Sexual Dysfunctions and Disorders
Few topics in psychology capture the interest and imagination of people more than human sexual behaviour. Aberrant sexual behaviour typically generates more interest and fascination than almost all other forms of abnormal behaviour (Comer, 1995). Nevertheless, earnest and candid scientific investigation of human sexuality began only very recently, making sexology one of the youngest areas of scientific inquiry.
Classification of Sexual Dysfunctions
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), (American Psychiatric Association, APA, 1994) has identified four general domains: Sexual Dysfunctions, Paraphilias, Gender Identity Disorders, and Sexual Disorder Not Otherwise Specified (NOS). This paper will, however, outline only the following areas of sexual dysfunction and disorders: Male Erectile Disorder, Female Orgasmic Disorder, Paraphilias, and Gender Identity Disorder.
Male Erectile Disorder
Male Erectile Disorder is an inability to gain erections, and was formerly known as impotence.
Prevalence rates may not be truly representative of the population, as many individuals may not wish to respond to such surveys. Some caution must therefore be exercised in interpreting the following figures (Comer, 1995). In the American population, the prevalence of erectile failure is between approximately 8 and 10 percent of the male population (Comer, 1995). Erectile problems are very much an age-related problem, with the incidence of the disorder increasing exponentially with age.
Erectile dysfunctions are rarely due to exclusively physiological or psychological factors, but rather are typically caused by a combination of both these factors. Current theorists and practitioners believe that many cases involve some partial organic or substance induced impairment of the erection response that initially causes an erectile problem. This then predisposes the man to increased vulnerability to the psychological factors that inhibit erection, which then serve to maintain the erectile dysfunction (Comer, 1995).
Some of the organic impairments (those due to a medical condition) that can cause erectile dysfunction include vascular abnormalities, nervous system damage, multiple sclerosis, alcoholism, kidney failure and dialysis, and radiation therapy (Myer, 1986)
Substances that can cause erectile dysfunction include alcohol, cigarettes, high blood pressure medication, anti-anxiety medication, antidepressants, cocaine, and major tranquillisers such as Melleril (Davidson & Neale, 1996).
The psychological factors underlying erectile failure can be extremely complex. Any number of personal and/or interpersonal factors can contribute to an erectile problem. A major psychological mechanism emphasised by Masters and Johnson (1966, 1970), as being central in the maintenance of an erectile problem is 'performance anxiety' and the 'spectator role'. Once a man begins to experience erectile problems, for whatever initial reason, he begins to become anxious about failing to have an erection, and his focus during sexual encounters centres on his penis’s performance. By focusing undue attention on performance he inadvertently distances himself from the sexual experience, adopting a spectator role, and thus is unable to simply relax and enjoy the sensations of sexual pleasure. Regardless of the initial cause of the erectile dysfunction, the self-evaluative spectator role serves to maintain the problem through a self-perpetuating cycle of anxiety and failure.
Treatments for erectile failure involve either physical or psychological interventions, depending largely on the underlying cause of the problem. In cases where the individual can experience nocturnal penile tumescence and rigidity, it would appear unlikely that physical factors are involved in the aetiology, and that the most appropriate treatment would involve some form of sexual counselling, ideally with a psychologist that specialises in sex therapy.
The past 20 years has seen a rapid and dramatic change in the psychotherapeutic procedures used to treat sexual dysfunctions. Contemporary sex therapy is a multifaceted treatment approach that incorporates several components, such as cognitive, behavioural, and communication-skill-building techniques. Therapy is focussed specifically on the erectile problem, involves both partners, and is systematic and directive in its course.
For the majority of men whose erectile dysfunction has mainly physical causes, there are three generally accepted physical treatment options: vacuum constriction devices, penile prosthesis, or injection therapy.
More recently the use of drugs and nutrients that increase peripheral blood flow has made a huge impact on the treatment of erectile dysfunctions; Cialis and Viagra being two such drugs. Before embarking on a course of drug use to increase erections men should be aware of contraindications and of the side effects, which for some can be fatal.
Best treatment options combine sex psychology counselling, nutrient supplementation and medication in the short term, following risk assessment by a qualified medical professional.
Female Sexual Dysfunction
Female orgasmic disorder is an absence of orgasm after a period of normal sexual excitement, must cause marked distress or discomfort, and be based on the clinician's assessment that a woman's orgasmic response is less than would be reasonable for her age, sexual experience and adequacy of stimulation (APA, 1994).
Female orgasmic disorder prevalence rates vary widely and include: 10-15% never had an orgasm; 10-15% rarely experience an orgasm; 50 % experience orgasm during intercourse (Comer, 1995); while some sex clinics give figures from 18% -76%, community based research indicates 5-10% experience orgasmic difficulty. Additionally, it does appear that a clear operational definition of dysfunction is missing with which to compare results (Spector & Carey, 1990; Morrow, 1994).
The aetiology of female orgasmic disorder is based on Masters and Johnson's (1970) theoretical model which highlights religious orthodoxy, psychosexual trauma, homosexual inclinations, inadequate counselling, excessive intake of alcohol, biological causes, and sociocultural factors as playing a role. These include the spectator role, fears about performance, and poor communication between partners which can lead to misinterpretation or failure of the partner to anticipate what the other partner wants. More recent theories have focused on linking parent-child relationships and orgasmic success (Spector & Carey, 1990). Biological conditions, such as diabetes and other neurological conditions, also interfere with orgasm.
A variety of approaches are adopted in the treatment of female orgasmic disorder, which include self-exploration, body awareness, genital acceptance, directed masturbation training, cognitive and behavioural therapies, sexual self-talk, the use of sexual aides (eg. vibrators) and the development of communication skills.
Research has shown that variables such as age, education, SES, marital status and gender can be contributing factors in sexual dysfunction. The majority of studies, however, have failed to stratify samples according to these variables (Spector & Carey, 1990).
Masters and Johnson (1970) proposed a model of normal sexual functioning based on scientific evidence regarding the physiological aspects of sexual functioning. Deviation from this standard has resulted in the perception of dysfunction and the pathologisation of sexual behaviour (Morrow, 1994).
Morrow (1994) states that sexual dysfunction may be the result of a masculine understanding of sexual interaction, implying a reproductive model of sexuality, emphasising coitus. The use of language is an illustration of this; " penis in vagina", "penis penetrates vagina". The emphasis is on what a "man" does to a "woman" as opposed to language that suggests active reciprocation; "vagina receives penis." Neither current psychology texts nor research address the relationship between the language used and its implications for understanding female sexuality.
The influence of Freud (1905; cited in Comer, 1995), in relation to the vaginal orgasm controversy has been damaging. Initially, Freud's psychoanalytic theory proposed that a woman who was unable to experience orgasm during coitus was dysfunctional. Masters and Johnson (1970) challenged this theory by scientifically demonstrating that the vaginal/clitoral orgasm is physiologically the same. Therefore, orgasm was considered "functional" with genital caressing. However, it is called situational orgasm, occurring beyond coitus, which tends to undermine the knowledge gained from Masters and Johnson (1970) and subtly upholds Freud's theory. Neither Comer (1995) nor current research pursues the repercussions from this masculine model of human sexuality.
In summary, while the methodology and theoretical models inform current knowledge and practice, they must necessarily be extended to portray a more integrated and accurate approach to understanding the psychology of female sexual behaviour.
To receive a formal diagnosis of a paraphilia, which is rare in general clinical facilities (APA, 1994), an individual, usually male (Davison & Neale, 1996), must meet two diagnostic criteria. First, the individual must experience recurrent and intense sexually arousing fantasies, sexual urges, or behaviours over a period of no less than six months (APA, 1994). These fantasies, urges, or behaviours generally involve children or non-consenting partners, non-human objects, or the humiliation or suffering of a partner or oneself (APA, 1994). Secondly, the sexually arousing fantasies, sexual urges, or behaviours must cause the individual to experience significant distress or to impact upon the occupational, social, or other important areas of functioning (APA, 1994).
The criteria that are noted above allow for the non-pathological use of sexual fantasies and urges of similar content to that of a paraphiliac, without the diagnosis of a paraphilia being made (Davison & Neale, 1996). If sexual urges and fantasies of similar content to a paraphiliac are experienced, though not recurrently or intensely as those of a paraphiliac are by definition (APA, 1994), and they do not cause the individual significant distress, or impairment of functioning, no diagnosis will be made.
The ability to achieve a state of erotic arousal, relative to the presence of the paraphilic stimulus, acting out the stimulus, or fantasising about the stimulus varies for individual paraphiliacs (Comer, 1995). For some individuals the paraphilic stimulus is obligatory for arousal whereas for others it may be necessary only at particular times, such as when under stress, while at other times they are able to function sexually without the stimulus (Comer, 1995).
Paraphiliacs are rarely self-referred (APA, 1994). Their behaviour is likely to come to the attention of mental health professionals as a result of conflict with sexual partners (APA, 1994), or as a result of the legal consequences that are associated with some paraphilias, particularly those that involve children or non-consenting partners (Davison & Neale, 1996). Further, individuals may engage in paraphilic activities that place them at risk of serious physical injury or even death (APA, 1994).
The literature fails to provide information pertaining to the prevalence of paraphilias in the general population. Although diagnoses of paraphilias in clinical settings are limited, a higher prevalence rate in the general community has been suggested in light of the large commercial market in paraphilic paraphernalia and pornography (APA, 1994). The APA (1994) notes that the majority of apprehended sexual offenders are individuals with exhibitionism, pedophilia and voyeurism. The figures pertaining to the apprehension of sexual offenders should not be interpreted as being indicative of the predominant forms of paraphilia. Such high rates of apprehension of individuals with these paraphilias may relate to these acts requiring ‘acting out’ in the sense that a non-consensual person or child is likely to be involved, therefore bringing these individuals into conflict with society and the law (APA, 1994).
Aetiology and Treatment
It has been suggested that research has revealed little with respect to the aetiology and treatment of the paraphilias (APA, 1994). Given the expansion of research into treatment of paraphilias and the knowledge that has filtered from such research, the validity of this statement may be questioned.
Marshall, Jones, Ward, Johnston and Barabee (1991), in a review of treatment outcomes with sex offenders (particularly incest offenders, child molesters, and exhibitionists), highlighted the effectiveness of comprehensive cognitive-behavioural programs whilst also advocating the use of pharmacological agents as adjuncts to therapy. A number of recent reports have highlighted the positive effects of pharmacological agents, particularly the anti-androgens, medroxyprogesterone acetate (Kravitz, Haywood, Kelly, Liles, & Cavanaugh, 1996; Kravitz, Haywood, Kelly, Wahlstrom Liles, & Cavanaugh, 1995) and cyproterone acetate (Bradford & Pawlak, 1993), for reducing paraphiliacs deviant sexual behaviours and fantasies. However, undesirable side effects have also been reported with the use of these substances and treatment effects fail to persist upon termination of treatment (Davison & Neale, 1996).
Recent research also attests the to the use of cognitive-behavioural intervention programs with sex offenders. An evaluation and 1-year follow-up study of a community based cognitive-behavioural program for 37 sex offenders, conducted over a 35-week period, showed a recidivism rate of 8.1% (Lee, Proeve, Lancaster, Jackson, Pattison, & Mullen, 1996). The recidivism figure of 8.1%, in the absence of control data due to ethical reasons for the inclusion of such a group, was argued by the authors to be a significantly low figure.
The success achieved with cognitive-behavioural and pharmacological interventions with sex offenders has given insight into the mechanisms that underlie the development of the paraphilias. Although speculative, a bio-psycho-social model of the development of paraphilias may be proposed. Support for such a model has been provided through the demonstrated suppression of deviant sexual behaviours and fantasies by anti-androgen medications and the efficacy of cognitive-behavioural interventions in reducing deviant sexual behaviours and fantasies.
Whilst the DSM-IV provides a comprehensive coverage of sexual deviance, it fails to address other forms of sexual deviance. The definition of paraphiliac behaviour is based on societal norms, however the deviant and highly unacceptable behaviours such as rape and incest are not included in the DSM-IV.
Gender Identity Disorder
Gender Identity Disorder (GID) is a disorder in which a person has the physical characteristics of one sex, and the perceived psychological characteristics of the other. The terms "Gender Dysphoric" and "Transsexual" are also often used to describe persons with this disorder.
A summary of the DSM-IV Diagnostic Criteria is as follows:
- A strong and persistent cross-gender identification
- Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
- The disturbance is not concurrent with a physical inter-sex or hormonal condition
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Transsexualism is a worldwide phenomenon, not limited to western societies. Many eastern and American Indian cultures view gender identity along a continuum in which it is acceptable for a male to choose to take the gender role of a female (see Money, 1986; cited by Gooren, 1988; Williams, 1986).
In Western countries, male-to-female transsexuals are most common, and the existence of female-to-male transsexuals is often not acknowledged, although 1 out of 3 transsexuals is female-to-male (Brzek & Hubalek, 1988).
The prevalence of transsexualism as assessed by the number of subjects applying for gender reassignment has been estimated in a few studies. One estimation of the prevalence in the USA is 1:100,000 for male-to-female transsexuals and 1:400,000 for female-to-male transsexuals (Pauly, 1968). However, the number of applicants for gender reassignment depends largely on social acceptance, legal rights and the availability of treatment. An estimate of 30,000-60,000 US citizens who consider themselves to be valid candidates for gender reassignment has been proposed (Gooren, 1988).
There are no firm explanations for the disorder, but there is increasing evidence to suggest a biological origin. It has been suggested that the sexual differentiation process in the brain of transsexuals has not followed the ordinary course during foetal development (Swaab et al., 1995; cited by Carlile, 1996).
A number of psychoanalytic theories have been proposed over the years but have failed to receive any empirical support. Studies of intra-familial relations, divorce rates, dominance of one of the parents, marital relations and many other factors have not revealed a common pattern that could account for transsexualism. In fact, stable and harmonious intra-familial relations don't exclude a transsexual outcome of one or more children (Cohen-Kettenis, 1986; cited by Gooren, 1988).
Behavioural theories explain gender identity development as being the result of a learning process that is imposed on an undifferentiated gender. Gender identity develops as the result of "imprinting" and "conditioning" processes, and in gender identity disorder, the wrong identity is acquired (Money, 1988).
Treatment / Intervention
Hormonal Therapy: The goal of hormonal therapy is to induce feminisation or masculinisation and to suppress the undesired characteristics of the original sex.
Surgery: Genital surgical sex reassignment involves surgery to the genitalia and or breasts performed for the purpose of altering the body to more closely resemble the preferred sex. Non-Genital surgical sex reassignment refers to any and all other surgical procedures of non-genital or non-breast sites (nose, throat, chin, cheeks, hips, etc).
In Victoria, sex reassignment procedures are offered at Monash. There they require participation in their program for at least 2 years, and this involves living full time in the new gender role for this period, although there is no guarantee of surgery at the end. Comprehensive Psychiatric, psychological and endocrinology assessments take place over the two year period. Following this, and if surgery is indicated, two operations generally take place over a 12 month period (Deering, 1997).
In addition to issues with family and community acceptance and employment, transsexuals in Australia are confronted with a number of practical difficulties following gender reassignment. These include the changing of birth certificates, passports, medical and tax records, bank accounts and Medicare.
Many people argue that transsexualism shouldn't be pathologised. The 'clinical distress' component of diagnosis can be viewed as a result of having to suppress one's gender identity because of imposed social expectations, rather than as a result of inherent psychological disturbance (Hammond, 1996). The fact that many of these people are treated with sex reassignment procedures, rather than trying to help them come to terms with their biological sex, certainly lends support to this notion.
American Psychiatric Association (1994). Diagnostic and statistician's manual-Fourth edition.Author:N.Y.
Bradford, J. M.W. & Pawlak, A. (1993). Effects of cyproterone acetate on sexual arousal patterns of pedophiles. Archives of Sexual Behavior, 22, 629-641.
Brzek A and Hubalek S. (1988) Homosexuals in Eastern Europe: Mental health and psychotherapy issues. Journal of Homosexuality 15:153-162.
Carlile, A., (1996). The Alex Carlile bill. Hansard, 270 (42). British Parliamentary Proceedings, HMSO.
Comer, R.J. (1995). Abnormal psychology (2nd ed.). New York: Freeman.
Davison, G.C., & Neale, J.M. (1996). Abnormal psychology (6th ed. Revised). New York: Wiley.
Gooren, L. (1988). An appraisal of endocrine theories of homosexuality and gender dysphoria. In J.M.A. Sitsen (Ed.) Handbook of Sexology: Vol 6 (pp. 410-424). Amsterdam: Elsevier Science Publishers
Hammond, B.E. (1996). Myth, Stererotype, and Cross-Gender Identity in the DSM-IV. Presented at the 21st Annual Feminist Psychology Conference, Portland, OR.
Kravitz, H.M., Haywood, T.W., Kelly, J., Liles, S., & Cavanaugh, J.L. (1996). Medroxyprogesterone and paraphiles: Do testosterone levels matter? Bulletin of the American Academy of Psychiatry and Law, 24, 7383.
Kravitz, H.M., Haywood, T.W., Kelly, J., Wahlstrom, C., Liles, S., & Cavanaugh, J.L. (1995). Medroxyprogesterone treatment of paraphiliacs. Bulletin of the American Academy of Psychiatry and Law, 23, 19-32.
Lee, J.K.P., Proeve, M.J., Lancaster, M., Jackson, H.J., Pattison, P., & Mullen, P.E. (1996). An evaluation and 1-year follow-up study of a community based treatment program for sex offenders. Australian Psychologist, 31, 147-152.
Marshall, W.L., Jones, R., Ward, T., Johnston, P., & Barabee, H.E. (1991). Treatment outcome with sex offenders. Clinical Psychology Review, 11, 465-485.
Money, J. (1988). Gay, straight and in-between. The sexology of erotic orientation. New York: Oxford University Press
Morrow, R. (1994). The sexological construction of sexual dysfunction. Australian and New Zealand Journal of Sociology, 30, 20-35.
Myers, D.M. (1986). Psychology. New York: Worth.
Pauly, I.B. (1968). The current status of the change of sex operations. Journal of Nervous Mental Disorders,147 (pp. 460-471).
Spector, I. P, & Carey, M. P. (1990). Incidence and prevalence of sexual dysfunctions: A critical review. Archives of sexual behaviour, 19, 389-408.
Williams, W.L. (1986) The spirit and the flesh. Boston: Beacon Press