Introduction: Treatment of Sexual
Disorders in the 21st Century
R. Taylor Segraves
Metrohealth Medical Center and Case Western Reserve
University School of Medicine, Cleveland, Ohio, USA
Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit, Michigan, USA
Evolution of Current Treatment Approaches
Epidemiology of Sexual Dysfunction
Medicalization of Sexuality
In the last decades of the 20th century, major changes have occurred in our under- standing, 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
to increase libido in women with hypoactive sexual desire disorder, and the com- bined use of anti-androgens and serotonergic antidepressants to treat paraphilias. The wide spread usage of effective biological therapies for sexual disorders has contributed to the increasing emphasis on biological models concerning etiology, often to the neglect of psychological factors. In the 1960s, it was commonly assumed that most sexual problems were psychogenic in etiology (1). However, the advent of effective biological therapies has shifted the focus to organic causes of erectile dysfunction (2). These changes in assumed etiology have had profound effects on treatment and conceptualization of the origins of sexual disorders. Many patients who used to be treated by behavioral therapy are now being treated pharmacologically. The rapid development of biological models of therapy has brought valuable help to many individuals who previously had minimal treatment choices. However, a number of factors including the large number of men who dont refill sildenafil prescriptions indicate that pharma- cotherapy alone may not always be sufficient (3). To date, there is insufficient data to indicate when pharmacotherapy alone, psychotherapy alone, or combined therapy is indicated for most of the sexual disorders.
A comparable situation in general psychiatry exists in the treatment of depression and obsessive-compulsive disorders. In each of these conditions, both pharmacological and psychological treatment approaches have been shown to be effective, and the most efficient clinicians select and combine thera- pies for the individual patient (4 – 7). Our experience in treating depression and obsessive-compulsive disorders may provide useful models for the treatment of sexual disorders. An example of an useful model is the study comparing nefazodone to cognitive-behavioral analysis system of psychotherapy to the com- bination of these two modalities (8). Although the monotherapies were effica- cious, they were not significantly different from each other. However, the combination of the two modalities was significantly better than either monother- apy. Actually, the combination resulted in a highest ever treatment response rate in clinical trials of chronic major depression. As Heiman (9) pointed out, the implications for treatment of sexual dysfunction are compelling, though we need to clarify which medications and psychological therapies might be com- pared and combined.
The rest of this chapter will briefly summarize the history of the develop- ment of treatment for sexual problems and the recent knowledge about the epidemiology of sexual dysfunction, and discuss problems with current nomenclature.
EVOLUTION OF CURRENT TREATMENT APPROACHES
In the 1960s, psychiatric treatment of sexual problems was predominantly psy- choanalytic 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 publication of “Human Sexual Inadequacy” by Masters and Johnson in 1970 (11). In the 1980s, case reports began appearing in the psychiatric literature about using monoamine oxidase inhibitors and low dose antipsychotic drugs to treat rapid ejaculation (12). However, the use of psychiatric drugs to treat rapid ejaculation became much more common after the introduction of the selective serotonin reuptake inhibitors.
Urologists have made important contributions to the treatment of erectile dysfunction. Both the Small-Carrion and inflatable penile prostheses were intro- duced in the 1970s. Although patents for vacuum erection devices were obtained as early as 1917, the introduction of the vacuum erection pump by Osborn in 1974 resulted in this being a common solution for many men before the introduction of other treatment options. Alprostadil intracorporal injections were introduced in the 1980s. However, the popularity of treatment approaches decreased dramati- cally with the introduction of sildenafil in 1998 and the subsequent introduction of tadalafil and vardenafil. Now a man could take an effective oral agent that allowed sexual behavior to occur in a more natural way. Understandably, as the primary etiology of erectile dysfunction for majority of aging men is vascular (13,14), the main focus of therapeutic oriented research of erectile dysfunction has been the vascular dysfunction/insufficiency area. The previously touted use of androgens in erectile dysfunction has been abandoned as it became clear that androgen administration does not improve erectile dysfunction in eugo- nadal men (15). Interestingly, testosterone replacement in men with age-related mild hypogonadism is not effective in reversing symptoms of hypogonadism (in contrast to the same situation in older men) (15).
The successful introduction of sildenafil contributed to the search for pharmacological treatments for female sexual disorders. Initially, many companies did clinical trials in women with substances that had proven successful in treating erection problems. In general, these trials were unsuccessful. The one exception is a clitoral vacuum erection device, which has FDA approval (16,17). Another approach is the study of androgens to stimulate desire in women. Off-label use of androgen preparations increased significantly after the work by Gelfand and Sherwin (18,19) demonstrated that supraphysiological levels of testosterone increased libido in postmenopausal women (20). The use of androgen preparations to treat desire problems in women is currently undergoing clinical trials. As Rosen (21) pointed out, many large pharmaceutical trials of female sexual dysfunction are unfortunately hindered by various methodological problems, such as the lack of use of physiological outcome measures and the lack of consensus classification system for female sexual dysfunction in determining inclusion and exclusion criteria. There is also no precise and stable definition of normal sexuality available. Definition is also of dubious clinical usefulness.
The lack of success in search for efficacious pharmaceuticals for treatment of sexual dysfunction in women led to the examination and use of various botanical or herbal, and other substances in these indications (22,23); for review see Ref. (24). As Rowland and Tai (24) caution us, the effects of herbals tend to be limited, relatively nonspecific, poorly studied, and associated with unpredict- able or unknown side effects.
The recent focus on pharmacological and other biological treatments of sexual dysfunction unfortunately takes away attention and emphasis from psychological treatments. However, as Heiman (9) points out, psychological treatments are efficacious (though their demonstrated efficacy is frequently limited) and needed (for various reasons, such as optimization of psychological treatments, patient choice, low frequency of side effects, etc.). Heiman (9) also cautions that the prescription of a physiologic treatment that ignores the fact that human sexuality is infused with individual meaning may invite further interference with sexual functioning.
EPIDEMIOLOGY OF SEXUAL DYSFUNCTION
Numerous population surveys in this and other countries indicate a high preva- lence 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 preva- lence 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 smoking. Serum dehydroepiandro- sterone and high-density lipoprotein cholesterol were found to be negatively correlated with erectile problems (26). Depression was correlated with erectile function in cross sectional studies, whereas passive personality traits tended to predict who would develop impotence in a prospective study (27). Studies in other countries have, in general, found somewhat similar rates of erectile dys- function in the same age population and also that erectile dysfunction tends to correlate with the presence of diabetes, higher age, cardiovascular disease, and depression (15,28 – 32).
It is important to note that depression is not the only mental disorder associ- ated with sexual dysfunction(s). Sexual dysfunction occurs in course of schizo- phrenia (33,34) or anxiety disorders (35).
Some recent studies went beyond collecting pure epidemiological data and studied the impact of sexual dysfunction on men suffering from various sexual dysfunctions. For instance, Moore et al. (36) described that younger men suffer- ing from erectile dysfunction reported comparatively less relationship satisfac- tion, greater depressive symptomatology, more negative reactions from partners, and less job satisfaction than older men. They concluded that older men experience less difficulty than younger men adjusting to life with erectile dysfunction. Symonds et al. (37) interviewed men with self-diagnosed premature ejaculation. In their relatively small sample, they found that men with premature ejaculation had a sense that premature ejaculation was causing (not exclusively)
lower self-esteem and had impact on forming a relationship. Findings of these two studies underscore the complexity of sexual dysfunctions/disorders and their connection to an overall functioning and well-being.
A population study of US females aged 18 – 65 (25) found that 33% of US females reported low libido, trouble with orgasm, or difficulty with lubrication for at least 1 month in the previous year. Other surveys have reported similar findings. Hawton (38) studied sexual activity in a community sample in Oxford, United Kingdom and found that 17% reported never experiencing an orgasm and only 29% reported experiencing orgasm at least 50% of the time. Marital satisfaction was the major predictor of sexual activity and satisfaction. Dunn (39,40) also reported several population studies in the United Kingdom. Approximately 40% of the women reported a sexual problem, the most common being difficulty reach- ing orgasm. A recent population survey in Sweden (41) of sexual behavior in women aged 18 – 74 found that the most common problems were low desire followed by orgasm and arousal difficulties. They also reported considerable co-morbidity between sexual disorders. Some (42) questioned the methodology of epidemiological studies of sexual dysfunction as too simplistic and medicalized.
Laumann et al. (43) have recently completed a survey of 27,500 men and women aged 40 – 80 in 29 countries. In Northern European countries, lack of sexual interest was reported in 25.3% of women. Problems with orgasm and pain were reported in 16.9% and 17.7%, respectively. In men, low libido was reported in 12%, erectile dysfunction in 12%, and rapid ejaculation in 20.6%. Similar values were reported for other world regions, with minor differences in prevalence among different regions.
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 Diagnostic and Statistical Manual of Mental Disorders (DSM) was devel- oped in the United States although it is employed by professional in other countries as well. The DSM is supposed to correspond to the International Classi- fication of Diseases (ICD).
The DSM-I was developed in 1952. The DSM-II was developed to correspond with the ICD-8. Psychosexual disorders in the DSM-II were grouped under one diagnostic entity, genitourinary disorders. The DSM-III was developed to reflect changes in diagnosis and still remains compatible with the ICD-9. The nomenclature developed by William Masters, Helen Singer Kaplan, and Harold Lief had tremendous impact on the development of classifi- cations of psychosexual disorders in DSM-III. This manual listed inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, functional dyspareunia, functional vaginismus, and ego-dystonic homosexuality. In DSM-IIIR, ego-dystonic homosexuality was deleted and sexual aversion disorder was added. The names of certain diag- noses were changed. For example, inhibited sexual desire became hypoactive sexual desire disorder. Sexual arousal disorder and male erectile disorder were substituted, respectively, for inhibited male and female sexual arousal disorders. Throughout, changes in criteria sets have been minimal. In DSM-IV, most of the names and criteria sets resemble DSM-IIIR. The requirement that a disorder be diagnosed only if it causes significant personal distress was added to put a high threshold for diagnosis (45). The DSM based classification remains unclear. For instance, it intermingles terms of sexual dysfunction(s) and sexual disorder(s) in an unclear manner.
Current nomenclature includes hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder, dyspareunia, vaginismus, premature ejaculation, erectile disorder, and male and female orgasmic disorders. In addition, each diagnosis is sub-typed into acquired or lifelong and global or situational. Several groups have suggested modification to the criteria sets for female sexual disorders (46).
Most of the clinicians involved in the treatment and/or research of sexual dysfunctions/disorders are probably not very satisfied with the current nomencla- ture, 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 for instance the Chapters 3 and 6).
A 26-year-old male who complains being distressed because ejaculating within 30 – 60 sec after penetration during sex with his wife, but reports no rapid ejaculation while masturbating technically meets the diagnostic criteria for premature ejaculation. Nevertheless, the diagnosis of premature ejaculation does not fully describe the scope and psychology of his sexual dysfunction. The same could be implied in the case of 67-year-old married male who started to compulsively masturbate about 2 years ago. He thinks about other men being around at times while masturbating, or at times he masturbates just “without any thoughts,” in various places, for example, while driving. Is his diag- nosis sexual disorder not otherwise specified? Or obsessive-compulsive disorder? Do these diagnoses-labels help the clinician in any way?
The recent diagnostic system, paraphrasing Winston Churchill, is probably the worst diagnostic system except for all those that have been tried. It certainly could be improved. Recently, Fagan (47) proposed a systematic way in which clinician organize the mass of information about sex. We discuss it in more details for two reasons—it clearly demonstrates that human sexuality, as other areas, requires a more complex and sophisticated descriptive/diagnostic system, and it illustrates one of probably many possible approaches.
Fagan suggests using the system of four perspectives, or four different ways to view a clinical case, which was originally developed by McHugh and Slavney (48) for all psychiatric disorders. He believes that these four perspectives are a more complex way of viewing clinical information and then communicating that information to clinicians, colleagues, and the individual with the clinical problem or disorder.
These four perspectives are:
1. The disease perspective
2. The dimension perspective
3. The behavior perspective
4. The life story perspective.
The disease perspective is categorical, the patient either has or does not have the disease. As Fagan (47) points out, this is the foundation of the medical model, but not the entire story. This perspective turns to physiology, anatomy, and medicine to learn about patient’s sexual problem.
The dimension perspective focuses on measurement (dimensional gradation and quantification). Examples of the objects of measurements are intel- ligence quotient, behavioral patterns, mood, or personality traits.
The behavior perspective focuses on the behavior of an individual who is goal directed, or teleological. Fagan explains that the behavior perspective is to cognitive-behavioral clinician what the disease perspective is to physician.
Finally, the life story perspective is what “most people associate with psy-chotherapy.” It relies on the narrative told by the patient to give some meaning and direction to their life.
Fagan emphasizes that “no single perspective is, in itself, more valuable than any other,” and each perspective can contribute to the formulation. His pro- posal helps, in part, to deal with several issues. First, human sexuality is much more complicated than just achieving reliable erection and, as noted, the medical diagnosis does not include psychological, relational, and other factors. Second, not all sexually disordered behavior has a psychiatric diagnosis. Third, sexual diagnosis is an alternate and developing construct. Fourth, sexual diagno- sis does not imply causality.
Fagan suggests that one should select the primary perspective that “best fits the patient and then integrate the other perspectives into the formulation and treatment to make use of the additional contributions they may provide.” He also emphasizes that perspectives are conjunctive and not disjunctive.
Fagan feels that using the four perspectives is more helpful in delineating sexual problems/dysfunctions/disorders and conceptualizing their treatment. Many will probably find this proposal too complex or not complex enough, overly inclusive or not inclusive enough, not practical enough or too practical. However, we feel that it is an interesting and thoughtful proposal, which may further stimulate and help the debate about the diagnostic issues in the area of sexual dysfunctions/disorders.
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) among others cautions just about a few important issues con- nected to medicalization of human sexuality. He points out that male sexuality has been medicalized for most of the 20th century, and that medical profession has paid more attention to female sexuality lately (interestingly, this increased interest seems to parallel with the increased interest of the pharmaceutical indus- try in female sexuality).
Bancroft points out that the interface between psychological processes and physiological response, especially in women, is not well understood. He discusses the numerous male – female differences in sexuality. He also asks, “when is a sexual problem a sexual dysfunction,” as many times impaired sexual interest or response in women is psychologically understandable and thus rather an adaptive response to a problem in the sexual relationship rather than sexual dysfunction.
Medicalization of sexual dysfunction and human sexuality has been ben- eficial to some extent in expanding part of our understanding of human sexuality and its impairment(s), and in expanding our treatment armamentarium. However, it also poses dangers in a form of trivialization of human sexuality and secondary suppression of exploring other avenues of our understanding of human sexuality.
From the discussion of the history of the field, the evolution of nomenclature, and emerging data on epidemiology, it is clear that this is a field in rapid evolution. Most of the impetus for this change came from the discovery of effective oral therapies for male sexual disorder and the subsequent search for similar therapies for women. This has contributed to better studies of the epidemiology of these disorders and to debates about the proper nomenclature. In addition, clinicians have begun trying to find which psychological, pharmacological, or combined approach is most suited to treat these disorders (49,50).
The purpose of this book was to assemble experts in treatment of each dis-order into one text so that this text could serve as a treatment guide for students and practicing clinicians. Ultimately, we hope that those who will benefit the most are our patients. Patient sexual satisfaction may be associated
with many health factors, including a reduced risk for subsequent new severe disabilities (51).