Sexual Disorders

A variety of organic (physical) and functional (psychological) sexual disorders may arise following injury. The boundary between what is physical and what is psychological becomes blurred.

Sexual Dysfunctions are characterized by disturbance in sexual desire and the physical changes that characterize the response cycle of sexual excitation and sexual activity. They are dysfunctions when they case personal distress and/or interpersonal (social) difficulties. They can arise in the area of desire, excitement, orgasm, and/or resolution. They can be of lifelong or acquired duration and can be generalized to many situations or situational and occur only in specific situations. They can be due to psychological factors or due to a combined physical and psychological problem.

The more common sexual dysfunctions include:

Hypoactive Sexual Desire Disorder: is described as a deficiency or absence of sexual fantasies and desire for sexual activity. This is considered a disorder if it causes distress for the patient or problems in the patient’s relationships. It must be determined that this is not the result of another psychological disorder which is the primary problem. If the sexual partner of a patient with suspected hypoactive sexual desire disorder feels that this is a problem within the relationship, that concern should be sufficient for the individual to seek psychological consultation.

Sexual Aversion Disorder: can be acquired or be of lifelong duration and it can be generalized to most relationship or be situational and occur only in some contexts. Some patients with this disorder will have extreme feelings of anxiety and the associated physical complaints of anxiety (panic, terror, nausea, shortness of breath, palpitations, etc) in anticipation that they will be exposed to a sexual situation. Occasional aversion is not considered a disorder but when it interferes with interpersonal relationships or creates marked emotional distress, it warrants professional attention. It results in either aversion or avoidance of almost all sexual contact and must be differentiated from other psychological conditions which may be the primary cause and have gone undiagnosed. Some have an aversion toward all sexual stimuli, even kissing and touching.”

Female Sexual Arousal Disorder like the other Sexual Desire Disorders can be of recent onset or of lifelong duration. It also may be associated with specific settings, situations and relationships or generally present in all sexual settings. It may be due to psychological factors or a combination of psychological and physical factors. It is characterized by inability to attain or maintain adequate physical response to sexual excitement. It is considered a disorder when it causes distress or interpersonal conflict, and it must be differentiated from other psychological problems for which it may be simply a symptom rather than the primary problem.

Male Erectile Disorder is the recurrent inability to achieve or maintain an adequate erection until completion of sexual activity. It is not considered male erectile disorder if it is merely an occasional problem or if it does not create distress and interpersonal difficulty. It can be due to psychological or a combination of psychological and physical factors, and it can occur in most or just some settings. For some, the onset occurs at a specific time in life (acquired) as in response to a specific situation. For others, it may be of lifelong duration. It is important to differentiate male erectile disorder from mood disorders or anxiety disorders for which this may merely be a symptom of a larger underlying problem. Complete psychological and physical examinations may be indicated for many patients. It should be noted that some research indicates that the acquired type (vs. lifelong type) will spontaneously disappear in 15-30% of cases and may be dependent upon the type of sexual partner and quality of the relationship.

Female Orgasmic Disorder a disorder which can result from trauma but can also be acquired through problems within relationships. There are those for whom the problem is of lifelong duration. And for others the problem may present in generalized (almost all) settings or be specific to situational (specific kinds of) settings.

The capacity for orgasm increases with age, and female orgasmic disorder is more common in younger women. Many women increase orgasm capacity as they acquire more knowledge of the responses of their own bodies.

The problem has not been found associated with specific personality traits or other psychopathology. Although we shall talk about this more later, there are substance -induced (drug related) sexual dysfunctions for which inhibited orgasm can be the result. Occasional orgasmic problems, which are not persistent or do not result in distress or interpersonal difficulty, are not considered a “disorder,” nor are orgasmic problems which result from the poor or inadequate nature of the sexual stimulation by a partner including “focus, intensity and duration.”

Male Orgasmic Disorder – the delay or absence of orgasm following what is typically a normal sexual excitation phase is not uncommon. As with other sexual disorders, it can have an onset later in life or have been in effect for the person’s entire life, and it can manifest in specific situations or in almost all situations. There are physical causes and drug related causes which must be differentiated, and there are psychological causes, the predominance of which is the anxiety associated with once again experiencing the frustrating outcome.

For some males, it is not the absence of the orgasm but what stimulation is required before it can occur. For some males, it can occur with stimulation but not with intercourse. If this occasionally occurs, it is not considered a disorder. For example, alcohol for some males will create the problem situationally. It is when it causes emotional distress and interpersonal problems that it is considered a disorder. For older males, the problem may simply be the normal longer period required with age which the person misinterprets as a problem rather than part of the aging process.

It is important to seek a complete psychological and physical evaluation since there are a number of causes that may have this as a symptom and not be the core cause of the problem. Most communities have specialists in the area of sexual dysfunction and/or have university programs that deal with the problem.

Premature Ejaculation – Arguably, for men, the most frustrating of the sexual disorders is that of premature ejaculation. It is the persistent or recurrent experience of ejaculation with minimal sexual stimulation before, or, or shortly after penetration. It occurs before the man wants it to occur. Sometimes, it is misperceived by the male as occurring “too soon” when, in reality, it is occurring within what is considered an average length of time. The man, therefore, may have inadequate information from others as to what constitutes “premature” and may have had punitive or ridiculing experiences. Also, the occasional occurrence of an early ejaculation does not constitute a disorder. The disorder may have an onset later in life or have been in effect for the person’s entire life, and it can manifest in specific situations or in almost all situations. There are physical causes which should be considered, but the vast majority of such situations arise from psychological experiences and become associated with fear that it will simply happen again. The patient should consider discussing this with someone who can refer him to a psychologist who diagnoses and treats this disorder. It is encouraging that this is typically an easily treated problem with very positive outcome.

Dyspareunia & Vaginismus – There are two problems, one is called dyspareunia. It involves pain in the genitals associated with sexual intercourse. It can also occur before or after intercourse and can occur in males and females. There may be an experience of mild discomfort or actual sharp pain. The result may be avoidance of intercourse or substitution of other forms of sexual activity in order to avoid intercourse. This problem is not caused by lack of lubrication and should be differentiated from similar symptoms arising due to an organic (physical) problem.

The other problem is called Vaginismus in which there is involuntary contraction of the perineal muscles which makes penetration uncomfortable, difficult and at times, impossible. Again, this can be due to a medical condition which should be considered.

In both cases, we are talking about functional (psychologically) caused problems with sexual penetration whether due to discomfort during, preceding or following sexual activity or involuntary muscle contraction which inhibits or complicates sexual intercourse.

There are also sexual dysfunctions due to general medical conditions: can be a change in desire, erection or pain/discomfort. Some people with diabetes may report sexual problems. Some people on antihypertensive medication for their blood pressure and even some antidepressants may cause sexual problems. Also, there are numerous problems which can arise from use/abuse of the so-called “recreational” or “street” drugs. Interestingly, and importantly, these problems are not consistent. Even the drug Propecia for hair loss creates sexual problems in some users.

When the decision is made to consult someone about any sexual complaint, be certain to organize not only your past sexual experiences/problems but also information you have about health, medications, other symptoms concurrently experienced and what, if any, nonprescribed drugs you are taking.

Usually the problems arising from substance use are subdivided into those which cause impaired desire, impaired arousal, impaired orgasm or sexual pain. Again, the important aspect is to report a complete history to anyone consulted for a problem.

There are paraphilias: recurrent, sexually arousing fantasies, urges and behaviors that may involve nonhuman objects, suffering or humiliation of self or sexual partner, children or other nonconsenting individuals. For some, sexual activity is not possible without these fantasies and/or behaviors and for some they are transient, and at times the individual is able to sexually function without these fantasies or stimulation.

Examples are problems such as exhibitionism in which the individual feel they must expose their genitals to others; fetishism is which non sexual objects (such as items of clothing) are needed for sexual stimulation; frotteurism which involves touching or rubbing against a nonconsenting individual; pedophilia involving sexual urges and actions against a child (often defined as those under 13 years of age); sexual masochism in which the need is to be beaten, humiliated, bound or otherwise made to suffer; sexual sadism in which the physical suffering of another individual is perceived as sexually arousing; transvestic fetishism in which a heterosexual male experiences intense needs for cross dressing and voyeurism in which the goal is to observe an unaware individual disrobing or engaging in sexual activity. The large commercial market in materials pandering to these needs/disorders suggests that their prevalence may be quite high, and these problems appear to begin in childhood. Often the criteria of “six months” is used in which the problem is considered a disorder if the drive lasts for more than six months and is not, therefore, merely the result of some transient (passing) stressor. The problems, very often can transgress legal boundaries, and most often create impairment in social and occupational functioning.

And there are gender identity disorders: occurs when a child, adolescent or adult has a strong and persistent cross-gender identification in which the person may insist that they desire or actually are the other sex . The may chose to dress and behave as if this fantasy is their reality. These individuals may seek to live within the role of the opposite sex, engages in the activities traditionally associated with the opposite sex, and peer group identification with members of the opposite sex. The person may insist at times that they are the opposite sex and that their thoughts, feelings, beliefs and attitudes demonstrate that their true gender is the opposite sex. This is accompanied by a desire to rid themselves of the characteristics of their biological sex and to alter their sexual presentation. This is not the same as preferring the advantages that you perceive are held by the other sex and envying their comparative benefits.

Sexual problems commonly complicate the physical recovery process. The patient, preoccupied with pain and fear, fails to respond to what should be effective medical care. The patient also fails to tell those involved in his/her care that sexual problems have arisen.

An unwillingness to discuss sexual dysfunction is almost universal, with each individual fearing that they are unique in their problem. Men are likely to acknowledge a problem indirectly, identifying their relationship as unsatisfactory rather than revealing the more frightening issue, for example, of erectile failure.

The marital conflicts which subsequently arise due the combination of sexual dysfunction and marital tension further complicate resolution of the symptoms arising from injury.

Clinical data suggest that women are likely to report pain during intercourse as well as generally diminished sexual interest arising after injury. While this change in sexual capacity may not be alarming to the patient, her underlying fears of abandonment or infidelity by a frustrated spouse can be inordinately frightening.

Fear of abandonment, importantly, is common among both men and women, and impacts symptom magnification for many patients. Unable to maintain the healthy interest of their spouse, physical symptoms may become the “glue” that the patient uses to maintain the relationship.

The healthy mate learns to assume a caretaker role, for “How can I leave him/her when they are in this much pain?” And indeed , it is difficult for a mate to justify leaving an ill spouse, even if the relationship was unstable prior to illness or injury. Patients may, consciously or unconsciously, utilize their physical symptoms to mask sexual problems, and to concurrently insure that the mate remains invested in their recovery.

Injured individuals frequently gain weight due to inactivity and increased food intake. This increased eating is not solely based upon the side effects of medication or boredom; food can become an alternate form of gratification in the absence of sexual activity. Obviously, obesity can then, in turn, become a complication to the sexual relationship due to potentially decreased physical appeal.

Interestingly, patients with a general dislike of sexual activity (hypoactive desire or aversion), at least with their current partner, can effectively use an injury to justify avoidance of sexual contact.

Sexual dysfunction can amplify the patient’s perceptions of the severity of their condition. Thus, while the physical condition may not be disabling, the psychological impact of the associated sexual dysfunction can erode the patient’s perceptions of functional capacity. The sexual disorder, because of its importance, becomes the single factor by which a patient measures the degree of their disability or recovery.

Men appear to have more difficulty acknowledging that a sexual disorder has occurred, and more difficulty accepting that there may be a psychological component to the disorder. The consequent delay in seeking care allows the symptoms to become entrenched and resistant to change.

When sexual dysfunction is suspected, evaluation should occur without delay. Targeted and appropriate care will shorten the recovery process, increase the patient’s positive assessment of their recovery, and aid in the goal of restoration of the pre-injury lifestyle.

Sexual Masochism involves the very real act of being humiliated, bound, beaten and otherwise made to physically suffer for purposes of sexual stimulation. While the fantasy of such things is not unusual, it is the acting upon these fantasies that can run the risk of true peril.

These patterns of behavior are not only disruptive to social and occupational functioning, but they run the risk of threat to physical safety. Hypoxyphilia for example, involves the cutting off of oxygen supply for purposes of sexual stimulation. One to two deaths per million may be attributable to this practice. While some may engage in minor sexual masochism, there are those who increase the risk to safety over the years, often thereby insuring that the risk of serious injury occurs.

Sexual Sadism is diagnosed when over a period of at least six months, the individual has intense and recurrent, sexually arousing fantasies, urges and actions (not simulated) in which psychological or physical suffering (including humiliation) is suffered by another and is sexually exciting to the perpetrator. Age of onset is commonly by early adulthood. The sadism may take the form of restraining, beating, torturing, mutilating or even killing another (especially when associated with anti-social personality disorder). If committed with a non-consenting cohort, the behavior may continue until the individual perpetrating the acts is apprehended.

Transvestic Fetishism involves a male who maintains a collection of female clothing that he intermittently utilizes for cross-dressing. This occurs in heterosexual males and is not part of Gender Identity Disorder. Some will wear a single item of apparel under masculine clothing. These heterosexual males may have very few sexual partners and have occasional homosexual relationships. When not cross-dressing, they may behave in stereotypic male fashion but this behavior may be quite feminine when wearing women’s clothing. It may be a means of reducing anxiety or depression, but in some cases, it can give rise to gender dysphoria (discontent with one’s own gender). Thus, the motivation for cross dressing may change over time. Clinically significant problems in social and occupational roles are most often the result.

Voyeurism – the paraphilliac focus of the voyeur is to observe unsuspecting individuals who are naked, in the process of disrobing, or engaging in sexual activity. The goal of the observing is to elicit sexual excitation in the observer, not to seek sexual contact with those being observed. The memories or the activity itself can be used by the voyeur to produce sexual gratification. Onset is typically before the age of fifteen, and the individual may become so invested in the voyeuristic activity as to have this as the sole sexual behavior. This often is a chronic condition.

Gender Identity Disorder consists of a strong identification with the opposite gender. The individual may insist that he/she is the other sex, cross-dressing and/or stereotypic attire, preference for cross-sex roles, cross-sex games and pastimes, and preference for playmates of the opposite sex. There is a pervasive feeling that one’s own sexual identity is inappropriate and include disgust with one’s genitals and/or rejection of sexual roles. In adults it may include request for surgery, hormonal treatment and other attempts at physical alteration.

Frotteurism is the term used to describe a sexual disorder in which individuals have recurrent intense sexually arousing fantasies and urges involving the need and action of touching or rubbing against nonconsenting persons. Most of these individuals are males in their mid-to-late teens and twenties. They chose public situations in which they can often then escape without prosecution and/or even avoid detection by the victim. During the action, they often fantasize of a relationship with the individual whom they are touching.

Exhibitionism involves intense, recurrent and sexually arousing fantasies involving the exposure of the individual’s genitals. This may, in turn, translate into putting this fantasy into action and engaging in these behaviors. However, a key feature of this need is that the individual be a stranger or unsuspecting. It may not widely apply to individuals who expose themselves for salary/tips and for whom their audience is anticipating the behaviors.