Sexual problems may present in various medical settings: primary care, general or specialist psychiatric practice, gynaecology, urology and genito-urinary medicine (GUM) clinics, also in non-health settings such as Relate (formerly the Marriage Guidance Council).

Whether or not certain variants of sexual behaviour or function are perceived as ìproblemsî will depend on the expectations, and moral values, of the individual and of his or her social group. Topics in this chapter are arranged as follows:

• Sexual dysfunctions: sexual performance fails to satisfy the subject or partner.
• Sexual deviations: sexual practice departs from convention in a way which distresses the subject or offends others.
• Gender identity disorders.
  

Homosexuality, which is not a disorder, is also conveniently considered here.

SEXUAL DYSFUNCTIONS These conditions, in which some aspect of sexual performance fails to satisfy the subject or partner, may be categorised in several ways but perhaps most clearly by relating them to the five stages in the model of normal sexual response described by Masters and Johnson.

Desire reduced libido (m. f)
Excitement erectile dysfunction (m) unresponsiveness (f)
Intercourse loss of erection (m) vaginismus (f)
Orgasm premature/delayed ejaculation (m) anorgasmia (m, f)
Resolution priapism (m)
All stages dyspareunia (m, f)

Reduced libido in women, and erectile and ejaculatory problems in men, are among the most common reasons that couples present for advice. The terms ìfrigidityî and ìimpotenceî are imprecise and judgmental, and should be avoided.

Causes

• Background factors: anxiety or ignorance about sex, past experience of sexual abuse, general disharmony between the couple concerned, a constitutional discrepancy in sex drive between the two partners or a lack of physical attraction between them.
• Ageing: sexual drive and performance in both sexes decrease with age, though the decline is more marked in males. For example, the prevalence of erectile dysfunction in men is about 2% at age 40, and 25ñ30% at age 65.
• Psychiatric illness: most psychiatric illnesses, especially depressive illness and anxiety states, reduce sexual drive, performance and pleasure. The exception is mania, in which sexual interest and activity increase.
• Organic brain disease: the dementias, and lesions of the frontal lobe, may produce sexual disinhibition.
• Genital and pelvic pathology: for example congenital abnormality, infection, injury to the genitalia or spinal cord.
• Endocrine and metabolic disorders: for example diabetes, sex hormone deficiency, hyperprolactinaemia, hypertension, arteriosclerosis, renal failure.
• Drugs: psychotropic drugs, especially antidepressants and neuroleptics, may affect sexual function and so may many of the drugs used in general medicine, for example antihypertensives and diuretics. The most common culprits are SSRIs, which frequently reduce libido and / or produce anorgasmia in both sexes.
• Alcohol: impaired sexual function may result from intoxication, peripheral neuropathy, disturbed sex hormone metabolism due to cirrhosis of the liver, marital conflict, or treatment with disulfiram.
  

Assessment

If both partners attend they should, if they agree, be interviewed separately and then together. The two parties frequently differ in their view of what the problem is, and in their desire for treatment, and it is important to be clear about such differences. The duration of the problem, and whether it is present with other partners and on masturbation, should be established. A medical history, psychiatric history and physical examination should always be obtained, followed by laboratory investigations if indicated. It is especially important to use a sensitive, non-judgmental style when interviewing people with sexual problems.

Treatment

Underlying causes such as psychiatric or medical illness should be managed appropriately.

• Psychological approaches: simple explanation and counselling may be all that is required, and sometimes can be best provided from the many useful books and videos available to the public. More complex cases may need formal psychotherapy, individually or as a couple.

• Sex therapy: this derives from the methods of Masters and Johnson. The couple is usually treated together. Treatment begins with a ìsensate focusî phase during which intercourse is not attempted, so that the couple stop repeating an experience of failure, but spend a set time alone together each day to concentrate on talking about relationship issues and exchanging non-genital physical affection. In stages, the couple then work towards genital stimulation, followed by intercourse. They may be taught specific techniques according to the type of dysfunction present, for example the ìsqueeze techniqueî for premature ejaculation, or extended foreplay in orgasmic delay.

• Systemic drugs: these are appropriate when a specific medical indication is present. Examples include:

• oestrogen/progesterone hormone replacement therapy in postmenopausal women

• sildenafil (Viagra), tadalafil and vardenafil are phosphodiesterase type-5 inhibitors. They increase cyclic guanosine monophosphate (cGMP) leading to penile smooth muscle relaxation. Taken 1 hour before sexual activity, they have revolutionized the treatment of erectile dysfunction.
  

• androgen treatment for reduced sexual drive in men who have low testosterone levels

• bromocriptine for male sexual dysfunction secondary to hyperprolactinaemia.
  

• Local treatments for female partner:

• topical lubricants/oestrogens for vaginal dryness
• vaginal dilators, of progressively larger size, for vaginismus.

• Local treatments for males with erectile failure:

• intracavernosal injection of vasoactive drugs such as papaverine, prostaglandin E1 (aprostadil)
• vacuum devices, using suction to establish erection which is then maintained by a ring

Prognosis

It is difficult to generalise, but most patients seen for advice about sexual problems improve to some extent. The advent of sildenafil will certainly have improved outcomes overall.

Case Example

A man aged 52, happily married for 23 years, was referred to psychiatric outpatients by his GP who said his patient was distressed by ìprogressive impotenceî, and had recently watched a television programme about ìViagraî which he was keen to try. The man himself seemed rather embarrassed by the referral. He attended without his wife, and had not told her about it; she had ìnot seemed especially keen on sexî after the menopause, and they had been having intercourse about every two weeks in recent years, largely at his request. He had recently taken an antihypertensive drug, and had been finding it more difficult to sustain an erection; although his blood pressure had since settled and he was able to stop this medication, his erectile difficulty had not entirely resolved. Direct inquiry established that there was less of a problem during masturbation.

The psychiatrist could detect no physical or mental disorder, and blood tests including prolactin were normal. He advised that the problem would probably continue to resolve, and that specific treatment was not required at present, though sildenafil (Viagra) would be effective, if it was necessary to use it in the future.

At follow-up, the patient was invited to ask his wife to attend. There had been some further improvement in his erections, but it emerged that his underlying fear was that he was ìfailing in his marital dutiesî. The psychiatrist advised that their sexual relationship, in particular their frequency of intercourse, was not abnormal for their age. Although it was possible that the wife was suffering from some oestrogen deficiency symptoms including vaginal dryness, which might well have responded to hormone replacement therapy, the couple declined further appointments, saying they were ìreasonably happy with things as they areî.


SEXUAL DEVIATIONS

Most variants of sexual orientation and behaviour, sometimes called ìparaphiliasî or ìalternative sexual practicesî, are no longer classed as psychiatric disorders, and more liberal attitudes in society have reduced the frequency of psychiatric involvement with them. However, sometimes these variants are associated with psychiatric disorder, social maladjustment, or transgressions of the law.

Psychiatric treatment is only indicated in carefully selected cases. When a sexual deviation leads to the patient developing secondary psychiatric problems, for example depression or substance misuse, them psychiatric assessment may be appropriate. However, the boundaries have to be clear. The patient must be clearly told that he retains responsibility for his behaviour.

In deviations which lead to conflict with the law, for example, paedophilia, mental health services have to be extremely cautious about involvement, in case they are blamed- probably wrongly, but mud sticks- when the subject re-offends.

Causes

The cause of sexual deviations is generally unknown. These preferences, which are much commoner in males than females, are usually present by early adulthood or before. They may therefore be regarded as a permanent feature of the personality which may become more marked with the passage of years or at times of stress.

Some of these behaviours are associated with difficulty in forming normal relationships, for example indecent exposure may occur in men with poor social skills and/or learning disability. Availability is also a factor, for example bestiality among men with ready access to animals. There may be a genetic component.

In rare cases, a first onset in later life may be due to functional psychiatric illness or organic brain disease.

Psychodynamic theorists have suggested these behaviours are due to abnormal parental attitudes, for example excessive dominance of one parent, or parental desire for a child of the opposite sex.

In the behavioural model, deviant sexual behaviour is conceived as being learned by conditioning or modeling, and maintained by reward in the form of orgasm and anxiety reduction.

Behavioural factors probably underpin cases where the person spends longer and longer viewing pornography, for example over the internet; however these may also have features of OCD and/or addictive behaviours.

Individual deviations will now be briefly described.

Sadism and Masochism Sadism is sexual gratification from inflicting cruelty on the partner. Masochism, which often co-exists in the same individual, is sexual gratification from being subjected to cruelty. Minor forms of both tendencies are common. Extreme forms of sadism can lead to sexual crimes.

Fetishism A group of conditions in which sexual desire is focused on a body part other than the genitals (for example the feet) or an inanimate object (for example a particular type of garment). If treatment is indicated at all, behaviour therapy is the treatment of choice.

Bestiality Bestiality is intercourse with animals, most common among male farm workers. It is illegal.

Indecent Exposure Indecent exposure (exhibitionism) is illegal exposure of the genitals to another person, usually carried out by a man in the presence of a girl or woman who is unknown to him. Most exhibitionists are young men who expose a flaccid penis; these are anxious, inhibited personalities whose sexual adjustment is poor, and feel guilty about exposing. They often cease the behaviour after detection.

A minority are sociopathic men who expose an erect penis whilst masturbating, and derive pleasure and excitement from the act. This group is more likely to repeat the behaviour, and to progress to more serious offences.

Paedophilia Paedophilia is a sexual preference for children. Sexual contact with a child under 16 is an imprisonable offence. Most cases involve men, and less often women, who have difficulty forming sexual relationships with adults. Many have themselves been abused as children. Homosexual and heterosexual types exist. Behaviour ranges from an apparently affectionate relationship with a known child to the homicidal rape of a strange one. Dangerous paedophiles require secure care and antilibidinal drugs.

Incest Incest is sexual intercourse with a parent, sibling, child or grandchild, and is an imprisonable offence. The most common forms are between father and daughter, and between brother and sister. It is associated with learning disability, social deprivation and overcrowding, and/or a poor sexual relationship between the parents in the family.

Some girls involved in incestuous relationships have sexual difficulties in later life, but the frequency of long-term ill-effects is unknown. However, there is certainly a raised incidence of mental disorder, especially personality disorder. There is a greatly increased risk of genetic defects in children conceived through incest.

Treatment

• Behavioural and cognitive therapy: older techniques such as aversion therapy were designed to discourage unwanted desires and behaviours, but are now little used because of ethical objections. (A type of aversion therapy which might be acceptable would be where the aversive stimulus is mild and administered by the patient, e.g. snapping an elastic band round the wrist when the unwanted thoughts occur)

• Group therapy is often used for offenders, who are thereby encouraged to confront the effects of their behaviour on victims. This may be within correctional facilities, run partly by warders and partly by a prison psychologist.

• Drugs: antilibidinal drugs for male sexual offenders include the anti-androgen cyproterone acetate, the major tranquilizer benperidol, oestrogens, and the gonadorelin analogue goserilin. These drugs may cause impotence, infertility and breast enlargement. Thus, they should only be used for dangerous sex offenders. Occasionally, they may be used under the Mental Health Act. If so, this requires the support of two approved consultant psychiatristsí opinions plus the subjectís own informed consent.

• Psychodynamic psychotherapy to explore possible origins of the sexual deviation in disturbed relationships or repressed events in childhood. This option is less used nowadays, because of the moved towards evidence-based treatments.
  

Few of the above treatments have been rigorously demonstrated to be effective, and it is particularly important to remember this in forensic cases. Therapeutic optimism has led to some recidivist sexual offenders being removed from the criminal justice system into the healthcare system, and subsequent re-offending wrongly attributed by the media to failures of psychiatric care rather than the elective behaviour of the offender. Some sex offenders express a wish for psychiatric help because they hope to avoid a prison sentence.

GENDER IDENTITY DISORDERS

Transvestism is a wish or compulsion to wear clothing of the opposite sex. Most transvestites are male, and most are heterosexual, but sometimes the condition is associated with homosexuality, transsexualism or sexual deviations. Transvestism is common and not illegal.

Transsexualism is a rare disorder of sexual identity in which there is a strong wish to change to the opposite sex, with a belief of having been born into the wrong sex, present since early childhood. Most subjects are biologically male. Many are married men with children. Some are homosexual.

Transsexuals usually present for treatment because they want surgical sex reassignment. Such surgery is (in the UK) done only in one or two centres. The subject should have received thorough information and counselling, and successfully lived in the role of the opposite sex for an extended period (perhaps using non-surgical measures the while, such as hormone treatment), and be free of psychiatric disorder.

Most subjects who fulfil these criteria are said to be pleased with the results of surgery. The male-to-female operation, involving removal of the penis and scrotum and creation of an artificial vagina, is more satisfactory than the female-to-male version and should enable the subject to experience sexual intercourse as a woman (but not, of course, to bear children as a few naÔve subjects expect).

The operation is combined with breast surgery, ongoing hormone treatment to change the secondary sex characteristics, and tuition in behaviour appropriate to the new sex.

In law, the sex has remained the original one as stated on the birth certificate, though there are pressures to amend this.

HOMOSEXUALITY

Homosexuality, an exclusive or predominant sexual preference for the same sex, is no longer classed as a psychiatric disorder. It is mentioned here because it may be associated with increased rates of depression, alcoholism and neurosis, probably because of the associated social stigma. Social attitudes towards male homosexuality have become well publicised since the advent of HIV and AIDS.

Female homosexuality has never been illegal, as, when such a law was mooted to HM Queen Victoria, she declined to believe that it existed. Male homosexual acts were illegal in the UK until 1967, when they were legalised between consenting males over the age of 21 (in private). Recently, the age of consent has been changed to 16 in the UK (17 in Northern Ireland). Male homosexuality remains illegal in many jurisdictions, however.

Homosexual interests or experiences are common in adolescence. According to community surveys, up to 4% of adult males are exclusively homosexual (gay) and an additional minority of men are bisexual to some degree. The percentages for females are similar.

Some homosexuals resemble the opposite sex in their physical habits, mannerisms or dress.

Causation of homosexuality, like heterosexuality, remains unclear. Reported biological factors include a genetic component as demonstrated by twin studies, and an X-linked gene in some male homosexuals has recently been reported. No consistent abnormalities of sex hormone secretion have been found, although hormone imbalance in the prenatal period has been suggested. Psychodynamic factors, for example the combination of a doting mother and weak or absent father, have also been implicated.

Bancroftís 1994 review concluded that ìit remains difficult, on scientific grounds, to avoid the conclusion that the uniquely human phenomenon of sexual orientation is a consequence of a multifactorial developmental process in which biological factors play a part, but in which psychosocial factors remain crucially importantî.

In the past, various interventions including psychotherapy, behaviour therapy and hormone treatments were tried in order to modify homosexual orientation, all to little effect. This is no longer considered appropriate, and modern approaches are designed to aid adaptation to the homosexual state, with any co-existing psychiatric disorder being treated in standard fashion. For homosexuals facing other difficulties, services organised by gays themselves, such as telephone advice and self-help groups, may be appropriate sources of support.

FURTHER READING

Bancroft J (1994) Homosexual orientation. British Journal of Psychiatry 164: 437ñ440