Until a paradigm shift occurred in 1970, psychoanalysis was the major source of understanding and treatment of problems in sexual life. Analysts assumed that the determinants of sexual problems in adults largely took place during childhood and adolescence and that impotence and frigidity were indicators of remote unfortunate interpersonal and intrapsychic developmental processes. Psychodynamic treatments focused on the individual, and therapy sought to identify and relieve the inhibitions of conventional sexual expression; reported results were anecdotal.
The publication of Masters and Johnson’s documented success in dealing with seven sexual dysfunctions (1) introduced a different set of assumptions. Masters and Johnson taught that the couple rather than the individual was the symptom bearer, was often the source of the problem, and was the proper focus of therapy. Their treatment of impotence, premature ejaculation, retarded ejaculation, excitement phase dysfunction, anorgasmia, vaginismus, and dyspareunia began with an affectively stimulating sequence of sensate focus exercises. This approach became the foundational technique of early sex therapy. After couples could easily become aroused using sensate focus exercises, behavioral treatment focused on their specific dysfunction. Masters and Johnson opened the subject of sexuality for cultural discussion and attracted many others to the field. The psychotherapeutic approach to sexual dysfunction quickly broadened (2).
The evolution in our understanding of sexual problems and their treatment has continued during the decades since then, including through empirical research (3, 4). While the single most important therapeutic advance was the introduction of sildenafil in 1998 (5), progress has been made in a variety of areas:
Clinical sexuality can be a window into personal development and individual and relationship psychology. Sex is about the unfolding of the individual self, the capacity to give and receive pleasure, the capacity to love and to be loved, the ability to be psychologically intimate, and the ability to manage the expected and unexpected changes that occur throughout adulthood.
Many patients believe that mental health clinicians are more likely than other health care professionals to be knowledgeable, skillful, and interested in addressing their sexual concerns. This background article describes several concepts about sexual life that are relevant to improving sexual history taking, individual or couples psychotherapy, and medication management for sexual concerns.
Three presentations of sexual problems
Patients generally bring sexual problems to psychiatrists in three ways. The most familiar one is the presentation of a sexual chief complaint or its emergence during therapy for another problem. Patients’ concerns fall into two categories:
Sexual identity—for example, patients may bring up their cross-dressing, anxiety about the possibility of being homosexual, or concern about violent sexual fantasies.
Sexual dysfunctions—for example, patients may complain of a new difficulty in attaining orgasm, aversion to intercourse, painful intercourse, too-rapid ejaculation, episodic inability to maintain an erection, or longstanding inability to ejaculate in the presence of a partner.
A second way psychiatrists may be asked to help is by a couple who complains of some difficulty in orchestrating their sexual life. The couple’s chief complaint may involve matters such as discrepancies in sexual desire, the inability of a young man to bring his partner to orgasm because of premature ejaculation, the cessation of sex, infidelity, dyspareunia, erectile dysfunction in a recently married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography. Some couples are too shy to bring up their sexual concerns and initially discuss nonsexual matters instead.
The third avenue derives from the clash of a person’s sexual behavior with social values or laws. Judges, lawyers, state boards, clergy, or other physicians may ask for our assistance with persons who are accused of sex crimes, cross sexual boundaries in their work, or have been sexually harassed, stalked, or otherwise victimized.
These three presentation types require slightly different processes of history taking and clinical involvement, not only because the differential diagnosis of the problems may be different but also because the number of people directly involved in the evaluation, the origin of the symptoms, and the treatment may vary.
Becoming comfortable listening to sexual stories
Sexual concerns are extremely common in the general population (14) and are more prevalent among those burdened by psychiatric disorders (15—17). Although psychiatrists are skillful in assessing individual patients who have major psychiatric disorders, we are not nearly as relaxed and confident about our capacity to respond to sexual complaints. Society regards a person’s sexuality as an intensely private subject—so private that most people do not have a sufficient vocabulary to describe their own sexual lives. Psychiatrists grow up with many of the same language deficiencies when it comes to sexual identity and function. Most psychiatrists experience a conscious countertransference barrier to exploring sexual issues in detail. This barrier is constituted by fear of:
Personal or patient sexual arousal while talking about sex
Not knowing what relevant questions to ask
Not knowing how to help with sexual problems
A sudden awareness of one’s own sexual concerns
Having one’s moral repugnance show to the patient (18)
The excellent training psychiatrists receive in biological psychiatry has come at the expense of training in psychotherapy, creating the illusion that professional comfort with sexual life is no longer a clinical requirement. Most psychiatrists have no experience with a mentor who has demonstrated that the ordinary fears about dealing with sexual topics can be readily mastered and that many patients can be helped through calm, perspective-giving psychotherapy.
Learning to inquire about sexual identity
Sexual identity is a personal sense of the self that is usually clearly attained by the end of adolescence. It consists of a series of self labels involving:
Gender identity—the degree of comfort with the self as a masculine or feminine person
Orientation—the gender of those who attract and repel us for romantic and sexual purposes
Intention—what we want to do with our bodies and our partners’ bodies during sexual behavior
We have to be prepared to explore how the patient thinks of his or her sexual identity and to assess whether the patient’s concerns indicate a gender identity disorder, whether the patient’s orientation is heterosexual, homosexual, or bisexual, or whether the patient’s fantasies and behavior indicate paraphilic intentions. Most people have conventional sexual identities—that is, their gender identities are consistent with their biological sex, they almost exclusively have heterosexual attractions and behaviors, and their intentions are to cooperate with their partners to create mutual pleasure. The problems they pose for psychiatrists are generally not severe. Psychiatrists are most likely to experience countertransference barriers with patients who have a gender identity disorder, homosexuality, or a paraphilia.
Learning to understand sexual function
Desire, arousal, and orgasm are the three dimensions of sexual function that are the basis for our current nosology; they may sound fairly straightforward, but assessing them is complicated. Clinicians need to recognize that desire and arousal merge into one another, particularly as the individual moves into middle age or settles down with one consistent partner, typically in marriage. Desire is usefully thought of as having a youthful biological element, called drive, and a lifelong motivational element that is reflected in the willingness to engage in sex with a particular partner (19). With patients who complain of a loss of desire for sex, the clinician needs to ascertain whether it is manifested by their having no sexual thoughts, fantasies, attractions, and masturbation (as might be seen in acquired hypogonadal states) or whether they have, in essence, lost the motivation to bring their bodies to their current partner for sex (as commonly occurs when alienated from a partner). Desire is also complicated by a vital gender difference (20). Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior with their partner precedes their intense desire for sex, whereas most men continue, through much of the life cycle, to find that their desire for sex precedes their arousal.
Steps in the classification of sexual symptoms
When listening to the patient’s story, the psychiatrist first ascertains whether the patient (or couple) is presenting an identity problem or a function problem and then defines its dimension: gender identity, orientation, paraphilia, desire, arousal, or orgasm. He or she then determines whether the problem has been present since the onset of sexual activity—defined as "lifelong"—or whether it followed a long period free of symptoms—defined as "acquired." If the problem is acquired, the psychiatrist determines whether it is currently always present, or is situational with one partner and not another, or is present sometimes with a partner. Identifying these factors enables the clinician to rationally pursue the etiology.
Any sexual behavior—normal and abnormal, masturbatory and partnered—rests on biological elements, psychological elements, interpersonal elements, and cultural concepts of normality and morality. These four elements are also the general sources of sexual problems. Biological causes can range broadly from a congenital androgen receptor disorder (21) to a current undiagnosed prolactinoma (22) to obvious disease such as multiple sclerosis. The problem also may be due to a medication side effect or to drug or alcohol abuse. Psychological causes may involve past developmental processes, such as a lack of warmth during childhood, neglect, or physical or sexual abuse. Current psychological states may involve, for example, an affect disorder or paranoia. Sociocultural influences may stem from an inability to free oneself from antisexual orthodox religious attitudes, homophobia, or beliefs about the abnormality of masturbation or oral-genital contact. The opportunity to listen to many sexual histories enables psychiatrists to gradually become more efficient in generating causal hypotheses and to use them to benefit their patients in individual or couples psychotherapy.
Each of these four causal elements undergoes short-term oscillations—for example, through the changing phases of the menstrual cycle—and long-term changes—for example, over the course of maturational evolution of attitudes toward sex. The oscillations in these elements explain the subjective and physiological differences between one sexual experience and the next with the same partner. The gradual evolution of the elements makes every sexual life a changeable or dynamic process. Dysfunctional sexual life is trapped in recurrent symptom formation, has less oscillation because it tends to be frequently emotionally unsatisfying, and tends to disappear earlier in the life of the couple or the individual because it is not mutually pleasing.
Clinical work requires cautious oversimplification
Gaining a comprehensive understanding of the four causal elements would be too complex, time-consuming, and cumbersome for most busy practitioners. In all specialties, professionals oversimplify the subject in order to be practical and efficient in providing treatment. In urology, for instance, the focus is on the biological contributions to sexual dysfunction. Gynecology concentrates on the anatomic and endocrine contributions to sexual dysfunction. Psychoanalysis emphasizes the psychological developmental aspects. Psychiatrists are often quick to assume that every patient who has a sexual dysfunction and is taking a selective serotonin reuptake inhibitor (SSRI) was sexually normal prior to taking the drug. Throughout medical practice, the pressure to provide a medication for a symptom is powerful. If we are to be accurate in our assessments of individuals and couples in our psychiatric practices, we must be willing to consider the current and past contributions of the biological, psychological, interpersonal, and cultural factors in every case. We may declare after the first or second session that a given patient’s hypoactive sexual desire is due to his critical assessment of his wife’s alcoholism, but we should be prepared to discover over time that it is more complicated (23).
Throughout adulthood, in a gradual and often unapparent manner, individuals pass through sexual stages, each presenting developmental challenges (24). In thinking about etiology and treatment, it is vital to have an understanding of these stages. The same sexual symptom—erectile dysfunction—can have very different psychological, interpersonal, cultural, or biological sources depending on the sexual stage in which it appears. The same psychological stress might cause erectile dysfunction in a 60-year-old but not in a 25-year-old because the biological capacities for arousal are different in these two stages of life. Anorgasmia in a 22-year-old woman does not have the same psychological and biological sources as in a 62-year-old.
The first stage, sexual unfolding, usually corresponds with adolescence and single adulthood. It is characterized by the growing awareness of individual identity and functional characteristics and experiments in the management of sexual drives, sexual opportunities, and relationships through masturbation and partner sex. It comes to an end when a person depends on one partner for sexual expression.
When monogamous partnership occurs, the two people establish their sexual equilibrium. The sexual equilibrium shapes the couple’s unique pattern of sexual expression. Their equilibrium is the byproduct of the interaction of the partners’ individual characteristics of identity, desire, arousal, and orgasmic attainment. The power of this interaction can be seen among previously functional men and women who quickly become dysfunctional in a new equilibrium because they discern their partner’s displeasure, lack of satisfaction, or disinterest in particular sexual acts. Their perception of their partner’s unhappiness can quickly induce performance anxiety during sex, anger about sex, or a sense of hopelessness about getting one’s needs met. The power of the sexual equilibrium can also be seen in previously dysfunctional individuals who quickly become comfortable and capable when they discern that their partners are pleased with them as partners. Inhibitions gradually lessen and the couple’s sexual life attains a good footing.
The third stage, the challenge to preserve sexual behavior, represents the developmental task of maintaining partnered sexual activity while life becomes more complex. The couple’s ability to do this rests on four other largely nonsexual capacities:
Management of disappointment over emerging knowledge of the partner’s character
Ability to resolve disagreements that periodically surface over nonsexual conflict
Ability to reattain psychological intimacy
Understanding of how important sex is as a means of erasing anger, reducing extramarital temptation, reaffirming the couple’s bond, and having fun
During this stage, it is apparent that sexual function cannot be separated from nonsexual psychological and interpersonal matters.
The fourth stage is marked by the physiological downturn that occurs in midlife. In women these biogenic changes begin during perimenopause and are characterized by diminished drive, vaginal dryness, and less vulvar and breast erotic sensitivity (17). In men the physiological downturn is usually apparent to them by their mid-50s and is characterized by less drive and less firm penile tumescence (25).
The fifth stage emerges gradually as individuals move into their 60s. Orgasmic attainment is usually more difficult in both sexes. Many women in this stage have sex primarily to please their partners, and many men notice that their potency is less reliable. Both sexes are relying on motivational aspects of desire to have sex rather than on drive per se. Women who maintained their natural vaginal lubrication during their 50s often begin using lubricants in this stage (26).
The sixth stage, characterized by serious physical or mental illness, may occur anytime in the life cycle. While some conditions—such as hypomania/mania, a new appreciation of a now impaired spouse, and substance abuse that decreases sexual restraints—may increase the frequency of sex, most serious illnesses diminish either the patient’s or the partner’s sexual desire and arousal. Illness, whether it is congestive heart failure or complicated grief, often limits a person’s sexual activities.
When relationship disruption occurs in coupled persons of any orientation, the individuals find themselves unattached again; they are again in the stage of unfolding. This time, at age 58 for instance, they have different desire, arousal, and orgasmic characteristics than they did when they were last unattached 35 years ago. Their next sexual equilibrium will be different (perhaps even better). Sex continues throughout the life cycle for many individuals, but its characteristics evolve.
Psychiatrists now have three effective and safe drugs at their disposal that improve erections to a significant degree in approximately 75% of men with various degrees and causes of erectile dysfunction—the phosphodiesterase type 5 (PDE-5) inhibitors sildenafil, vardenafil, and tadalafil. Although the development of this class of drugs has revolutionized the treatment of erectile dysfunction, a substantial minority of men who are given a PDE-5 inhibitor do not continue its use. With or without the experience of taking a PDE-5 inhibitor, some men and couples realize that their sexual problems are more complex than a good erection can fix (27). The mental health professional is the only specialist who may have the interest and skill to address the other forces that limit their sexual behavior (28). The psychiatrist who is willing to conduct psychotherapy is in a unique position to work with a PDE-5 inhibitor while addressing the psychological, interpersonal, and cultural forces that limit their patients’ sexual capacities (29). The psychiatrist who inquires about sexual life is likely to encounter many men with erectile dysfunction who have never been able to acknowledge it to a physician (30).
When selecting an antidepressant as a first-line treatment for a depressed or anxious patient, psychiatrists should consider several questions:
What were the patient’s desire, arousal, and orgasmic capacities when he or she was last free of the depression or anxiety disorder?
What impact did the disorder have on these components (15)?
Does the patient currently have an active sexual life with a partner or with masturbation?
What does the patient think about the use of a drug that carries a high likelihood of an iatrogenic sexual dysfunction? (Do I believe that the ethical precept of informed consent requires me to disclose in advance the high likelihood of a sexual side effect?)
If a patient whose depression or anxiety is now much improved brings up a new sexual symptom, before the psychiatrist concludes that it is iatrogenic, he or she and the patient should consider whether the social precipitant of the disorder—discovery of infidelity, job loss, divorce, breast cancer, and so on—is a reasonable explanation for the sexual dysfunction as well. If the conclusion is that the acquired sexual dysfunction is iatrogenic, the psychiatrist and patient are faced with the dilemma of choosing between better sexual functioning and the return of depressive or anxiety symptoms. They have to work their way through the dilemma knowing that most of the recommendations available for reversing these sexual side effects have not yielded convincing evidence of effectiveness or utility. While changing to a medication with a lower incidence of sexual side effects may be required, attention to the sexual issue before selecting a medication may be a better approach to creating a therapeutic partnership with the patient.
The development of skill in listening to and providing psychiatric care for patients’ sexual concerns can be a theme of interest in the life of a general adult psychiatrist. While sexual life is quite varied from person to person and from era to era in a person’s life, interested psychiatrists soon begin to grasp that sexual life is tied up with the larger existential dilemmas of living. However, along the way patients indirectly reinforce our interests by spontaneously telling us how helpful our questions, clarifications, or suggestions have been and how their previous physicians avoided the topic entirely.