A Reintroduction to Clinical Sexuality

Patients generally bring sexual problems to psychiatrists in three ways. The most familiar one is the presentation of a sexual chief complaint or its emergence during therapy for another problem. Patients’ concerns fall into two categories:

A second way psychiatrists may be asked to help is by a couple who complains of some difficulty in orchestrating their sexual life. The couple’s chief complaint may involve matters such as discrepancies in sexual desire, the inability of a young man to bring his partner to orgasm because of premature ejaculation, the cessation of sex, infidelity, dyspareunia, erectile dysfunction in a recently married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography. Some couples are too shy to bring up their sexual concerns and initially discuss nonsexual matters instead.

The third avenue derives from the clash of a person’s sexual behavior with social values or laws. Judges, lawyers, state boards, clergy, or other physicians may ask for our assistance with persons who are accused of sex crimes, cross sexual boundaries in their work, or have been sexually harassed, stalked, or otherwise victimized.

These three presentation types require slightly different processes of history taking and clinical involvement, not only because the differential diagnosis of the problems may be different but also because the number of people directly involved in the evaluation, the origin of the symptoms, and the treatment may vary.

Sexual concerns are extremely common in the general population (14) and are more prevalent among those burdened by psychiatric disorders (15–17). Although psychiatrists are skillful in assessing individual patients who have major psychiatric disorders, we are not nearly as relaxed and confident about our capacity to respond to sexual complaints. Society regards a person’s sexuality as an intensely private subject—so private that most people do not have a sufficient vocabulary to describe their own sexual lives. Psychiatrists grow up with many of the same language deficiencies when it comes to sexual identity and function. Most psychiatrists experience a conscious countertransference barrier to exploring sexual issues in detail. This barrier is constituted by fear of:

The excellent training psychiatrists receive in biological psychiatry has come at the expense of training in psychotherapy, creating the illusion that professional comfort with sexual life is no longer a clinical requirement. Most psychiatrists have no experience with a mentor who has demonstrated that the ordinary fears about dealing with sexual topics can be readily mastered and that many patients can be helped through calm, perspective-giving psychotherapy.

Sexual identity is a personal sense of the self that is usually clearly attained by the end of adolescence. It consists of a series of self labels involving:

We have to be prepared to explore how the patient thinks of his or her sexual identity and to assess whether the patient’s concerns indicate a gender identity disorder, whether the patient’s orientation is heterosexual, homosexual, or bisexual, or whether the patient’s fantasies and behavior indicate paraphilic intentions. Most people have conventional sexual identities—that is, their gender identities are consistent with their biological sex, they almost exclusively have heterosexual attractions and behaviors, and their intentions are to cooperate with their partners to create mutual pleasure. The problems they pose for psychiatrists are generally not severe. Psychiatrists are most likely to experience countertransference barriers with patients who have a gender identity disorder, homosexuality, or a paraphilia.

Desire, arousal, and orgasm are the three dimensions of sexual function that are the basis for our current nosology; they may sound fairly straightforward, but assessing them is complicated. Clinicians need to recognize that desire and arousal merge into one another, particularly as the individual moves into middle age or settles down with one consistent partner, typically in marriage. Desire is usefully thought of as having a youthful biological element, called drive, and a lifelong motivational element that is reflected in the willingness to engage in sex with a particular partner (19). With patients who complain of a loss of desire for sex, the clinician needs to ascertain whether it is manifested by their having no sexual thoughts, fantasies, attractions, and masturbation (as might be seen in acquired hypogonadal states) or whether they have, in essence, lost the motivation to bring their bodies to their current partner for sex (as commonly occurs when alienated from a partner). Desire is also complicated by a vital gender difference (20). Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior with their partner precedes their intense desire for sex, whereas most men continue, through much of the life cycle, to find that their desire for sex precedes their arousal.

When listening to the patient’s story, the psychiatrist first ascertains whether the patient (or couple) is presenting an identity problem or a function problem and then defines its dimension: gender identity, orientation, paraphilia, desire, arousal, or orgasm. He or she then determines whether the problem has been present since the onset of sexual activity—defined as “lifelong”—or whether it followed a long period free of symptoms—defined as “acquired.” If the problem is acquired, the psychiatrist determines whether it is currently always present, or is situational with one partner and not another, or is present sometimes with a partner. Identifying these factors enables the clinician to rationally pursue the etiology.

Any sexual behavior—normal and abnormal, masturbatory and partnered—rests on biological elements, psychological elements, interpersonal elements, and cultural concepts of normality and morality. These four elements are also the general sources of sexual problems. Biological causes can range broadly from a congenital androgen receptor disorder (21) to a current undiagnosed prolactinoma (22) to obvious disease such as multiple sclerosis. The problem also may be due to a medication side effect or to drug or alcohol abuse. Psychological causes may involve past developmental processes, such as a lack of warmth during childhood, neglect, or physical or sexual abuse. Current psychological states may involve, for example, an affect disorder or paranoia. Sociocultural influences may stem from an inability to free oneself from antisexual orthodox religious attitudes, homophobia, or beliefs about the abnormality of masturbation or oral-genital contact. The opportunity to listen to many sexual histories enables psychiatrists to gradually become more efficient in generating causal hypotheses and to use them to benefit their patients in individual or couples psychotherapy.

Each of these four causal elements undergoes short-term oscillations—for example, through the changing phases of the menstrual cycle—and long-term changes—for example, over the course of maturational evolution of attitudes toward sex. The oscillations in these elements explain the subjective and physiological differences between one sexual experience and the next with the same partner. The gradual evolution of the elements makes every sexual life a changeable or dynamic process. Dysfunctional sexual life is trapped in recurrent symptom formation, has less oscillation because it tends to be frequently emotionally unsatisfying, and tends to disappear earlier in the life of the couple or the individual because it is not mutually pleasing.

Gaining a comprehensive understanding of the four causal elements would be too complex, time-consuming, and cumbersome for most busy practitioners. In all specialties, professionals oversimplify the subject in order to be practical and efficient in providing treatment. In urology, for instance, the focus is on the biological contributions to sexual dysfunction. Gynecology concentrates on the anatomic and endocrine contributions to sexual dysfunction. Psychoanalysis emphasizes the psychological developmental aspects. Psychiatrists are often quick to assume that every patient who has a sexual dysfunction and is taking a selective serotonin reuptake inhibitor (SSRI) was sexually normal prior to taking the drug. Throughout medical practice, the pressure to provide a medication for a symptom is powerful. If we are to be accurate in our assessments of individuals and couples in our psychiatric practices, we must be willing to consider the current and past contributions of the biological, psychological, interpersonal, and cultural factors in every case. We may declare after the first or second session that a given patient’s hypoactive sexual desire is due to his critical assessment of his wife’s alcoholism, but we should be prepared to discover over time that it is more complicated (23).