Sexual Disorders or Sexual Dysfunction

Overview

A comprehensive psychiatric evaluation of any patient in the general hospital setting should include close attention to complaints, impairments, and deviations of sexual function. Although on occasion, sexual problems are the primary reason for consultation, more often they may provide important clues about an underlying medical or psychologic condition. Consider the “difficult” patient on obstetrics who repeatedly refuses gynecologic exams, the formerly mild-mannered elderly gentleman who now shouts obscenities and gropes at nurses, or the sexually provocative patient who evokes strong reactions from the medical team. Could the patient on obstetrics have a history of sexual trauma, the elderly man a frontal lobe tumor, or the provocative patient a personality disorder? These are a few of many examples that serve to highlight the role that understanding sexuality plays in caring for patients both compassionately and effectively.

The consulting psychiatrist should also be reminded of the importance that being able to maintain a healthy sexual life holds for many patients, regardless of the reason for hospitalization. Sexuality may take on even greater significance for patients suffering from illness that directly impairs sexual function, because of the difficulties both real and perceived. Psychiatric consultants should be alerted to high rates of sexual problems in patients with chronic diseases (especially cardiovascular disease, cancer, diabetes, neurologic problems, end-stage renal disease, and pain). Many chronic diseases result in depression, which in turn contributes to decreased sexual desire. Moreover, psychological reactions to existing illnesses run the gamut, from fear that sex can kill (post-myocardial infarction) to distress over low sexual self-image (post-disfiguring surgery), to avoidance of sex, to fear of pain during sex, to fear that sexual advances will be rejected, all leading to decreased sexual intimacy.

When offering suggestions for patient management, such as prescribing a new psychotropic medication, care should be taken to minimize or treat sexual side effects as much as is possible. This may also help to improve patient rapport and compliance. In cases where sexual dysfunction appears to have a psychological component, or where longer-term behavioral, psychotherapeutic, or pharmacologic therapy may be warranted, referral for outpatient psychiatric care can be arranged. The consulting psychiatrist may be the first to diagnose a sexual problem and can facilitate the transition from inpatient to outpatient care.

Epidemiology and Risk Factors

Sexual disorders are extremely common. It has been estimated that 43% of women and 31% of men in the United States suffer from sexual dysfunction. In addition, lack of sexual satisfaction is associated with significant emotional (including depression and marital conflict) and physical (e.g., cardiovascular disease and diabetes mellitus) problems.

Sexual disorders affect individuals across the epidemiologic spectrum. Risk factors include: female gender, older age, and co-existing psychiatric or medical (e.g., cardiovascular) disease. It has been estimated that 10% to 54% of patients do not resume sexual activity after myocardial infarction (MI); 45% to 100% of patients with uremia or who are undergoing hemodialysis experience low sexual desire; and 26% to 50% of patients with untreated depression experience erectile dysfunction (ED).

Among those with obesity and a sedentary lifestyle, weight loss and increased physical activity are associated with improved sexual function. The association between race and sexual dysfunction is more variable. There is a strong association between ED and vascular diseases. In fact, ED may be the presenting symptom of cardiovascular disease. ED may be more frequent among individuals with specific genetic mutations (e.g., polymorphisms in genes for nitric oxide synthase) in molecular pathways responsible for resisting endothelial dysfunction. Sexual trauma for both sexes is associated with long-term negative changes in sexual function. A strong association exists between paraphilic disorders and childhood attention-deficit/hyperactivity disorder (ADHD), substance abuse, major depression or dysthymia, and phobic disorder. The prototypical patient with a paraphilic disorder is young, white, and male. Anxiety, depression, and suicidal thoughts or actions, as well as homosexual or bisexual orientation, are commonly associated gender dysphoria.

Pathophysiology

The ability to maintain adequate sexual function depends on complex interactions among the brain, peripheral nerves, hormones, and the vascular system. Disease states in these systems are associated with sexual dysfunction. However, no single comprehensive view has been established.

Brain regions involved in sexual arousal include the anterior cingulate gyrus, prefrontal cortex, thalamus, temporo-occipital lobes, hypothalamus, and amygdala. The neurotransmitters dopamine and norepinephrine appear to stimulate sexual function, whereas serotonin may inhibit orgasm. Testosterone, estrogen, progesterone, oxytocin, and melanocortin hormones have a positive effect on sex, but prolactin is an inhibitor.

Recent data suggest a central role for nitric oxide (NO) at the vascular level. In women, NO is thought to control vaginal smooth muscle tone; higher levels of NO are associated with increased vaginal lubrication. In men, NO allows for increased intrapenile blood flow, which facilitates erection. NO acts via the generation of cyclic guanosine monophosphate (cGMP), which has vasodilatory properties. Phosphodiesterase type-5 (PDE-5) inhibitors (the prototype of which is sildenafil) act to inhibit the degradation of cGMP, which prolongs the effects of NO. Cholinergic fibers, prostaglandin E, vasoactive intestinal peptide (VIP), and possibly neuropeptide Y (NPY) and substance P may also improve vasocongestion.

Sexual dysfunction may be best understood by having knowledge of the stages of the normal sexual response; these vary with age and physical status. Medications, diseases, injuries, and psychological conditions can affect the sexual response in any of its component phases, and can lead to different dysfunctional syndromes ( Table 25-1 ). Three major models of the human sexual response have been proposed.

Masters and Johnson developed the first model of the human sexual response, consisting of a linear progression through four distinct phases: (1) excitement (arousal); (2) plateau (maximal arousal before orgasm); (3) orgasm (rhythmic muscular contractions); and (4) resolution (return to baseline). Following resolution, a refractory period exists in men.

Kaplan modified the Masters and Johnson model by introducing a desire stage; this model emphasized the importance of neuropsychological input in the human sexual response. The Kaplan model consisted of three stages: (1) desire; (2) excitement/arousal (including an increase in peripheral blood flow); and (3) orgasm (muscular contraction).

Basson, who recognized the complexity of the female sexual response, more recently proposed a biopsychosocial model of female sexuality that consisted of four overlapping components: (1) biology, (2) psychology, (3) sociocultural factors, and (4) interpersonal relationships. Notably, this conceptualization suggested that women may be receptive to, and satisfied with, sex even in the absence of intrinsic sexual desire if other conditions were met (such as emotional closeness). The fact that physical measurements of female arousal (such as increased vaginal secretions) are poorly correlated with sexual satisfaction lends support for Basson's view.

Aging is associated with changes in the normal human sexual response. Men are slower to achieve erections and require more direct stimulation of the penis to achieve erections. Women have decreased levels of estrogen, which leads to decreased vaginal lubrication and narrowing of the vagina. Testosterone levels in both sexes decline with age, which may result in decreased libido.

Clinical Features and Diagnosis

The newly revised Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) classifies sexual disorders into three major categories. Sexual dysfunction is characterized by a clinically significant disturbance in the ability to respond sexually or to experience sexual pleasure. Paraphilic disorders are characterized by recurrent, intense sexual urges that involve unusual objects or activities and cause personal distress or harm to self or others. Gender dysphoria involves conflict between one's assigned and experienced genders, resulting in personal distress or functional impairment. The DSM-5 has made substantial changes to the classification of sexual disorders, as detailed later in this chapter.

The diagnosis of a sexual problem relies upon a thorough medical and sexual history. Physical examination and laboratory investigations may be crucial to identification of organic causes of sexual dysfunction. Primary psychiatric illness may present with sexual complaints ( Table 25-2 ). However, most sexual disorders have both an organic and a psychological component. Physical disorders, surgical conditions ( Table 25-3 ), medications, and use or abuse of drugs ( Table 25-4 ) can affect sexual function directly or cause secondary psychological reactions that lead to a sexual problem. Psychological factors may predispose, precipitate, or maintain a sexual disorder ( Table 25-5 ).

Approach to Sexual History-Taking

The sexual history provides an invaluable opportunity to uncover sexual problems ( Case 1 ). Because patients are often embarrassed to discuss their sexuality with physicians or view sex as outside the realm of medicine, and because physicians are often reluctant to broach the topic of sex for fear of offending their patients, the need to make sexual history-taking a routine part of practice is paramount. Physicians should always attempt to be sensitive and non-judgmental in their interviewing technique, moving from general topics to more specific ones. Questions about sexual function may follow naturally from aspects of the medical history (such as introduction of a new medication, or investigation of a chief complaint that involves a gynecologic or urologic problem).

Screening questions include: Are you sexually active? If so, with men, women, or both? Is there anything you would like to change about your sex life? Have there been any changes in your sex life? Are you satisfied with your present sex life? To maximize its effectiveness, the sexual history may be tailored to the patient's needs and goals. Physicians should recognize that paraphilics are often secretive about their activities, in part because of legal and societal implications. Patients should be reassured about the confidentiality of their interaction (except in cases where their behavior requires mandatory legal reporting, e.g., as with child abuse).

In taking a sexual history, the consulting psychiatrist should recognize that chronic illness often contributes to sexual dysfunction, whether by direct physical damage or associated psychological effects. Patients with cancer, end-stage renal disease, coronary artery disease, multiple sclerosis, and diabetes are all at increased risk of sexual problems. To explore the role physiologic illness may play in sexual dysfunction, consultants should ask questions about diseases, procedures, and medications that might affect hormone balance, disrupt normal anatomic genitalia, cause CNS dysfunction, damage vascular or peripheral nerve supply to sexual organs, or contribute to pain during sexual activity.

With Internet pornography and “cybersex” activities now available on-demand, anytime, psychiatrists should be aware of increasing patient concerns about “sexual addiction.” The sexual history-taker should feel comfortable exploring, as needed, the role of the Internet in the patient's sexual and non-sexual functioning and the potential for excessive and/or compulsive sexual activities. In fact, a new “hypersexual disorder” was proposed for inclusion in DSM-5, although ultimately not included in the text. Yet, the possibility of impulsive, excessive sexual behavior causing distress to self or others remains. Thus, appropriate screening by a trained clinician is essential. “Hypersexuality” may be a primary problem. However, if behaviors are new or rapidly escalating, an underlying medical or neurological problem should be first excluded, particularly in the inpatient setting.

Diagnostic Criteria of Specific Sexual Disorders