Dennis B. Kottler, MD
Westlake Village, CA
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Of course the proper diagnosis and treatment of the various sexual disorders is best left to a skilled professional with particular experience in the area of human sexuality.
As with most topics in Psychiatrix.com, it is difficult to talk of "normal" or even a "range of normal" when considering sexual behavior. Differing cultural and moral attitudes toward sexuality must also be considered.
A convenient way to categorize sexual disorders, for both men and women, is that popularized by Helen Singer Kaplan, MD. In this scheme the various sexual problems fall into one or more of the following categories:
DISORDER OF DESIRE:
Most commonly a persistent absence or severe reduction in sexual fantasies and/or the desire for sexual activity. Of course, this condition must be evaluated in the context of age, situation, and cultural factors.
DISORDER OF AROUSAL:
In the male: Persistent difficulty in achieving and maintaining an erection suitable for satisfying sexual activity.
In the female: Persistent difficulty in achieving lubrication and other physiological responses (e.g. clitoral engorgement) suitable for satisfying sexual activity.
DISORDER OF ORGASM:
Persistent difficulty in attaining orgasm (or in some cases absence of orgasm) following arousal when the sexual simulation is thought to have been adequate. This category includes premature as well as delayed orgasm.
(Note: In all the above categories it is recognized that there are extremely wide variations among individuals in the nature and extent of sexual stimulation required to produce the desired result. Also, age, cultural background, and personal background certainly influence one's sexual response).
Causes of Sexual Dysfunction
Secondary Sexual Dysfunction
One of the common causes of sexual dysfunction is medication, especially antidepressants and antihypertensives, as well as various "recreational" substances, such as alcohol and marijuana. Numerous medical conditions can also be the problem, especially diabetes, arteriosclerotic cardiovascular disease, and neurologic disorders. Finally, psychiatric disorders such as major depressive disorder, bipolar disorder, and anxiety disorders can frequently lead to sexual dysfunction.
Once the above causes have been ruled out (or ruled in and corrected), the disorder can be considered a primary sexual dysfunction (i.e., not secondary to some non-sexual problem).
Primary Sexual Dysfunction
Primary sexual disorders have multiple causes and there are various treatment strategies. To help understand the nature of the disorder it is useful to consider whether the problem has been "lifelong" or "acquired." If it has been acquired it is very useful to try to understand the events surrounding the beginning of the problem. Also, is the problem specific to certain circumstances? For example, does the problem arise only with a partner or also in masturbation? Is the problem unique to sex with a particular partner? Does the problem occur when the person is preoccupied with particular thoughts? The skilled practitioner will, like a good detective, pursue these various lines of inquiry to develop clues to the cause of the problem.
An Important Concept About Causes and Treatment
Many sexual disorders are multifactoral. Thus, for example, a fifty year old man who complains of touble getting an erection may be suffering from any combination of, or even all of the following: 1- An age effect without a corrresponding adjustment in expectations; 2- Possible complications from other medical or psychiatric conditions as well as side effects from the medications used to treat them; 3- Psychological issues; 4- Relationship problems; 5- Occuptional or other source of stress; 6- Negative cognitive/hehavioral patterns such as performance anxiety. Multifactoral causation can apply to any of the sexual disorders.
Similarly, effective treatment often needs to be multifaceted to address the various underlying causes. The decision to involve a partner varies with each situation, but is often beneficial if this person is willing and supportive. If this is not the case, this may in fact be part of the problem.
Other Forms of Sexual Dysfunction
Just as varied as sex itself, are the many ways in which sex can become dysfunctional.
For example, there are instances in which sex becomes excessive to the point that the excess causes distress, both physically and mentally. A case in point is "compulsive masturbation" which can be a symptom of obsessive compulsive disorder.
Seemingly at the other end of the spectrum is sexual aversion disorder, in which sex with a partner is completely (or almost completely) avoided.
Vaginismus is a female sexual disorder characterized by the persistent involuntary contraction of the muscles surrounding the outer third of the vagina when any penetration is attempted.
Dyspareunia is the persistent association of pain with sexual intercourse.
Desire can also get out of hand as in the case of the hypersexuality associated with bipolar (manic depressive) disorder.
Even arousal can be the victim of excess. In a condition known as priapism (a medical condition named after the mythological figure Priapus), the penis is the victim of persistent painful erection. This condition can be caused by various medical conditions as well as medication side effects.
Finally, there is the huge category of paraphilias. In general, paraphilias involve sexual desires, fantasies, and arousal directed towards situations which are not considered appropriate (what's appropriate?) sources of sexual satisfaction and often involve illegal, socially unacceptable, or personally distressing behaviors or the victimization of another individual. Examples of paraphilias are fetishism, transvestic fetishism, pedophilia, frotteurism (rubbing against a non-consenting person), exhibitionism, voyeurism, masochism, and sadism. Other paraphilias involve strong preference for certain body configurations in the partner, such as extreme obesity, amputee condition, or other disfigurement. Paraphilias occur almost exclusively in males, although there are exceptions. Finally, what might be considered a paraphilia in one culture might be considered appropriate behavior in another culture.
Much progress has been made in medication treatment, particularly of male sexual dysfunction. Viagra is now well-know as an FDA approved treatment for male erectile disorder (ed). Recently Levitra, a similar type of medication, has been approved, also for male erectile disorder. Other medications in this class are in development.
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