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Approximately 43% of women complain of sexual difficulties that are long-standing, and the difficulties decreases with age. Around 33% of men complain of serious sexual difficulties and this increases with age. Sexual dysfunction includes the arousal phase disorders, orgasm phase disorders, and the desire phase disorders sexual dysfunction, vaginismus, sexual disfunction, impotence, disparunia, dysparunia
About 10% of men struggle at various points with erectile difficulties. In the younger group, say 18-30 range, it is much more focused around worries about competence and where there is much more of a psychodynamic component to it. But we are understanding much more as people get older. There is the effect of aging, disease, illness and medications and it has much more of an effect, so that people in their 60’s and 70’s the incidence of erectile difficulties may be as high as 50-60%. The definition of the erectile difficulty is the inability to attain or maintain an erection for a period of at least three months. This may be associated with other sexual difficulties such as premature ejaculation or premature ejaculation may develop as a secondary rank of
For women, the arousal phase disorders: there is an inability to maintain an adequate vaginal lubrication. Intercourse may be painful or uncomfortable. One of the distinctions though between men and women is that women may choose to keep this hidden from their partners. In other words, they will continue to either use a lubricant and if they have intercourse, intercourse may be uncomfortable. Where if they have an arousal phase disorder it is obvious, known, and nothing further happens as relates to intercourse. The physiological mechanisms for both men and women, as it relates to the
The medical issues one needs to consider when thinking about erectile difficulties and the arousal phase difficulties, first of all, medication and the list is really endless. But the three important ones that I want to mention are: antihypertensives, antiarrhythmics and antidepressants. They very often have significant effects on the ability to get and maintain an erection. Diabetes is a very common cause of sexual dysfunction. Around 27-30% of men and
Neurological issues: multiple sclerosis, traumatic injury, post-pelvic surgery which includes prostatectomies, and traumatic, which is what I mentioned to you as an injury to the groin.
We now come to the orgasm disorders. First of all the organism disorders in men can be categorized as either premature ejaculation, retarded ejaculation or painful ejaculation. The premature ejaculation is something that is extremely common. There is something like 25-35% of men struggle with premature ejaculation on an ongoing basis. Now this is to be distinguished from the difficulty of maintaining control. It has to do with lack of frequency. For example, in a study of college age kids they found that the incidence of premature ejaculation on Friday night is around 90%. But by Saturday afternoon it had gone down to about 55%. What we are talking about there is really the absence of frequency. But the number of men who struggle again silently with this issue of premature ejaculation is enormous. It leads to a
Now there are a variety of approaches to premature ejaculation that I think are really quite helpful. What they really involve is some trading. I think that people have tended over the years to come up with a variety of formulations to explain premature ejaculation. They would say, "This person obviously hates men and there is this suppressed and what he wants to do is just assault women and then leave the scene." People talked about castration anxiety and on an one. And I might add, these are people in the field of long term therapies and have a better understanding of their individual dynamics with absolutely no change in the premature ejaculation. So not only did they fail at therapy, they also continued to have the symptoms. What I find is the
There are a variety of things you can do. One, it is that you need to pay attention to, that helps you maintain more control. It is not unlike bladder and bowel control. An infant initially doesn’t have bladder control will begin to have an awareness of the sensation of a full bladder. They being to have an awareness of what muscles need to be contracted and then they have an awareness of "I now feel a full bladder, I contract the muscles". And this is a similar situation with premature ejaculation. It is always interesting, and this is where I think we need to focus, keeping in mind some of the psychodynamics because the treatment itself is relatively simple. What I find very often happens is that people don’t follow directions. And come back week after
Now I want to mention, I’m sure most of you have had some experience with the SSRI’s and their effect on lowering sexual desire, making orgasm much more difficult for both men and women. Well, after awhile people began to wonder whether you could use SSRI’s for treatment of premature ejaculation. In fact there have been a number of good studies showing that you can. They can all be used. Paxil is one that has been quite helpful. Zoloft, and it really varies from person to person. They are effective and when I see people I mention this but my inclination, though, is to really encourage people to try the behavioral approach first to see if they can develop some mastering. In fact most of the people that I see like to
Now there have been some other studies with Anafranil, clomipramine. Where if you give 50 mg of Anafranil about two to three hours before somebody is planning to have intercourse, that in a significant number, something like 30-40% of men, the ejaculatory latency period is increased considerably. So if you have somebody who doesn’t do well with the exercises or sometimes what you find is that culturally the idea of doing some of
The retarded ejaculation, I’ve found in my practice, is more complicated to treat and in that instance people that I’ve seen usually are much more socially reserved, isolated, schizoid, and retarded ejaculation is, in that situation, kind of a parallel to the difficulty in the relationship. When you have painful ejaculation it is important to have him worked up for either a bladder or
Now the orgasm disorders in women are: approximately 5% of women do not have orgasms under any circumstances, that is one spectrum. Then there is this whole spectrum of women - roughly around 40% - who will have an orgasm with masturbation or have an orgasm with manual stimulation but will not have orgasms during intercourse. What Helen Kaplan has talked about is the variation and what she says is that intercourse itself is not an efficient mechanism by which the clitoris is stimulated and to some women they need more direct stimulation than is provided by intercourse. So if you
Then we come to the desire phase problems and this you will see earlier in the handout. One of the things I’ve put in there is "Where have these cases gone." I think as I’ve mentioned, Masters and Johnson their focus was really on performance anxiety and they were enormously helpful. I think that what this then led to was the burgeoning of the whole self-help movement with tapes, books, courses and so forth so that a lot of the people that earlier on would have seen Masters and Johnson with performance anxiety problems are now doing it on their own and doing it very well. I think it is really the success story of the 90’s. The most frequent problems that I get to see in this vein are the mixed, complicated variety in which the desire
One of the things also to think about when you are hearing about low sexual desire, usually it’s the couple who comes in and says, "We are not doing it very often." What I often do, when I see a couple, I’ll see a couple together initially and then I’ll see each individual alone to get more of a family background and history. In that setting, one of the things that you want to ask about is, "Are they feeling sexually aroused in other situations?" In other words, do they masturbate? And is that something that they are doing frequently? Because they may not have low sexual desire. You know it may be relationally based or are they having sexual fantasies about somebody else with whom they feel a high level of sexual desire? So you know, it really is at times a much more complicated issue than it may appear on the surface.
Then there are the mixed halves, the reciprocal difficulties. Often I will see women who come in with vaginismus. This is where there is involuntary contraction of the vagina. And as you engage in a treatment, which is to behaviorally modify treatment - which actually is quite helpful - what gets
I want to mention something about pain. We are now realizing that the incidence of pain with intercourse for women is very high. It’s between 15-20%. It’s more common in the younger group of women, 18-24. Less common in women over 50. There are basically two categories here. One vulvar pain. This is pain in the vulvar region and the diagnosis that we’ve now come up with is vulvovestibulitis. There are many women suffering with
The other kind of pain that one needs to think about is dyspareunia. This is pain associated with intercourse. It may be deep pain, it may have to do with a retroverted uterus, endometriosis or pelvic adhesions. The DSM-IV talks about sexual pain disorders as recurrent or persistent general pain, before, during or after sexual intercourse causing marked distress or
Then we come to the issues of paraphilias. DSM-IV lists paraphilias as a group of disorders whose essential features are recurrent, intense sexual urges, sexually arousing fantasies generally involving non-human objects, suffering, humiliation of oneself or partner or with children or other
Paraphilias involve sexual compulsion. Voyeurism, pedophilia, domination and submission, exhibitionism, sadomasochism and compulsive pornography. I want to also mention that the Internet is, as I think at this point, to truly redefine infinite. The primary engine as you may be interested to know, of getting the Internet going was the pornography industry. This is was the first industry that really realized the economic possibilities of the Internet and the Internet sites that are available is really beyond your wildest imagination. Anything that you could think of, that you couldn’t think of is now on the Internet. With user groups, with all-sex, bondage, mutilation, submission, I mean whatever you could imagine is now on the Internet. And I think it really is something that one needs to ask about. I had a couple that I saw about sexual issues. They did very well in the sexual issue. In the treatment there were arguments about how much the husband was spending on the Internet. I was quite naive at the time. The husband said he was
Let me go onto the issues of evaluation of sexual dysfunction. As I said, you have to keep in mind the intrapsychic, interpersonal, medical, organic. One also needs to think about the developmental phases. The complexities of committed relationships, the kinds of changes that take place as
The treatment approach to sexual difficulties involves a sexual history. What I find helpful is a sharing of the ideas. Asking a couple what they think are some of the root causes and engineering your own ideas in terms of what you think is going on. And then there’s the integrating of a variety of
I want to mention a few of what is new and the big new is obviously Viagra. This is a drug that has really had profound effects on sexual dysfunction. What we understand now in terms of the production of an erection is we have enzyme nitric oxide release the production of nitric oxide. Nitric oxide is a neurotransmitter that leads then to the production of cyclic guanosine monophosphate, cyclic GMP. And cyclic GMP leads to the relaxation of the smooth muscle in the artery of the penis. The cyclic GMP leads to the dilatation of the artery, which then allows blood to come in. As soon as that happens there is the production of a substance called phosphodiesterase which breaks down cyclic GMP and Viagra is a phosphodiesterase inhibitor. It slows down this enzyme and breaks down the GMP so that ultimately what happens is that the erection is facilitated. It is enormously effective. I should just mention briefly how it was discovered. It was initially in trials as a drug where they were treating hypertension and it was not very effective
Some of the other issues that are new in sexuality, for women, is the impact of childhood sexual abuse. We are learning a lot more about that. I think previously it was quite under-diagnosed. Many people have low sexual desire or drive and other difficulties, really have some history of sexual abuse and the treatment there is slow and supportive. We are now understanding more about the impact of testosterone on sexual desire. Postmenopausal women, what they found is that if you replace the hormones with just estrogen people say they reduce vaginal dryness, but they don’t feel themselves.