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Sexual Dysfunction

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.

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 60ís and 70ís 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.

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.

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.

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.

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.

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 doesnít 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 donít follow directions.

Now I want to mention, Iím sure most of you have had some experience with the SSRIís 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 SSRIís 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.

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.

The retarded ejaculation, Iíve found in my practice, is more complicated to treat and in that instance people that Iíve 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.

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.

Then we come to the desire phase problems and this you will see earlier in the handout. One of the things Iíve put in there is "Where have these cases gone." I think as Iíve 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 90ís. The most frequent problems that I get to see in this vein are the mixed.

One of the things also to think about when you are hearing about low sexual desire, usually itís the couple who comes in and says, "We are not doing it very often." What I often do, when I see a couple, Iíll see a couple together initially and then Iíll 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.

I want to mention something about pain. We are now realizing that the incidence of pain with intercourse for women is very high. Itís between 15-20%. Itís 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 weíve now come up with is vulvovestibulitis.