Gizem Arıkan (BSc)
Middle East Technical University, Department of Psychology, Turkey
Biographical staement: Graduated from Middle East Technical University Department of Psychology and Department of Philosophy (Double Major) in 2005. Graduate student in Psychology (Clinical Psychology option) at Middle East Technical University.
In this paper, Sexual Dysfunctions are explained in terms of DSM-IV-TR criteria. Information about prevalence and occurrence rates is specified. Phases of sexual intercourse is explicated which enhance knowledge about disorders. Physiological factors such as reproductive life cycle, urinary track infections, diabetes, cardiopathies and drug side-effects and past and current psychological conditions are explained to assess the basis of sexual dysfunctions. Influence of variables on treatment is underlined with respect to different therapeutic tools, techniques and methods. Outcome and effectiveness research support evaluated. Lastly, important aspects in the course of therapy, elements and key concepts that would be beneficial for successful outcome are discussed.
Keywords: Sexual Dysfunctions, physiological factors, psychological factors, therapy outcome
Sexual dysfunction is one of the most important areas, which require special knowledge and different perspectives to apply varied therapeutic concerns. Sexual Disorders are categorized into four main sections according to DSM-IV-TR (2000): Sexual Desire Disorders, Sexual Arousal Disorders, Orgasmic Disorders and Sexual Pain Disorders. Firstly, Sexual Desire Disorders are defined as general persistent or recurrent deficiency of sexual fantasies or sexual activity leading to disturbance with causing marked distress. Sexual Desire Disorders are Hypoactive Sexual Desire Disorder and Sexual Aversion Sexual Desire Disorder. Secondly, Sexual Arousal Disorders include Female Sexual Arousal Disorder and Male Erectile Dysfunction. Sexual Arousal Disorders explained as persistent or recurrent inability to attain or to maintain sexual response like lubrication and erection until the end of intercourse. This leads to marked distress. Thirdly, Orgasmic Disorders contain Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation. Orgasmic Disorder defined as persistent or recurrent delay or absence of orgasm following a normal sexual excitement phase. This causes distress. Clinician while evaluating diagnosis should consider the age. Lastly, Sexual Pain Disorders characterized as recurrent or persistent pain associated with sexual intercourse which results in marked distress. Dyspareunia and Vaginismus are subcategories of Sexual Pain Disorders. Dyspareunia can be diagnosed in both males and females however Vaginisumus, which is recurrent or persistent spasm of the musculature of the outer third of vagina that interfering sexual intercourse, diagnosed in females. The sexual dysfunctions should not be better accounted by another Axis I or direct physiological effects of a substance or a general medical condition (DSM-IV-TR, 2000).
Causes, epidemics and therapy
Sexual disorders reflect problems in the phases of sexual intercourse. These phases are excitement, orgasm and resolution (Oltmanns & Emery, 2001). Excitement starts from initial stimulation with physiological changes until orgasm takes place. Secondly, orgasm is explained as gradual build up of sexual excitement and ends with sudden release of tension. Lastly, resolution occurs in which excitement is lessened in the end of intercourse.
According to prevalence rates %49 of females have one sexual dysfunction, lack of sexual desire problems seen in the rate of %26, pain during intercourse prevalence is %23, and %21 of Brazil population has orgasmic dysfunction (Abdo, Oliveria, Moreira & Fittipaldi, 2004). In National Health and Social Life Survey reports that, %43 of women and %31 of men undergoes sexual dysfunction in USA (Lauman, Paik & Rosen, 1999 cited from Heinman, 2002). Another study contains information from 29 countries’ prevalence of any sexual dysfunction and reports that between ages of 40-80, prevalence of sexual dysfunctions is %28 (Mohan, & Bhugra, 2005).
All studies propose that prevalence rates of sexual dysfunctions cannot be undermined and importance of knowledge on sexual disorders is vital.
Sexual dysfunctions are derived and maintained by both physiological and psychological causes. Physiological causes may occur due to reproductive life cycle, urinary track infections, diabetes, cardiopathies and drug side-effects. For females most relevant physiological sources for sexual problems is reproductive life cycles (Warnock, 2002). Menstrual cycles may come up with high sexual desire because of ovulation and readiness for offspring production or decreased sexual desire as a result of sensitivity and Premenstrual Syndrome. In addition, hormonal contraceptives affect reproductivitiy causing low levels of testosterone level. Also, postpartum states and lactation results in low levels of estrogen and vaginal dryness. These conditions lead to decrease in sexual desire.
Peri-post menopause periods for women carry a critical influence on reproductivity. In such age periods, operations on ovaries, uterus can be seen and sensation in sex decreases which may lead to problems in sexual life (Warnock, 2001). Both males and females are inclined to undergo sexual problems as a result of urinary track infections. Urinary track infections associated with sexual arousal and pain disorders in females and erectile dysfunction in males (Heinman, 2002; Mohan & Bhugra, 2005; McCabe, 2005; Morton & Hartman, 1985).
Furthermore, diabetes leads to lack of sexual desire and orgasmic dysfunctions (Abdo, et.al., 2004). The diabetes itself causes some problems and medication related to that illness may results in sexual problems in adults. Another medical condition is cardiapethies which may be observed in both late adulthood and early ages. Especially, Vaginismus and pain during sex may take its source from cardiovascular system malfunctioning (Abdo, et.al., 2004). Therefore in the treatment plan, hormonal tests and cardiovascular assessment definitely required for adequate categorization.
Also some drugs’ side effects result in sexual dysfunctions. MAO Inhibitors, Benzodiazepines, Tricylics and Antidepressants are related to orgasmic delay (Segraves, 2002). It is required to know drug use and possible side effects of both legal and illegal drugs.
Psychological basis of sexual dysfunctions are varied in the sense that they may be sourced from past and current conditions of adult. Past conditions like childhood history, sexual development, adolescence period and parental relations carry importance for later sexual functioning.
Some female sexual dysfunction cases are found to be in relation with traumatic sexualization and childhood sexual abuse. According to Merrill, Guimond, Thomsen, & Milner (2003) traumatic sexualization shapes child’s sexuality in an interpersonally dysfunctional manner, this may cause inappropriate sexual activity and arousal. It is found that arousal disorder in females related to experiencing childhood sexual contact or male sexual force in childhood (Heinman, 2002). One of the major effects that may trace in childhood is sexually touched before puberty. In males sexually touched before puberty three fold increases erectile dysfunction and two fold increases ejaculation problems and sexual desire disorders (Heinman, 2002).
In addition to that history of childhood abuse or other abnormal sexual development problems lead to longer periods of erectile dysfunction in males (Banrofti Herbenick, Barnes, Hallam-Jones, Wylie, Janssen & Members of BASRT, 2005). If there is history of childhood sex or sexual abuse, sex becomes associated with negative emotions and memories which is generalized to non-abusive sexual experiences and leading to phobic reactions to sexual intimacy and avoidance of sex (Merrill, et.al., 2003).
In Meston & Heiman study it is found that sexually abused women compared to nonsexual abused women uses negative affect and giving less positive meaning to sexual behavior words (2000). It could be suggested that one of the major concern while dealing with sexual disorders is the past history related to abuse or other abnormalities in development since this reflects the cognitive structuring about sexuality and associated feelings towards sex.
In addition to that, parental attitudes towards sexuality may bring up problems in sex life of adults. Therefore, it should be concerned too. Secondly current psychological functioning is vital to acknowledge the details about sexual disorders and maintaining factors. Other dysfunctionalities in the form of psychological disorders are relevant to assess since comorbidity can be observed in most cases. It is known that patients diagnosed with Depression, Schizophrenia, Eating Disorders, Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, and Panic Disorder may suffer from sexual difficulties and these may result in sexual dysfunctions (Segraves, 2002; Mohan & Bhugra, 2005).
It is crucial to know current status of the patient in terms of stress and emotional problems since they may be related to sexual dysfunctions. In the study of Bozkurt, it is found that psychogenic impotence patients get higher scores on anxiety and depression scales and recorded higher scores in somatic complaints, obsessive compulsive symptoms, interpersonal relationship sensitivity, hostility, psychoticisim, and paranoid thinking than organic impotence patients (1996).
All these indicated that sexual dysfunctions may lead to stress in life and difficulties in many areas. Patients’ evaluations about themselves and towards sexual intercourse are important elements in sexual dysfunctions. Parallel to that, attributions, experiences, attitudes, self-esteem and body image found to be influential in sexual dysfunctions (Mohan & Bhugra, 2005). In females, attitudes toward sex, which were shaped in childhood in accordance with parental attitudes and beliefs, and performance anxiety are found to be related to sexual dysfunctions (McCabe, 2005).
Anxiety during sexual activity carries great importance in the continuation of dysfunction. In most cases of male sexual dysfunctions, performance anxiety has a role. In erectile dysfunction, attentional biases, distraction, negative cognitions are found to be linked with maintenance of problems (Heiman, 2002; Mohan & Bhugra, 2005; Morton & Hartman, 1985). Once sexual dysfunction develops both males and females starts to monitor their levels of interest and arousal, leading to increase in anxiety (McCabe, 2005). There are two proposed mechanisms for sexual responses (Banroft, et.al, 2005): Excitatory and Inhibitory. These systems should be in equilibrium for normal sexuality. If excitatory mechanisms works excessive there may occur risky sexual behaviors. When inhibitory mechanism’s influence increases, sexual dysfunctions may take place. Some of the relevant concepts for male sexual dysfunctions are sourced from cognitive fallacies that can be developed towards sexual intercourse: Anger and resentment; fear of causing harm; guilt masochism and depression; feeling of inadequacy and fear of rejection; fear of rejection of partner; and fear of injury (Morton & Hartman, 1985).
Most of these concepts are psychodynamic theory originated. Still they have influence in misunderstandings towards sexual intercourse and self perception in relationship with partner. Thus, to question these fallacies would reveal the basis of male sexual dysfunctionality. Since sexual intercourse relates two people, it is central to know relationship quality and intimate relationship style. Relationship quality and interpersonal relations are found to be important for both male and female sexual dysfunctions (McCabe, 2005; Bozkurt, 1996). Nevertheless, Demirkol, 1998 suggested that marital conflict not related with sexual dysfunction and therapy outcome. This may resulted from different measures used in studies to assess marital relationship effects.
For therapy and outcome studies there are varied results in terms of application of therapy, kind of therapy and duration of therapy. Furthermore, outcome measures differ study to study. For that reason, it is not likely to make concrete conclusions about treatment effectiveness and most appropriate methods to be enhanced.
Nonetheless, there is a chance to overview what influence process of treatment. Demographic characteristics are influential in the outcome study of Demirkol. In the study, erection dysfunction, premature ejaculation patients with erection dysfunction comorbidity, premature ejaculation, vaginismus, orgasmic dysfunction and dyspreniua patients went through three sessions of cognitive behavioral therapy. Results suggest that, males, older adults and singles were dropped out more than females, younger adults and married ones.
The most successful cases were vaginismus and premature ejaculation without comorbidity (1998). It is found that therapist intervention is not really critical in Van, Everaerd & Grotjohann (2001) study. Ten week bibliotherapy including cognitive and behavioral methods, self help strategies, masturbation techniques, physiological mechanisms, exercises, exploration of genitals and sexual fantasies applied with phone support therapist. Results indicated that there is general improvement about sexual problems (Van, et.al, 2001).
Sexual dysfunction if associated with anxiety, systematic desentization would be effective (LoPiccolo & Stock, 1986). The most used therapy method is Master’s & Johnson Behavioral Therapy. In addition to that, directed masturbation, sexually arousing stimulation, education, self exploration, partner acknowledgement, cognitive work, exercises, cognitive homework, vaginal self dilation, sensate focus, cognitive restructuring, masturbation techniques are found to be effective for treatment (LoPiccolo & Stock, 1986; McCabe, 2001; Kabakçı & Batur, 2003).
Combined sex and marital therapies, hormone therapy and couples therapy found to be effective (Rosen & Leiblum, 1995). However, there are alternative results suggesting no difference in varied therapy methods. O’Carrol (1991) found that there is no difference between Masters & Johnson Therapy against relaxation with marital therapy, for instance.
In Turkey, most responsive cognitive behavioral therapy results are taken from vaginusmus cases (Kabakçı & Batur, 2003; Demirkol, 1998). This would be related to desire of having baby of couples since vaginusmus do not allow penetration and full sexual intercourse. Therefore, attendance to therapies and treatment procedures is high for such a secondary gain. Still, it is not very likely to have good feedbacks about cognitive behavioral therapies due to active directiveness expected from therapist by patients (Kabakçı, 2003).
Therapist should have adequate knowledge base and has the capacity to explain methods and sources of problem to other side by informing in many aspects. People who are coming with different myths like masturbation is harmful, sexual fantasies are immoral and unroyal, erection is the key for making love etc. should be reflected upon in therapy sessions (Özmen, 1999). Basic information about nature and development of sexual dysfunctions, emotional reactions, hypothesis about dysfunction, attempts to solve problems, psychiatric history, physical health status, medicines and taken drugs, motivation of treatment, initial sexual history, changes in sexual history, method of satisfaction, birth control, family culture, religious background, early sex play, education, initial experiences, abuse and adolescence period should be questioned before initiating therapy sessions.
Detailed evaluation of these key concepts would be beneficial for what sort of plan should be chosen and which aspects should be more emphasized in therapy. For solving the problems, standpoints of both partners should be taken into account and therapy session should be formed with interactive communication and participation.
Consequently, in sexual disorders varied therapeutic tools needed to understand the basis and maintaining elements of problems. Therapist should encourage patient to be clear and open for dealing with sexual disorder. Also partner should be included in the treatment plan for successful outcome.
DSM IV, (2000). American Psychiatric Association Quick Reference to Criteria from DSM-IV-TR. Fourth Ed.
Abdo, C.H.N., Oliveria, W.M., Moreira, E.D., and Fittipaldi, J.A.S.(2004) Prevalence of Sexual Dysfuncitons and Correlated Conditions in a Sample of Brazilian Women: Results of the Brezilian Study on Sexual Behavior (BSSB). International Journal of Impotence Reseach. 16, 160-166.
Banroft, J., Herbenick, D., Barnes, T., Hallam-Jones, R., Wylie, K., Janssen, E., & Members of BASRT. (2005).The Relevance of the Dual Control Model to Male Sexual Dysfunction: The Kinsey Institute/BASRT Collaborative Project. Sexual and Relationship Therapy. 20(1), 13-30.
Bozkurt, A. (1996). Psychopathology in Male Dysfunctions. (Thesis)
Demirkol, A. (1998). Charateristics, Treatment Outcome and Factor related to Prognoses of Sexual Dysfunction Cases. (Thesis)
Heiman, R.J. (2002). Sexual Dysfunction: Overview of Prevalence, Etiological Factors, and Treatments. The Journal of Sex Reseach, 39, 73-78.
Kabakçı, E. & Batur, S.(2003). Who Benefits from Cognitive Behavioral Therapy for Vaginismus? Journal of Sex & Marital Therapy. 29(4), 277-288.
LoPiccolo, J. & Stock, W.E. (1986)Treatment of Sexual Dysfunction. Journal of Consulting and Clinical Psychology. 54(2), 158-167.
McCabe, M. (2005) The Role of Performance Anxiety in the Development and Maintenance of Sexual Dysfunction in Men and Women. International Journal of Stress Management, 12(4), 379-388.
McCabe, M. (2001). Evaluation of Cognitive Behavioral Therapy Program for People with Sexual Dysfunciton. Journal of Sex and Marital Therapy. 27, 259- 271.
Merrill, L.L., Guimond, J.M., Thomsen, J.C., & Milner, J.S. (2003). Child Sexual Abuse and Number of Sexual Partners in Young Women: The Role of Abuse Severity, Coping Style and Sexual Functioning. Journal of Consulting and Clinical Psychology, 71 (6), 987- 996.
Meston, C.M., & Heiman, J.R.(2000)Sexual Abuse and Sexual Function: An Examination of Sexually Relevant Cognitive Processes. Journal of Consulting and Clinical Psychology. 68(3), 399-406.
Mohan, R. & Bhugra, D. (2005). Literature Update: A Critical Review. Sexual and Relationship Therapy, 20 (1), 115-122.
Morton, R.A. & Hartman, L.M. (1985).A Taxonomy of Subjective Meanings in Male Sexual Dysfunction. The Journal of Sex Research. 21(3), 305-321.
O’Carroll, R (1991)Sexual Desire Disorders: A review of Controlled Treatment Studies. The Journal of Sex Research 28(4), 607-624.
Oltmanns, T.F & Emery, R,E. (2001). Abnormal Psychology. 3rd Ed. Prentice Hall: USA (CHAPTER 12)
Özmen, E. (1999). Cinsel Mitler ve Cinsel İşlev Bozuklukları. Psikiyatri Dünyası. 2, 49-53.
Rosen, R.C., & Leiblum, S.R.(1995).Treatment of Sexual Disorders in the 1990’s: An Integrated Approach. Journal of Consulting and Clinical Psychology, 63(6), 877-890.
Segraves, R.T. (2002). Female Sexual Disorders. Canadian Journal of Psychiatry, 47(5), 419-425.
Van., J.J.DM., Everaerd, W., & Grotjohann.(2001)Cognitive Behavioral Bibliotherapy for Sexual Dysfunctions in Heterosexual Couples: A Randomized Waiting-list Controlled Clinical Trial in the Netherlands.The Journal of Sex Research. 38(1), 51-67.
Warnock, J.J.K. (2002) Female Hypoactive Sexual Desire Disorder: Epidemiology, Diagnosis and Treatment. CNS Drugs 16(11), 745-753.