Current Treatment Strategies

As with classification and diagnostic approaches to dyspareunia, treatment approaches have historically adopted a similar dualistic approach by attempting to alleviate the pain via a variety of medical interventions, failing which, psychotherapy is recommended. Typical medical treatment is characterized by a focus on the vestibule to the exclusion of other systems that may be involved (e.g., pelvic floor musculature). In addition, current medical interventions have not incorporated empirically...

Research and Methodology

Research on lifelong delayed ejaculation is scarce. Most of the literature consists of hypotheses that have not been investigated according to methodological well-designed studies. Several factors may have contributed to this state of affairs. Delayed ejaculation is a relatively rare condition. Both in the general population and in the clinical practice, the prevalence of delayed ejaculation is rather low (84). Furthermore, delayed ejaculation is known as a disorder that is relatively difficult...

Family Dysfunction Models of Etiology

Other etiological theories, while not based specifically in psychoanalytic thought, view paraphilias as developing out of adverse early life experience and dysfunctional family processes. Studies have found varying degrees of association between the childhood experiences such as emotional and sexual abuse, family dysfunction, behavior problems, and the paraphilias. In a recent study, childhood sexual abuse was determined to be a specific developmental risk factor for pedophilia, whereas...

Does He have a Psychogenic Basis to His ED

In the anxious individual, there can be overactivity of the sympathetic system leading to increased smooth muscle tone. Alternatively, signals from the brain of an individual with a psychogenic issue can override the erectogenic parasym-pathetic output from the sacral spinal cord. Psychosexual therapy can help the individual to deal with issues such as performance anxiety, reduced attraction to his partner (which may or may not be linked to a relationship problem), past sexual trauma,...

The Sociocultural View

Sjenitzer believes that vaginismus is caused by the social position of women in our society and their dissatisfaction with their role (41). According to this author, vaginismus is a protest against the patriarchal norms that reduce women to either a lust object or a mother. In addition, she makes a stand against sexist ideas in the treatment of vaginismus, particularly against placing coitus in the central position in the sexual relationship. The feminist view states clearly that women often...

Gender and the Paraphilias

As far as is known, the paraphilias occur predominantly in males, with the exception of sexual masochism, which is also commonly observed in females, although still with less frequency than in males. Exceptions have been reported, including single case reports of female genital exhibitionism and female fetishism (11-13). Two recent reports described, collectively, five cases of accidental autoerotic death in females, with evidence strongly suggesting the presence of the paraphilia...

Treatment General Considerations

The DSM-IV-TR (6) diagnosis of any sexual dysfunction has four requirements first, diagnostic subtyping must occur (see Classification section in this chapter) second, another Axis I diagnosis be excluded (except another sexual dysfunction) third, an existing medical condition could not explain the dysfunction and fourth, substance abuse also not be present. In the absence of a thorough assessment (history, physical and laboratory exams when appropriate), the clinician is actually considering a...

Hormonal Treatment

Long-term data for safety and benefit of testosterone therapy in women are lacking, but such data are required before long-term use of testosterone can be recommended. Similarly, safety data for the use of testosterone in nonestrogen replaced postmenopausal women are lacking and no recommendation for its use can be made currently. Nor can the supplementation of T to premenopausal women be recommended until such time there exist safety and efficacy data. Unfortunately, any enduring benefit after...

Combination Therapy A Brief Relevant History

During the 1970s, psychiatrists and psychoanalysts argued, with analysts insisting that psycho-pharmaceuticals interfered with analysis. Today, mainstream psychiatry is characterized by a CT of psychotherapy and psychopharmacology. In the 1990s, psychiatrists finally integrated SSRIs synergistically with cognitive-behavior therapy to treat depression. Indeed such a model, frequently practiced in modified form by PCPs, probably dominates the treatment of depression today. There is an emerging...

Psychological Treatments

Psychological therapy is the mainstay of the management of low sexual desire interest. Given the mandatory blending of mind and body, making deliberate changes in thoughts, attitudes behavior, leads not only to changed feelings and emotions but altered sexual physiology. Under the term sex therapy typically the woman's negative thoughts and attitudes to sex, her distractions during sexual stimulation, the need for more varied, more prolonged, or simply different sexual stimuli, the need for the...

Case study

Alex is 35 years old and Sharon is 33 (not their real names). They have been married for 7 years and have no children. Neither have had any major health difficulties, smoke, or use street drugs. She asked her family doctor to refer both of them because of his disinterest in sex. Three injections of testosterone did not result in any sexual change. Alex was initially reluctant to talk with someone else about this issue but eventually acceded to Sharon's strongly worded request (and that of the...

Biopsychosocial Approach to Therapy

There is a general expectation that modulation of the neurotransmitters involved in sexual arousability and desire from hormonal and nonhormonal therapy, will become available. As there are psychological and interpersonal sequelae of medical disruption of the sexual response, benefit beyond placebo may only be seen if a holistic biopsychosexual treatment approach is used. For instance, loss of arousability and desire in breast cancer survivors is strongly linked to ovarian failure induced by...

Proposed Sexual Aversion Criteria Revision

Given the difficulties inherent in the current classification systems for sexual aversion disorder (DSM-IV-TR and the 1999 Consensus Classification), we have proposed (11) a revised classification system that is based on a modification of these taxonomies. This proposed classification maintains the distinction between primary and secondary sexual aversion. However, this distinction will only be useful for the diagnostic differentiation of the acquisition of aversion early in life and the...

Psychological Therapies for Men with ED

In the majority of cases of ED, psychological factors are involved in either the development of the disorder or the maintenance of the problem. While recognising that many men would not seek a psychological approach to resolving the condition, an outline of performance anxiety about continued erectile failure and the effect this has on their partner and their relationship, is often appreciated by the man. Difficulties with communication and the development of suspicion and mistrust between...

Pharmacological Approaches

Of the few placebo-controlled studies examining the effectiveness of pharmacological agents for treating female orgasmic disorder, most examine the efficacy of agents for treating antidepressant-induced anorgasmia. Whether pharmacological agents would have the same treatment outcome effect on non-drug- vs. drug-induced anorgasmia is not known. Modell et al. (89) reported no significant effect beyond placebo of either 150 or 300 mg day bupropion-SR on orgasm in 20 women with delayed or inhibited...

General Treatment Considerations

In Joyce's case, effective treatment first required relating her history of sexual abuse to her husband, Bill, so that we could begin to interpret her aversion to him in the context of her adolescent experience. This revelation evoked some sensitivity to Joyce's response from Bill and temporarily tempered his insistence on intercourse. We used this period to assess more fully their sexual history, to describe her sexual disorder to them both, and to develop a treatment plan. The theory and...

Positron Emission Tomography Scan Studies in Humans

Although male rat studies are of utmost importance for a better understanding of the neurobiology of ejaculation, brain imaging studies in humans are the tools which provide a better understanding of how the human brain mediates ejaculation and orgasm. Brain imaging studies will probably lead to a deeper insight into which parts of the brain mediate ejaculation and which parts are involved in the mechanism of orgasm, how these neural areas are linked to each other, and which parts are disturbed...

Medical Treatments for Erectile Dysfunction

The 1980s saw a progressive shift away from psychological treatments of SD to an emphasis on surgical and medical solutions for improving sexual health. Simultaneously, there was a progressive shift within the medical community and public at large, towards viewing the etiology of SD as organic, rather than the psychogenic understanding emphasized by sex therapists. Use of improved sophisticated diagnostic procedures, such as duplex sonography and cavernosograms (although not necessarily...

Serotonin 5Hydroxytryptamine Neurotransmission and 5HT Receptors

For a better understanding of the neurobiology of premature and delayed ejaculation and its treatments, it is a prerequisite to have some basic knowledge of what is happening in serotonergic neurons in the central nervous system (1,2). Serotonergic neurons originate in the raphe nuclei and adjacent reticular formation in the brainstem. There is a clear dichotomy in the serotonergic (5-hydroxytryptamine, 5-HT) system neuronal cell groups (1). A rostral part with cell-bodies in the midbrain and...

Evolution Of Current Treatment Approaches

In the 1960s, psychiatric treatment of sexual problems was predominantly psychoanalytic psychotherapy. In the mid- to late-1960s, behavioral therapists began publishing clinical series documenting the successful treatment of sexual problems by the use of classical conditioning techniques. Indeed, the start-stop technique for the treatment of rapid ejaculation was first described by Semans in 1956 (10). However, the major use of behavioral techniques to treat sexual problems began after the...

Orgasm

There is limited knowledge about the physiological mechanisms and neurobiol-ogy underlying the sensation of orgasm. Orgasm is a complex response involving the whole body. During orgasm, there are changes in the genitalia, in skeletal muscle tone (characteristic spastic contractions of the feet), contractions of facial musculature, vocal reactions (moaning or sighing), semivoluntary movements, general cardiovascular (elevated systolic and diastolic blood pressure) and respiratory changes,...

Pharmacotherapy for Men with ED

Few licensed drugs are currently available for the treatment of men with ED. Those that are available elicit their effect by one of two mechanisms. The agent boosts either the neuronal control mechanism or the local control mechanism (13). As we shall see, oral therapies can have their effect on either system, whereas the intracavernosal and intraurethral systems act locally to produce an erection. Oral agents used to treat ED should be reliable, have minimal side effects, and be simple to use...

The Maiden Must Be Kissed Into A Woman

Most pharmacological treatments that are currently being developed for women with sexual arousal disorder are aimed at remedying a vasculogenic deficit. In a study we did in the late 1990s we compared pre- and postmenopausal women with and without sexual arousal disorder, diagnosed according to strict DSM-IV criteria (1). Women with any somatic or mental comorbidity were excluded. This study investigated whether pre- and postmenopausal women with sexual arousal disorder were less genitally...

Working Together A Multidisciplinary Team Approach

The concept is a simple one with a long history sometimes, two heads are better than one. Treatment may require a multidisciplinary team in cases of severe dysfunction, and may be recalcitrant to success even under this ideal circumstance. There are many models for working together. Team approaches and composition will vary according to clinician specialty training, interest, and geographic resources. Although some expert physicians work alone, other PCPs, urologists, and gynecologists have set...

What is a Sexual Dysfunction

The experimental evidence and theoretical notions presented earlier strongly suggest that for women, sexual dysfunction is not about genital response. The women in our study who were diagnosed with FSAD according to strict DSM-IV criteria (42) turned out not to be sexually dysfunctional according to these same criteria because their genital response was not impaired. This study demonstrated that it is difficult to be sure that sexual arousal problems are not caused by a lack of adequate sexual...

Drugs

Unfortunately, few double-blind placebo-controlled trials exist to guide clinicians in understanding the sexual impact of medications. As a result, much of the information that follows is based on less refined information as, for example, case reports. Caution in interpretation is therefore advisable. Unless otherwise referenced, information in this section has been taken from Segraves and Balon (22) and Kaufman and Vermeulen (23). In general, there is often great difficulty in differentiating...

Laboratory Examination

A labaratory exam is only warranted when the sexual desire problem is clearly generalized. When a lab exam is required, the following should be considered 1. Testosterone (T) (see section on Hormones in this chapter). 2. Prolactin (PRL) When an abnormal value is detected, it is best to repeat the test at least once and preferably twice since errors are common. When PRL is high, the T level is also often abnormal. More elaborate assessment of an abnormal PRL level involves brain imaging magnetic...

Ejaculation Threshold Hypothesis

In order to understand the suggested biological variation of the IELT in relation to the serotonergic system, delaying effects of SSRIs and suggested genetics, Waldinger and co-workers have proposed the existence of a threshold of the IELT (5,49). In the case of a low setpoint of the threshold, men can only sustain a small amount of sexual arousal prior to ejaculation. Whatever these men do or fantasize during intercourse, any control of ejaculation remains marginal and these men ejaculate...

Sex Counseling Tips For Clinicians

A sex counseling model is frequently being recommended by CME courses for physicians, under the rubric of optimizing care when using PDE-5 treatments. As discussed earlier, multiple MHPs have attempted to raise awareness of the importance of psychosocial factors in the etiology and treatment of ED (15,17,20,32). However, this sex counseling model will apply to clinicians treating both men and women for the entire range of SDs, not merely those treating ED. Clinician difficulty with either...

Gender Differences in Sexual Feelings

Our hypothesis is that in women other (stimulus or situational) information beyond stimulus explicitness determines sexual feelings, whereas for men peripheral feedback from genital arousal (and thus stimulus explicitness) is the most important determinant of experience of sexual arousal. This hypothesis fits well with the observed gender difference in response concordance. It coincides with Baumeister's assertion that women evidence greater erotic plasticity than men (90). After reviewing the...

Special Situations Requiring Interventions for Men with ED

Depression and Serotonin Reuptake Inhibitors Sexual dysfunction associated with the use of serotonin reuptake inhibitors has been reported in 30-70 of treated patients and is a significant contributor to discontinuation of these medications. A review of selective phosphodiesterase type-5 inhibitors for antidepressant-associated sexual dysfunction suggests treatmet of this side effect of antidepressant medication could improve depression disease management outcomes (105). Androgen replacement...

Behavioral Models of Etiology

Theorists of classical conditioning have proposed that some forms of fetishism can be explained by early learned associations between sexual stimulation and common objects of infancy such as diapers, bottles, and pacifiers (22). One early study using aversion techniques with sexual offenders provided modest support for conditioning theories, in that frequency of masturbation to exhibitionist fantasies, implying stronger conditioning, was associated with treatment failure (96). However,...

Sexual Sadism and Sexual Masochism

Sexual sadism denotes sexual arousal and excitement in response to the psychological or physical suffering of another, whereas sexual masochism denotes a preferred fantasy of selfsuffering. The term sexual sadism derives from the name of the 18th century French aristocrat and pornographic author, Marquis de Sade, who reportedly lived a disreputable adult life abusing young prostitutes. The term sexual masochism was coined by the 19th century psychiatrist Richard von Krafft-Ebing, who derived...

Normal Sexual Desire For

If one accepts the notion that sexuality generally and sexual desire in particular may be different in men and women, another question quickly follows when considering sexual desire, what is 'normal' for men A corollary to this question is since there is a general understanding that sexual activity changes with age, what represents normal sexual desire for men as they get older An exceptional source of information on men and sexuality (including sexual desire) is the Massachusetts Male Aging...

Combination Therapy Guidelines Who How and When

There are two alternative models for CT both will likely be adopted within the framework of sexual medicine, by different clinicians. First, working alone, PCPs, urologists, psychiatrists, and eventually gynecologists will integrate sex counseling with their sexual pharmaceutical armamentarium to treat SD. Sex counseling in this situation, is utilizing sex therapy strategies and techniques to overcome psychosocial resistance to sexual function and satisfaction (20). In a second model, the above...

Followup and Therapeutic Probe

Discussions of follow-up most vividly illustrate the importance of integrating sex therapy and pharmacotherapy. Urologists, Barada and Hatzichristou improved sildenafil nonresponders by emphasizing patient education (e.g., food alcohol effect), repeat dosing, partner involvement, and follow-up (52,53). Patient education about the proper use of sildenafil was crucial to treatment effectiveness. Physicians can increase their success by scheduling follow-up, the first day they prescribe. As with...

Case Example Joyce

Joyce is a 38-year-old woman who has been married for 8 years. She presents with a long, intermittent history of bulimia and other features consistent with Table 5.3 Elements of the Current Classification System (DSM-IV-TR) for Sexual Aversion Disorder and a Proposed Revision to the Classification System Lifelong (primary sexual aversion) Acquired (secondary sexual aversion) Primary sexual aversion Secondary sexual aversion Current DSM-IV-TR criteria Lifelong anxiety, fear, or disgust to sexual...

Psychosocial Factors Related To Womens Orgasm

Age, education, social class, religion, personality, and relationship issues are the psychosocial factors most commonly discussed in relation to female orgasmic ability. Laumann et al. (60) found only the youngest group of women (18-24 years) showed rates of orgasm lower than the older groups for both orgasm with a partner and orgasm during masturbation. This is likely to be attributable to age differences in sexual experience. There was no significant relation between education level and...

Does He have Drug Related Issues

Drugs, whether prescribed or taken recreationally, may be a source of the problem. Commonly prescribed medications are known to affect erectile function Table 7.2 Causes of Hyperprolactinaemia in Men Table 7.2 Causes of Hyperprolactinaemia in Men Any hypothalamic or pituitary tumour Source Adapted from Kumar and Clark. Source Adapted from Kumar and Clark. (see Table 7.2). In addition, street drugs such as cannabis, cocaine, amphetamines, and heroin have all been linked to decreased erectile...

References

Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J et al. Report of the international consensus development conference on female sexual dysfunction definitions and classifications. J Urol 2000 1163(3) 888-893. 2. Lu TF, Basson R, Rosen R, Guiliano F, Khoury S, Montorsi F (eds). Sexual Medicine. Sexual Dysfunctions in Men and Women. 2nd International Consultation on Sexual Dysfunctions. Health Publications, Paris, 2004 932. ISBN 0-9546956-0-7. 3. Reissing ED, Binik YM, Khalife S,...

Postmenopausal Dyspareunia

Postmenopausal dyspareunia is considered a major indicator for hormonal treatment (103). If nonhormonal vaginal lubricants, such as Replens, are not adequate, then estrogen-based creams or estradiol inserts in ring or tablet format are often recommended. In principle, systemic estrogen-based hormone replacement therapy may also be prescribed. Significant reduction of urogenital atrophy can be obtained through estrogen supplementation, which may, in turn, provide the context for improvements in...

Evolving Models

Most of the clinicians involved in the treatment and or research of sexual dysfunctions disorders are probably not very satisfied with the current nomenclature, which is mostly unidimensional and not including all nuances and aspects of sexual problems. The nomenclature does not deal with psychological, relational, and situational factors of human sexuality. Some of these issues, especially the ones related to female sexuality, are discussed in more detail in several chapters of this book (see...

Intimacy Difficulty

See Theoretical Perspectives immediately above (11,32,33). Endocrine Abnormalities Little endocrine research has been done on men with HSDD. Schiavi et al. compared 17 physically healthy men with HSDD to 17 age-matched non-dysfunctional volunteers (34). All were 25-55 years old. The HSDD men were described as having a generalized and persistent lack of sexual desire. Men with HSDD who did and did not have accompanying erectile problems, were also compared. The authors found that men with HSDD...

Operational Definition of Premature Ejaculation

For evidence-based research, it is of utmost importance to have a definition of premature ejaculation. However, because of conflicting ideas about the essence of premature ejaculation, sexologists have never reached an agreement on a definition. DSM-IV (47) defines premature ejaculation as persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it. Until recently, any scientific basis for the DSM-IV definition...

Gender Differences In Orgasm

Although some therapists have suggested that different types of orgasm exist for men, it is generally believed that typologies of orgasm intriguingly exist only for women (25). Most of the research in this area is derived from self-reports of women who distinguish orgasmic sensations induced by clitoral stimulation (warm, ticklish, electrical, sharp) from those induced by vaginal stimulation (throbbing, deep, soothing, comfortable). Masters and Johnson (2) claimed that all orgasms in women were...

Psychiatric Disorders

Sexuality is commonly affected by mood disorders. Specifically, diminished sexual desire is often seen as a feature of depression (42). Schreiner-Engel and Schiavi looked at the relationship between HSDD and depression using an unconventional strategy (35). They examined couples where one partner reported generalized HSDD (22 of the men and 24 of the women all of whom were euthymic at the time) and compared them to a control group. Interestingly, they found that those with sexual desire...

Testosterone

O'Carroll's survey uncovered only one study describing the therapeutic use of a hormone alone. This investigation involved a double-blind crossover comparison of T and placebo in a group of men with normal circulating T levels (59). Ten men complained principally of loss of sexual interest and 10 men complained of erectile failure. The authors found a significant increase in sexual interest produced by T in the first group but qualified this by saying that in only 3 10 of the subjects was it...

Behavioral Therapy

The aim of group or individual behavioral therapy is to break the stimulus -response pattern and regain optimal control over the situation. For the group therapy protocol, the reader is referred to centers where group therapy is given. The protocol described below is for individual behavioral therapy. Treatment comprises self-exploration, relaxation of the pelvic floor muscles, and systematic desensitization. This can be achieved in a step-by-step exercise program that consists of...

Combination Therapy for Sexual Dysfunction Integrating Sex Therapy and Sexual Pharmaceuticals

We know, clinically, that many PDE-5 nonresponders will be restored to sexual health through a CT integrating sex therapy and sexual pharmaceuticals. Yet how do we conceptualize such a model so that standard treatment algorithms could be stretched to incorporate this concept The answer is twofold. We need a schema for understanding psychosocial obstacles (PSOs) to successful treatment, integrated into a model that executes that understanding. Combination therapy is the therapeutic modality of...

Medicalization Of Sexuality

The recent developments in sexual pharmacology only reinforced some to warn us about the medicalization of sexual dysfunction and human sexuality in general. We believe that the treatment of sexual dysfunctions disorders belongs to the realm of medicine. However, we also believe that the sexual pharmacology and total medicalization of sexuality does not provide the best understanding of the complexities of human sexuality and is not always in the best interest of our patients. Bancroft (42)...

Pharmacotherapy

In the relatively short time span, compared to psychologic treatments, that pharmacological treatments have become available for men, since 1998, the effect of pharmacological treatments in women with sexual arousal problems has been investigated in several controlled and uncontrolled studies. To date, none of the treatments listed here have been approved. Sildenafil is the first pharmacological treatment that has been investigated on a reasonable scale in controlled studies with female...

Richard Balon

Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit, Michigan, USA In the last decades of the 20th century, major changes have occurred in our understanding, conceptualization, and treatment of sexual problems. Much of this change was heralded in by the development of oral therapies for the treatment of erectile disorders, the off-label usage of serotonergic antidepressants to treat rapid ejaculation, the increasingly common use of unapproved use of androgens...

Epidemiology

The best information on the epidemiology of sexual disinterest in men comes from surveys of the general population and convenience samples. In the literature on this subject, little attempt is made to distinguish between the different diagnostic subtypes described in the Classification section of this chapter. An excellent source of population-based information on sexual disinterest in men comes from the National Health and Social Life Survey (NHSLS 15). Laumann and his colleagues interviewed a...

Vulvar Vestibulitis Syndrome

Following numerous yeast infections after using a new oral contraceptive pill 2 years ago, Sandra, a 25-year old primary school teacher, started experiencing an intense burning pain at the entrance of her vagina during sexual intercourse. The pain started with initial penetration, lasted throughout intercourse, and was present for 30 min afterwards. Thinking that it was caused by yet another yeast infection, Sandra purchased her usual treatment from the pharmacy over-the-counter antifungal...

Theoretical Perspectives Biological Psychological and Social

Not only are there multiple origins for HSDD in men, but the theoretical perspective of the observer regarding sexual issues as a whole make understanding sexual problems like HSDD even more difficult. One might look first at differing points of view about sexuality in general. Some view sexual difficulties from primarily a biomedical perspective and regard sex as natural. Kolodny et al. wrote to define sex as natural means just as an individual cannot be taught to sweat or how to digest food,...

History And Clinical Examination The History

A complete and accurate history of ED is essential for a reliable diagnosis. Communication about this issue can be loaded with cultural, religious, secular, and personal connotations and therefore the problem of ED must be approached with the right attitude. The clinician should at least appear to be open, sensitive, respectful, confident, and nonjudgemental. Questions should be unambiguous. Language must be clear and uninhibited by complex medical terminology. Never make an assumption about...

Classification General Sexual Issues

Sexual disorders in general are classified in the Text Revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).* One of the sections in DSM-IV-TR is titled Sexual and Gender Disorders. Sexual disorders classified in the DSM system follow the thinking of Masters and Johnson (1), and Kaplan (10). The former described a Sex Response Cycle (SRC) that consisted of four phases, each of which they named excitement, plateau, orgasm, and resolution. Kaplan...

The Psychoanalytical View

Musaph defined vaginismus as a hysterical symptom, or a conversion symptom (18). In other words, a psychological complaint (anxiety) is changed into a physical symptom (a vaginistic reaction). According to Musaph, why some women are vaginistic whereas other are not depends on whether they have a primary disposition towards suppression as a defense mechanism this might be towards a disrupted mother-child relationship, or other stressful situations that occurred in the oral and oedipal phase of...

Traditional Markers Of Sexual Desire

Evidence from nationally representative community samples of midlife women confirms that spontaneous sexual thinking is rather infrequent in the majority of sexually healthy women in long-term relationships (38,46,47). Fantasies, which are a marker of sexual desire in DSM-IV-TR may, in fact, serve as a deliberate means of creating arousal and reinforcing desire. Data confirm the clinical experience that women fantasize to deliberately focus on their sexual feelings and avoid the distractions...

Acquired Delayed Ejaculation

The only way to determine the cause(s) of delayed ejaculation is the clinical interview. There are no specific characteristics of psychologically induced acquired delayed ejaculation. Obviously, the ejaculation disturbance has not existed previously. In addition, the onset may be sudden, the delay may be situational and also intermittent. Some factors may be related to the development of acquired delayed ejaculation, such as a psychological trauma (for example, the discovery of the partner's...

Use of Questionnaires

The use of questionnaires, such as the International Inventory of Erectile Function (IIEF), are sometimes of relevance, and are a useful way of measuring improvement over time (18). The IIEF is a self-report tool that has been used in the clinical trials to assess the response of a subject to oral treatments for ED. It comprises 15 questions which cover five key areas of sexual function in men erectile function intercourse satisfaction orgasmic function sexual desire and overall satisfaction....

Diagnostic Procedures

An ideal protocol for the assessment of FSAD should be constructed following theoretical and factual knowledge of the physiological, psychophysiological, and psychological mechanisms involved. The protocol then describes the most parsimonious route from presentation of complaints to effective therapy. Unfortunately, we are at present far from a consensus on the most probable causes of FSAD. Despite this disagreement, at least two diagnostic procedures should be considered. Firstly, assessment...

Treatment Psychological Treatments

Currently, we are in a climate that overlooks and dismisses psychological treatments (99). One of the reasons for this may be that due to sociocultural pressure in the medical and larger culture, physiological treatments are seen as superior (100). The emphasis on impaired genital unresponsiveness in the DSM-IV and the success of pharmacological treatments for men's erectile dysfunction have undoubtedly contributed as well. Prior to publication of Masters and Johnson's seminal book on sex...

Physical Examination

A physical examination is necessary when HSDD is acquired and generalized in a man. However, one might legitimately ask what to look for since HSDD can be seen as a symptom of a disorder, or, as a syndrome (i.e., as a collection of symptoms which result from a wide variety of causes). When associated with another disease, loss of sexual desire may resemble other phenomena like loss of appetite or fatigue symptoms linked to many different medical and psychiatric disorders ranging from depression...

Why Is it Important to Study and Treat Dyspareunia

Recent epidemiological surveys indicate that dyspareunia affects between 15 and 21 of women between the ages of 18 and 59 (7-9). Although dyspareunia is a common problem, many sufferers do not pursue treatment because of the embarrassment associated with talking about genital pain and sexuality. Of those who do consult, many do not receive adequate care it is reported that 40 of dyspareunic women who sought treatment did not receive any diagnosis even after multiple consultations (8). These...

Closer Look At The Biological Basis Of Womens Sexual Desire And Arousability Including The Role Of Androgens

The neuroendocrine basis of sexual desire interest is poorly understood. The effects on sexuality of medications with known or partially known mechanisms of action suggest that more than 30 neurotransmitters, peptides, and hormones are involved in the sexual response. Currently, the most clinically important include noradrenaline, dopamine, oxytocin, and serotonin via 5HT1A and 5HT2C receptors all considered to be prosexual. Serotonin acting via most 5HT receptor sites, prolactin, and GABA, are...

Index

Acquired delayed ejaculation, 237-238 methodology, 238 organic factors, 237 psychological factors, 237 research, 238 treatment, 237-238 Aging, effect on, ejaculation, 230 Albumin, testosterone, 83 Androgen decline in the aging male (ADAM), 98 Androgen deficiency syndrome, Andropause (ADAM, PADAM) diagnosis, 98 hypogonadal syndrome, 97 -99 Anesthetic ejaculation, 239 definition, 239 etiology, 240 symptoms, 239 treatment, 240 Anesthetic topical ointments, premature ejaculation, 232 Anhedonia,...

Activation And Regulation Of Sexual Response Processing of Sexual Information

In a series of studies we conducted in the 1990s see Ref. (14) for a review , we consistently found that women's genital response and sexual feelings are not strongly correlated, and that affect influences sexual feelings. Other studies had similar findings (43 -45,47-49,65). In men, correlations between genital response and sexual feelings are usually significantly positive, suggesting that for men's sexual feelings awareness of their genital response is the most important source. A surprising...

Definition Of Female Orgasmic Disorder

On the basis of findings from the National Social and Health Life Survey conducted in the early 1990s (60), orgasmic problems are the second most frequently reported sexual problems in US women. Results from this random sample of 1749 US women indicated 24 reported a lack of orgasm in the past year for at least several months or more. This percentage is comparable to the clinic-based data. Orgasmic problems were noted by 29 of 329 healthy women (ages 18 -73) who attended an outpatient...

Does He have an Endocrinological Cause to His ED

Androgen and prolactin levels are of particular concern. Hyperprolactinaemia occurs secondary to stress, drugs (such as neuroleptics and infertility treatments), cirrhosis, breast manipulation, or pituitary adenoma tumour. A high level of circulating prolactin causes inhibition of gonadotrophin releasing hormone which lowers levels of testosterone. Men with low testosterone levels may exhibit a decrease in sexual interest. Causes of low testosterone include renal failure, hypogonadism,...

Case Study Jon and Linda

Jon and Linda were referred to the author by Jon's current psychopharmacolo-gist. Jon is a 62 years old financier who has been married to Linda (53 years old) for over 20 years. She began HRT 4 years ago, which successfully stopped her hot flashes. This is his second marriage and her first marriage. They had three teenage children together. Their marriage was marked by periods of disharmony secondary to multiple etiologies. Jon and Linda had a symbiotic relationship where she dominated much of...

Classification

Barnes derived the term dyspareunia from the Greek term meaning difficult or painful mating (1). This definition, based on interference with sexual intercourse, is understandable given that it is this interference that brings many women to clinical attention. Unfortunately, the focus on difficult mating has resulted in the classification of dyspareunia as a sexual dysfunction (3), and has deflected attention away from the major clinical symptom of pain. The nosological questions concerning...

Course of Rapidity

It is generally believed that aging delays ejaculation. This assumption, might be true for men with a normal or average ejaculation time but has never been investigated in men with premature ejaculation. In a stopwatch study (48) of 110 consecutively enrolled men (aged 18-65 years) with lifelong premature ejaculation, 76 reported that throughout their lives, their speed of ejaculation had remained as rapid as at the first sexual contacts in puberty and adolescence, 23 reported that it had...

Cognitive Therapy

The cognitive therapeutic approach is based on the notion that between stimulus and response, there are factors within the individual that determine the nature and intensity of the response. Interventions in this field aim to change the behavior and feelings of the woman by teaching her to think and behave differently. To achieve this, the doctor as primary treating physician of vaginistic patients, will probably require the assistance of a psychologist sexologist, psychotherapist, or...

Epidemiology Of Sexual Dysfunction

Numerous population surveys in this and other countries indicate a high prevalence of sexual problems in the general population. These surveys indicate that 40 of women have evidence of psychosexual dysfunction. The corresponding number for men is 30 (25). We have more evidence concerning the prevalence of sexual problems in men than women although the data base in both groups is rapidly growing. Correlates of erectile dysfunction in men include diabetes, vascular disease, age, and cigarette...

Nonhormonal Pharmacological Treatment of Low Desire Interest

The place of pharmacological management for women's complaints of low desire interest is undecided. This is because of broad normative range of women's appreciation of sexual desire, especially in the long-term relationship and because of the importance of women's subjective arousal in influencing and triggering their desire and the minimal focus until now on the whole entity of subjective arousal. Thus, the appropriate outcome criteria for a desire drug are unclear. Studies with bupropion...

Diagnosis

Given that andropause ADAM PADAM is purported to be one form of hypo-gonadism, the phenomena described under Assessment above in this chapter, applies here as well. Low sexual desire is usually seen as a symptom of andropause ADAM PADAM. To explain the desire change, a great deal of emphasis has been given to laboratory values, especially alterations in T. However, the typical history has received much less attention. Only one study of aging men seems to have examined various manifestations of...

Future Directions

Major confusion exists in the literature with respect to the nomenclature and classification of dyspareunia. The DSM-IV-TR classifies idiopathic dyspareunia as a sexual dysfunction (3), whereas the ICD-10 (4) distinguishes between organic and psychogenic dyspareunia, neither of which are explicitly defined. In addition, the current nomenclature with respect to dyspareunia subtypes is confusing and fails to clearly differentiate among the various conditions (16). We suggest that a careful...

Identifying Psychosocial Barriers to Success

Importantly, pharmaceutical advertising and educational initiatives have altered the delivery of sexual medicine services, especially in the United States. Specifically, these changes in practice patterns resulted in PCPs becoming the principal healthcare providers for men who present with a primary complaint of ED, with urologists typically seeing the more recalcitrant cases. MHPs rarely are the initial treating clinicians anymore. This both helps and contributes to the problem of success and...

Ill Partner

Severe medical and psychiatric illness can alter partner-related sexual desire. Case Study Tanya and Phillip (not their real names) were each 27 years old and married for the first time for 3 years. They did not have children, did not smoke or use street drugs, and neither had had major health problems in the past. They described themselves as Christian and although they did not have intercourse before marriage, they could not keep their hands off each other during that time and...

Nomenclature

There are a number of cogent criticisms of the current nomenclature system. The system developed to diagnose psychosexual disorders has been adopted to classify disorders presumed to be organic in etiology (44). Duration and severity criteria for diagnosis are unclear. Many of the diagnoses overlap, and the criteria for diagnosing female sexual disorders have been criticized. To put all of this in perspective, a brief description of the history of the diagnostic system will follow. The...

Terminology and Definitions

Hypogonadism refers to the consequences of diminished function of the gonads occurs at any age and for a variety of reasons and is classified into two forms on the basis of the source of the problem, that is, either of testicular origin, or as a result of disorder in the hypothalamic-pituitary axis (Fig. 4.3). Sex-related phenomena associated with hypogonadism are described in the Hormones section of this chapter. The term andropause indicates a particular type of hypogonadism that is related...

The Definition

The assumption that dyspareunia and vaginismus are distinct types of sexual pain disorders has recently been challenged (3-8). Research has demonstrated persistent problems with the sensitivity and specificity of the differential diagnosis of these two phenomena. Both complaints may comprise, to a smaller or larger extent (1) problems with muscle tension (voluntary, involuntary, limited to vaginal sphincter, or extending to pelvic floor, adductor muscles, back, jaws, or entire body), (2) fear...

The Interactional View

The interactional view assumes that vaginistic complaints have a function in maintaining the balance between partners, or in the emotional functioning of the woman herself. In this sense, the complaint can form a solution There are very few authors who explain the phenomenon of vaginismus fully on the basis of this view. However, much of the literature mentions the behavior and the personality structure of the male partner. He comes forward as a low self-confidence, anxious, passive, dependent...

The Somatic View

From a purely somatic point of view, constriction or an obstruction can be solved by using a scalpel. Although Walthard rejected surgical intervention for the treatment of vaginismus as early as in 1909 (45), and Sikkel-Bufinga (46), who performed a follow-up study found that only one vaginistic patient had benefitted from the surgical knife, until recently a few doctors could still be found who opted for such a surgical approach (47). The least vigorous method is dilatation plasty, in contrast...

What Does the Term Dyspareunia Mean

In 1874, Barnes (1) coined the term dyspareunia. He felt that it would be a convenient way of summarizing the different conditions underlying painful intercourse just as 'dyspepsia' is used to signify difficult or painful digestion, we want a word to express the condition of difficult or painful performance of the sexual function (p. 68). Although the usefulness of the term dyspepsia is a matter of some controversy (2), the diagnosis of dyspareunia has not been seriously challenged and is still...

Why Do Women Have Orgasms

It is generally accepted that female orgasms are not essential for reproduction, and any benefit that they may have for female biology is, as yet, unclear. Early theorists believed that orgasm via intercourse activated ovulation and closed off the womb to air, thus facilitating conception (28). When it was later shown that the human female was a spontaneous ovulator at mid-cycle, and that this was unconnected to coitus, the discourse re-focused on the role of uterine suction created by orgasmic...

What Is Orgasm

Orgasm is a transient peak sensation of intense pleasure that is accompanied by a number of physiological body changes. In men, orgasm is normally accompanied by ejaculation, which makes the event easily identifiable. In women, however, the achievement of orgasm appears to be less facile than for males and recognizing that it has occurred is often difficult for some women. Objective indicators that orgasm has occurred have been sought for many years. Kinsey et al. (1) proposed the abrupt...

Premature Ejaculation and Genetics

In 1943, Schapiro noted that men with premature ejaculation seemed to have family members with similar complaints (19). Remarkably, this interesting observation has never been cited. To investigate the potential familial occurrence of premature ejaculation, I routinely asked 237 consecutively enrolled men with premature ejaculation about the family occurrence of similar complaints (23). Because of embarrassment only 14 men consented to ask male relatives about ejaculation latency. These 14 men...

Evidence Based Medicine

Evidence-based medicine means that the formulation of a seemingly attractive hypothesis of the cause of a disease is not enough for scientific acceptance. There needs to be empirical evidence, preferably replicated in various controlled studies. For many decades, premature ejaculation was considered to be a psychological disorder that had to be treated with psychotherapy. However, psychological treatments and underlying theories mostly relied on case reports, series of case report studies, and...

Neuroanatomy

In recent years, much progress has been made in neuroanatomical research of eja-culatory processes. Most knowledge about the functional neuroanatomy of ejaculation is derived from male rat studies. With regard to male rat copulatory behavior, one has to distinguish among brain, brainstem, and spinal cord regions that become activated before and following ejaculation, when sensory information returns from the genitals (Fig. 9.1). The medial preoptic area (MPOA) in the rostral hypothalamus and...

Medical Letter In Reference To Erical Dysfunction

Kinsey AC, Pomeroy WD, Martin CE, Gebhard PH. Sexual Behaviour in the Human Female. Philadelphia WB Saunders Company, 1953 628. 2. Masters WH, Johnson V. Human Sexual Response. Boston Little, Brown & Co, 1966. 3. Levin RJ. Measuring the menopause genital changes a critical account of laboratory procedures past and for the future. Menopause Rev 1999 1V 49-57. 4. Henson DE, Rubin HB, Henson C, Williams JR. Temperature changes of the labia minora as an objective measure of female eroticism. J...

Treatment For Vaginismus

The above-described views and treatment models show that there is wide variation in the causal attributes of vaginismus and that this diagnostic variety leads to an even wider variety of therapeutic interventions. In itself this is not particularly surprising when we consider that in order to have sexual intercourse in a satisfactory manner, obviously apart from the physical conditions that have to be met, there must also be special knowledge, expertise, attitudes and, last but not least,...

Premature Ejaculation

Premature ejaculation (ejaculatio praecox, rapid ejaculation, or early ejaculation) is the most frequent male ejaculatory disturbance. During the last century, premature ejaculation has been considered from both a medical and a psychological view, often resulting in contrasting psychotherapeutic and drug treatment approaches. For a better understanding of the current debate regarding its etiology and treatment, it is important to consider the history of how clinicians thought about and treated...

Biological Theories of the Paraphilias

Understanding of the neurobiology of sexual functioning, both normal and deviant, is incomplete. Nevertheless, it is clear that sexual interest and function derive from both the central nervous system and endocrine factors. In normal sexual arousal, central nervous system involvement includes a cascade of connections from the neocortex to the limbic system and the hypothalamus, particularly the preoptic area and the brainstem (113). Sexual arousal begins via either sensory input, such as...

Summary And Conclusions

Some may see it as a truism that men and women are sexually different, but in the latter half of the 20th century there has been a strong effort to view the two as functionally symmetrical. In spite of this attempt at equation, evidence about just how men and women differ, especially in the crucial area of sexual desire, is rapidly accumulating. Although doubtlessly unintentional, investigations of sexual desire in women have shed light on the same in men. These observations have insinuated...

Psychoanalytic Models of Etiology

Psychoanalytic writers posit that early life experiences are fundamentally related to the development of the paraphilias. Stoller asserted that vengeful hostility, in response to the young child's ambivalent struggle to separate from his mother, is the core of all perversion (67). Many variations of this theme have been proposed. Psychoanalytic theory suggests that fetishism is due to unconscious fears and a sense of inadequacy related to early childhood experience (68,69). Freud proposed that...

Models For Treating Sexual Dysfunction Sex Therapy

Sex therapy theory and technique were derived from the pioneering works of both Masters and Johnson (1) and Kaplan (2). Initially Masters, a gynecologist, used an innovative 2 week, mixed-gender, co-therapy team, quasiresidential approach. Sex therapy rapidly morphed into weekly sessions provided within a solo MHP's office based practice. Treatment continued to emphasize sensate focus exercises and the reduction of performance anxiety. By the 1980s, sex therapy reflected a cognitive-behavioral...

Anatomy And Physiology Of Erection

In its flaccid state, the penis acts as a tube through which urine is passed directly from the bladder via the urethra (13,14). The urethra is also a conduit for the ejaculate, which can be expelled by the penis in both its flaccid and erect state. The penile urethra is encased by a sleeve of erectile tissue called the corpus spongio-sum, which expands at the tip of the penis forming the glans and at the base forming the bulb. The function of the spongiosum is to maintain the patency of the...

Is Absent or Impaired Genital Responsiveness a Valid Diagnostic Criterion

In a recent study we investigated whether pre- and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems (42). Twenty-nine women with sexual arousal disorder (15 premenopausal and 14 postmenopausal), without any somatic or mental comorbidity, diagnosed using strict DSM-IV criteria, and 30 age-matched women without sexual problems (16 premenopausal and 14 postmenopausal) were shown...