysfunctions be diagnosed?

Sexual dysfunctions are problems in the normal sexual cycle that prevent an individual from experiencing sexual pleasure. It is always important to include age in the diagnosis. Sexual activity and performance often decline with age. Other factors such as culture and religion should also be considered.

There are three disorders that occur in the first two stages of the sexual cycle: male hypoactive sexual desire disorder, erectile dysfunction, and female sexual interest/arousal disorder.

Male hypoactive sexual desire disorder is characterized by an absence or decreased interest in sexual activity or erotic/sexual thoughts. Prevalence is about 6% among young men and 41% among older men. DSM-5 criteria for this disorder are:

• Incessant or recurrent inadequate sexual/erotic thoughts or desires for sexual activity for at least six months, causing distress to the patient; and
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

Erectile dysfunction is characterized by an inability to maintain an erection during sexual activity. About 10% of men report erection problems and this increases to 20% in men over 50 years old. DSM-5 criteria for this disorder are:

• At least one of the following occurs in 75% of sexual activity for at least six months, causing patient distress: difficulty getting an erection during sexual activity, difficulty maintaining an erection to the end of sexual activity, and reduction in the stiffness of the erection.
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

The female sexual interest/arousal disorder is characterized by a combination of decreased sexual interest and lower arousal. DSM-5 criteria for this disorder are:

• Decrease or lack of interest in sexual arousal/openness, where at least three of the following are present for a period of at least six months, causing distress to the patient:
•  Lack of or decreased interest in sexual activity
•  Lack of or decreased interest in sexual/erotic thoughts or fantasies
• None or decreased initiation of sexual activity and no responsiveness of the partners to attempted sexual activity
• None or decreased arousal or pleasure during sexual activity for at least 75% of the time
• A lack of or diminished sexual interest in response to all internal and external sexual cues
• A lack of or diminished genital or non-genital sensations during sexual activity at least 75% of the time
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition

There are three disorders that occur during the orgasm phase: female orgasmic disorder, delayed ejaculation and premature ejaculation.

What is Female Orgasmic Disorder?

Female Orgasmic Disorder is one of the most common disorders treated. Depending on various factors, the prevalence is between 10% and 42%. DSM-5 criteria for this disorder are:

• Delay, infrequency, or absence of orgasms or decreased intensity of orgasm in at least 75% of sexual activity for a period of at least six months, causing distress to the patient
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition

What is delayed ejaculation?

Delayed ejaculation is the permanent or recurrent delay in ejaculation following a normal sexual arousal phase. This occurs in less than 1% of men. DSM-5 criteria for this disorder are:

• Delay, infrequency, or absence of ejaculation in at least 75% of sexual activity for a period of at least six months, causing distress to the patient
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

What is premature ejaculation?

Premature ejaculation is having an orgasm with minimal sexual stimulation. This occurs in about 1% of men. DSM-5 criteria for this disorder are:

• Continuous or recurrent patterns of ejaculation at approximately one minute of vaginal penetration and before the patient desires it during at least 75% of sexual activity for at least six months
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition

Pain can occur at all stages of the sexual cycle. A new diagnostic category has been created for this in the DSM-5: genito-pelvic pain/penetration disorder. The criteria for this are:

Persistent or recurrent problems with at least one of the following for at least six months:

• Sexual vaginal penetration
• Vulvovaginal pain or pelvic pain during or prior to vaginal penetration
• Distress due to vulvovaginal pain or pelvic pain during or prior to vaginal penetration
• Contraction or tightening of the pelvic floor muscles during vaginal penetration
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

What are the risk factors for sexual dysfunctions?

Menopause is an important risk factor for female sexual interest/arousal disorder. Aging, depression, smoking and medical conditions such as diabetes and cardiovascular and genitourinary disorders are risk factors for dysfunction in men. Education also has an influence: men who are more educated are more likely to have early ejaculation and less educated men are more likely to have erectile dysfunction. Childhood abuse is also a risk factor for sexual dysfunction. Finally, sexual dysfunction is more common in women than in men (43% versus 31%).

What is the aetiology of sexual dysfunctions?

From the psychoanalytic point of view, vaginismus is seen as women expressing hostility towards the man and, in premature ejaculation, when men express hostility towards the woman. Vaginismus is the involuntary contraction of the muscles around the vagina during vaginal penetration. Of all people seeking treatment for sexual dysfunction, 15%-17% suffer from vaginismus.

Masters and Johnson's two-factor model has two major components that contribute to sexual dysfunction:

1. A learned or conditioned factor in which negative early events produce a learned fear response to sexual activity, such as psychosexual trauma, religious and social taboos, shameful early experiences of sex, or excessive alcohol consumption (in men); and
2. The spectator role that individuals take in response to their fears.

However, it is not yet entirely clear how these two components interact. Although people with sexual dysfunctions are known to suffer from performance anxiety, it is not known whether this is a cause or consequence of the dysfunction. Performance anxiety is the fear a person has that he will not be able to achieve an acceptable level of sexual performance, causing a person to distance himself from it and not be able to get aroused.

Interpersonal problems can also be the cause of sexual dysfunctions. If negative emotions are central to a relationship, other emotions such as fear, and mistrust will interfere with the development of positive feelings required in the desire and arousal phase of the sexual cycle. It is also possible that one of the partners or both partners have little or no knowledge and experience. It is difficult to say whether these problems are really the cause of the dysfunctions, but it is true that couples therapy is often successful.

Sexual experiences are satisfying if the individual is open to experiencing positive emotions during the sexual activity. Negative emotions interfere with sexual performance and depression and anxiety are risk factors for sexual dysfunction.

One view of the causes of sexual dysfunction is that it is due to a combination of direct and indirect factors. Direct factors directly affect sexual functioning, such as performance anxiety and communication problems between partners. However, these direct problems can arise from indirect (remote) factors, such as feelings of shame and guilt about sexual activity, feelings of inadequacy, feelings of conflict caused by lifelong stress, and so on.

There are also biological factors that can be of influence on sexual dysfunction, namely:

1. Dysfunction caused by an underlying medical condition, such as dyspareunia: genital pain that may come before, during, or after sexual intercourse
2. Dysfunction caused by abnormalities in sex hormones, such as testosterone (steroid hormone that stimulates the development of male secondary sex characteristics), oestrogen (steroid hormone that stimulates the development and maintenance of female secondary sex characteristics), and prolactin (pituitary hormone that stimulates milk production after the birth of a child)
3. Changes in sexual receptivity with aging

Finally, there are socio-cultural factors that can cause sexual dysfunction. Cultures often have 'rules' about sexual behaviour. These rules can cause conflict and sexual dysfunction. For example, poverty, financial problems and unemployment are linked to erectile dysfunction in men and in some cultures, society asks women to suppress their sexuality.

How can sexual dysfunctions be treated?

There are two specific techniques to help clients with premature ejaculation. The first is the stop-start technique, in which the partner stimulates the penis until the client signals to climax and tells the partner to stop. The second is the squeeze technique, where the client's partner squeezes the tip of the penis hard just before ejaculation.

The tease technique is a method intended to remedy erectile dysfunction or orgasmic disorders. Here, the partner caresses the client's genitals, but stops when the client becomes aroused or close to orgasm. In this way, it is taught to experience sexual pleasure without having to achieve an orgasm. For people with arousal or orgasm problems, targeted masturbation training is often helpful, using videos, diagrams and sometimes erotic material to teach how to achieve an orgasm.

Couples therapy is a treatment for sexual dysfunction that involves both partners and discusses issues. Sex skills and communication training is a treatment method in which a therapist can help clients gain a more expert perspective on sexual activity and where the therapist effectively communicates about sex with partners and reduces fear of giving in to sexual activity. Self-instructional training is also used to teach the client to use positive self-instruction at various times during sexual activity in order to guide their behavior and reduce anxiety. In addition, appropriate guidance is necessary, because sexual dysfunction often underlies negative events. Talking about this can help relieve the symptoms.

What are the biological treatments?

The most well-known drug treatments for sexual dysfunctions are the PDE-5 inhibitors Viagra and Cialis, both used to treat erectile dysfunction. These drugs relax the smooth muscle in the penis which improves blood flow and promotes erection.

Yohimbine is also used to treat erectile dysfunction by facilitating the excretion of noradrenaline in the brain. This seems to solve brain neurotransmitter problems that cause erectile dysfunction. SSRIs are used for premature ejaculation. Hormone replacement therapy is used if there are low oestrogen levels in women or low testosterone levels in men.

Mechanical devices have also been developed to help with erectile dysfunction. A penile prosthesis is an example of this. This consists of a fluid pump that is placed in the scrotum and a semi-rigid rod that is placed in the penis. Squeezing the pump releases fluid into the rod, making the penis erect. An alternative to this is the vacuum erection device (VED). This is a hollow cylinder that is placed over the penis. The client removes the air from the cylinder using a hand pump, which draws blood into the penis, causing an erection.

What are paraphilic disorders?

Paraphilic disorders represent sexual needs and fantasies involving unusual sources of gratification. Some paraphilias involve the person's own activities and some involve erotic targets. It is difficult to draw a line between what is normal and abnormal. Most people do not want to act on their fantasies and are happy to limit their sexual interest in paraphilic activities to watching erotic or pornographic material. In addition, behaviour is only labelled as abnormal if a person's sexual tendencies are linked to a specific type of stimulus or behavior.

What is a Fetish Disorder?

A fetish disorder is described in the DSM-5 by the following criteria:

• Recurrent and strong sexual arousal over a six-month period through the use of inanimate objects or a strong specific focus on non-genital body parts in fantasies, needs, or behaviors. This causes distress or impairment in social, occupational, and other areas;
• The fetish is not limited to dressing as in cross-dressing or to objects such as vibrators and other genital stimulators.
• Fetishes are often limited to items associated with sex, such as bras or feet. Some show the phenomenon of partialism, where there is a fascination with a specific object or part of the body to the point that normal sexual activity is no longer involved.

What is a transvestite disorder?

Cross-dressing disorder is described in the DSM-5 as experiencing persistent strong sexual arousal from dressing as the opposite sex as part of fantasies, needs, or behaviors for at least six months. This causes distress or impairment in social, occupational, and other areas. About 2.8% of men and 0.4% of women report a cross-dressing episode in their lifetime.

What is Exhibitionism?

Exhibitionism means that a person has sexual fantasies about showing the genitals to a stranger. The disorder occurs in approximately 2% to 4% of men. The DSM-5 criteria for this disorder are:

• Sustained strong sexual arousal by exposing the genitals to an unsuspecting public for at least six months as part of fantasies, needs, or behaviors;
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas.

What is Voyeurism?

Voyeurism is described in the DSM-5 with the following criteria:

• Sustained strong sexual arousal from observing an unsuspecting person naked, undressing, or engaging in sexual activity for at least six months as part of fantasies, needs, or behaviours
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas
• The patient is at least 18 years old

The lifetime prevalence of voyeuristic activities is approximately 12% in males and 4% in females.

What is frotteurism?

Frotteurism is described in the DSM-5 with the following criteria:

• Sustained strong sexual arousal from touching or rubbing against an unauthorized person for at least six months as part of fantasies, needs, or behaviors;
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas.

About 10% to 14% of men seen for paraphilic disorders meet these criteria.

What is Pedophilia?

Pedophilia is the sexual attraction to children normally 13 years or younger. The DSM-5 criteria for this disorder are:

• Sustained strong sexual arousal from fantasies, needs, and behaviors that include sexual activity with children 13 years of age or younger
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas
• The patient is at least 16 years old and at least 5 years older than the child involved
• The patient is not in late adolescence in a sexual relationship with a 12- or 13-year-old child.

The highest probable prevalence of pedophilia in men is between 3% and 5%. Often, pedophiles do not feel that what they are doing is wrong.

There are several unofficial subtypes of pedophilia. First, some pedophiles limit themselves to immediate family. Incest differs from other forms of pedophilia in that it concerns older, (almost) adult children and that it is often accompanied by a normal heterosexual sex life. Pedophiles who do not engage in incest, but are aroused by sexually immature children, are also referred to as preference molesters. Second, pedophiles never actually intend to hurt their victims. Child rapists are pedophiles who do hurt and sometimes even kill their victims and only get sexual satisfaction through this. Most pedophiles proceed in a standard way, which involves going through several steps: (1) choosing an open,

In the US, 12% of men and 17% of women have been sexually touched as children. Many victims experience long-term psychological problems because of this.

What is Sexual Masochism and Sexual Sadism?

In a sexual masochism disorder, an individual becomes sexually aroused by humiliation. The DSM-5 criteria for this disorder are:

• Sustained strong sexual arousal from being humiliated, tied up or beaten or from suffering for at least six months as part of fantasies, needs or behaviours
• The needs cause distress or impairment in social, occupational, and other areas

In a sexual sadism disorder, an individual becomes aroused by the suffering of others. The DSM-5 criteria for this disorder are:

• Sustained strong sexual arousal from the physical or psychological suffering of others for at least six months as part of fantasies, needs, or behaviors;
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas.

Often masochism and sadism go together because one person likes to be hurt and the other likes to see another person suffer. Masochists often cause their own suffering, as in hypoxyphilia, where an individual uses a noose or plastic bag to induce oxygen deprivation during masturbation.

About 5% to 10% of people are involved in sadomasochistic activities at some point in their lives.

What is the aetiology of paraphilic disorders?

First, being a man is a risk factor. For example, there are 20 times as many male masochists as there are female ones. In addition, a link has been found between being heavily involved in sexual activities (hypersexuality) and paraphilias, such as exhibitionism, voyeurism, masochism and sadism.

Much research has been done on the risk factors for pedophilia. Both remote factors (including childhood sexual abuse) and direct factors (including depression) can play a role in this. Psychopathology can be a contributing factor in triggering pedophile behavior.

What is the psychodynamic perspective on paraphilias?

In this view, paraphilias are seen as either defense mechanisms to protect the ego from repressed fears, or fixation on a pregenital stage in development. For example, fetish and pedophilia can be seen as behaviors of individuals who find normal sex too frightening, perhaps because of castration anxiety (a psychological complex in which a man fears being castrated), and voyeurism as a behavior that protects against having to deal with a relationship, which is often part of a sexual life.

How does classical conditioning explain paraphilias?

A simple explanation for paraphilias is that unusual sexual desires result from early sexual experiences associated with an unusual stimulus or behavior through associative learning.

How do abuse and neglect play a role in paraphilias?

Childhood abuse and neglect are important predictors of developing psychological problems and paraphilias later in life. This can cause, among other things, low self-esteem and an inability to form lasting relationships, which in turn can lead an individual to seek sexual satisfaction in ways that do not require a normal sexual relationship or involve children who are still underdeveloped so that the individual is not at a disadvantage. However, not all individuals with paraphilias have experienced abuse and neglect, so it is not a requirement.

How do dysfunctional beliefs, attitudes, and schemas play a role in paraphilias?

Cognitive biases are beliefs that sexual offenders have that allow them to justify their sexual transgressions. For example, pedophiles believe that children want sex with adults, making their behavior socially acceptable and not harmful to the child. Sex offenders or rapists often have developed integrated cognitive schemas that guide their interactions with their victims and justify their behavior, known as implicit theories. Five types can be distinguished, including the views that:

1. Women are unknowable
2. Women are sex objects
3. The male sex drive is uncontrollable
4. Men are naturally dominant over women
5. The world is a dangerous place.

What biological theories are there regarding paraphilias?

Because the majority of individuals with paraphilias are male, paraphilias are believed to be caused by abnormalities in male sex hormones or by imbalances in brain neurotransmitters responsible for regulating sexual behavior. For example, androgen is the main male sex hormone. Unusual sexual behavior, such as committing impulsive sexual transgressions, may be due to imbalances in this hormone.

There are also some brain regions that show abnormalities, such as in sadism, exhibitionism, and paedophilia in the temporal lobe.

How can paraphilic disorders be treated?

Treatment is complicated by the fact that criminal behavior is often involved, so that there is not always fairness, that clients often enjoy their behavior and by cognitive biases. Most treatments use a multifaceted approach.

What behavioral techniques are there?

Aversion therapy can be used to break the positive association between inappropriate stimuli and sexual arousal. This form of therapy can be used in a covert conditioning form, where the client's imagination is used to associate sexual stimuli with negative outcomes.

Masturbation saturation is a treatment where the client is asked to masturbate in the presence of arousing stimuli. Right after he cums, he should start masturbating again. This will lead to a decrease in the erotic value of the first arousing stimuli. Orgasm redirection is a treatment that replaces inappropriate or distressing sexual activity with arousal from more usual stimuli.

What cognitive treatments are there?

Cognitive treatments aim to help the client identify and challenge dysfunctional beliefs, often in the form of CBT. The Sex Offender Treatment Program uses CBT methods to treat incarcerated sexual offenders. Risk factors such as sexual preoccupation, sexual preferences for children and a lack of emotional intimacy with adults are mentioned.

What does relapse prevention training entail?

Relapse prevention training helps clients identify conditions, situations, moods, and types of thoughts that may trigger paraphilic behaviors.

What hormone and drug treatments are there?

Antiandrogenic drugs are used to reduce levels of sex hormones and thus decrease sexual desire. Medroxyprogesterone acetate and cyproterone acetate are examples of this, these drugs specifically lower testosterone levels.