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Questions of
the Week
July through September, 1998
July 6, 1998
Q "I have been following the questions
about Sexual and Gender Identity Disorders, and I wondered if the
following applies to me. I am a married woman, married for six years,
and I have no change in sexual desire but my body is responding
differently than before, and it frustrates my husband and me.."
A There is a disorder called Female
Sexual Arousal Disorder, and like the other Sexual Desire Disorders,
it can be of recent onset or of lifelong duration. It also may be
associated with specific settings, situations and relationships or
generally present in all sexual settings. It may be due to
psychological factors or a combination of psychological and physical
factors. It is characterized by inability to attain or maintain
adequate physical response to sexual excitement. It is considered a
disorder when it causes distress or interpersonal conflict, and it
must be differentiated from other psychological problems for which it
may be simply a symptom rather than the primary problem.
In many communities there are doctors who specialize in sexual
problems, and your gynecologist may have a recommendation. There is
also a national organization of sex educators and therapists located
in Washington, DC which maintains a referral list and recommendations
as to whom they recommend in your community.
July 13, 1998
Q I am not certain that I understand what
Viagra is used for...looking over the last few weeks of discussions of
Sexual and Identity Disorders, it
did not seem that Viagra would be of much help. What is the common
problem for which Viagra and that suppository they talk about are
used?."
A Male Erectile Disorder is the recurrent
inability to achieve or maintain an adequate erection until completion
of sexual activity. It is not considered male erectile disorder if it
is merely an occasional problem or if it does not create distress and
interpersonal difficulty. It can be due to psychological or a
combination of psychological and physical factors, and it can occur in
most or just some settings. For some, the onset occurs at a specific
time in life (acquired) as in response to a specific situation. For
others, it may be of lifelong duration. It is important to
differentiate male erectile disorder from mood disorders or anxiety
disorders for which this may merely be a symptom of a larger
underlying problem. Complete psychological and physical examinations
may be indicated for many patients. It should be noted that some
research indicates that the acquired type (vs. lifelong type)
will spontaneously disappear in 15-30% of cases and may be dependent
upon the type of sexual partner and quality of the relationship.
July 20, 1998
Q As a female, drugs and suppositories are
not likely the solution for my problem which is chiefly an absence of
orgasm. This has disrupted my two marriages and other relationships I
have attempted. I find this terribly depressing, but I don't feel it
occurs because I am otherwise depressed. What are some of the
causes...and hopefully solutions?"
A There are psychological specialists
that deal with Female Orgasmic Disorder a disorder which can result
from trauma but can also be acquired through problems within
relationships. There are those for whom the problem is of lifelong
duration. And for others the problem may present in generalized
(almost all) settings or be specific to situational (specific kinds
of) settings.
The capacity for orgasm increases with age, and female orgasmic
disorder is more common in younger women. Many women increase orgasm
capacity as they acquire more knowledge of the responses of their own
bodies.
The problem has not been found associated with specific personality
traits or other psychopathology. Although we shall talk about this
more later, there are substance-induced (drug related) sexual
dysfunctions for which inhibited orgasm can be the result. Occasional
orgasmic problems, which are not persistent or do not result in
distress or interpersonal difficulty, are not considered a
"disorder," nor are orgasmic problems which result from the
poor or inadequate nature of the sexual stimulation by a partner
including "focus, intensity and duration."
July 27, 1998
Q Most guys have heard about, or know,
women who had difficulty with orgasm, but as a male, this has been a
recent problem for me. I am only in my 20s, and I cannot seem to have
orgasm except with a great deal of assistance. This frustrates me and
my girlfriend a lot. I have not talked to anyone about this. It seems
that most guys have the opposite problem and would think my situation
is great, but it it isn't. It is very frustrated and very
embarrassing. Is this something that others have? I have never heard
of the problems."
A The delay or absence of orgasm
following what is typically a normal sexual excitation phase is not
uncommon. As with other sexual disorders, it can have an onset later
in life or have been in effect for the person's entire life, and it
can manifest in specific situations or in almost all situations. There
are physical causes and drug related causes which must be
differentiated, and there are psychological causes, the predominance
of which is the anxiety associated with once again experiencing the
frustrating outcome.
For some males, it is not the absence of the orgasm but what
stimulation is required before it can occur. For some males, it can
occur with stimulation but not with intercourse. If this occasionally
occurs, it is not considered a disorder. For example, alcohol for some
males will create the problem situationally. It is when it causes
emotional distress and interpersonal problems that it is considered a
disorder. For older males, the problem may simply be the normal longer
period required with age which the person misinterprets as a problem
rather than part of the aging process.
It is important to seek a complete psychological and physical
evaluation since there are a number of causes that may have this as a
symptom and not be the core cause of the problem. Most communities
have specialists in the area of sexual dysfunction and/or have
university programs that deal with the problem.
August 10, 1998
Q My problem is likely not
an uncommon one, but since you have been discussing sexual disorders,
I wanted to ask about my difficulty. Simply put, I am finished before
I begin, and it is embarrassing, and it makes me feel immature and
unmasculine. I really have not tried to do anything about it except
worry and avoid sexual contact. That does not seem to help. Can you
give me any information?"
A Arguably, for men, the most frustrating
of the sexual disorders is that of premature ejaculation. It is the
persistent or recurrent experience of ejaculation with minimal sexual
stimulation before, or, or shortly after penetration. It occurs before
the man wants it to occur. Sometimes, it is misperceived by the male
as occurring "too soon" when, in reality, it is occurring
within what is considered an average length of time. The man,
therefore, may have inadequate information from others as to what
constitutes "premature" and may have had punitive or
ridiculing experiences. Also, the occasional occurrence of an early
ejaculation does not constitute a disorder. The disorder may have an
onset later in life or have been in effect for the person's entire
life, and it can manifest in specific situations or in almost all
situations. There are physical causes which should be considered, but
the vast majority of such situations arise from psychological
experiences and become associated with fear that it will simply happen
again. You should consider discussing this with someone who can refer
you to a psychologist who diagnoses and treats this disorder. You can
be encouraged that this is typically an easily treated problem with
very positive outcome.
August 17, 1998
Q My problem is, to me, rather
embarrassing. I am a male, and I find intercourse to be painful.
Sometimes it is painful before sex, sometimes after sex and frequently
during sex. I know that women get this and heard it was due to
problems with lubrication, but I have never heard of a male with this
problem. Have you heard of this...can it occur in a man?"
A There are two problems, one is
called dyspareunia. It involves pain in the genitals associated with
sexual intercourse. It can also occur before or after intercourse and
can occur in males and females. There may be an experience of mild
discomfort or actual sharp pain. The result may be avoidance of
intercourse or substitution of other forms of sexual activity in order
to avoid intercourse. This problem is not caused by lack of
lubrication and should be differentiated from similar symptoms arising
due to an organic (physical) problem.
The other problem is called Vaginismus in which there is involuntary
contraction of the perineal muscles which makes penetration
uncomfortable, difficult and at times, impossible. Again, this can be
due to a medical condition which should be considered.
In both cases, we are talking about functional (psychologically)
caused problems with sexual penetration whether due to discomfort
during, preceding or following sexual activity or involuntary muscle
contraction which inhibits or complicates sexual intercourse.
August 24, 1998
Q I have a question after reading the
discussion of various sexual dysfunctions: are there not sexual
problems that are purely physical? I have an endocrine problem and my
sexual response has been greatly decreased, and when I drink...well
you might as well forget it. I would appreciate any thoughts."
A There are sexual dysfunctions due to
a general medical condition, and this can be a change in desire,
erection or pain/discomfort.
Some people with diabetes may report sexual problems. Some
people on antihypertensive medication for their blood pressure and
even some antidepressants may cause sexual problems. Also, there are
numerous problems which can arise from use/abuse of the so-called
"recreational" or "street" drugs. Interestingly,
and importantly, these problems are not consistent. Even the drug
Propecia for hair loss creates sexual problems in some users.
When you decide to see someone about any sexual complaint, be certain
to organize not only your past sexual experiences/problems but also
information you have about health, medications, other symptoms
concurrently experienced and what, if any, nonprescribed drugs you are
taking.
Usually the problems arising from substance use are
subdivided into those which cause impaired desire, impaired arousal,
impaired orgasm or sexual pain. Again, the important aspect is to
report a complete history to anyone whom you consult for your problem.
August 31, 1998
Q Are there not sexual
problems that do not have to do so much with mechanical functioning
but with sexual preferences. In other words, are there not purely
unhealthy sexual needs or fantasies. What is this called and what are
some of them?"
A paraphilias are recurrent, sexually
arousing fantasies, urges and behaviors that may involve nonhuman
objects, suffering or humiliation of self or sexual partner, children
or other nonconsenting individuals. For some, sexual activity is not
possible without these fantasies and/or behaviors and for some they
are transient, and at times the individual is able to sexually
function without these fantasies or stimulation.
Examples are problems such as exhibitionism in which the individual
feel they must expose their genitals to others; fetishism is which non
sexual objects (such as items of clothing) are needed for sexual
stimulation; frotteurism which involves touching or rubbing against a
nonconsenting individual; pedophilia involving sexual urges and
actions against a child (often defined as those under 13 years of
age); sexual masochism in which the need is to be beaten, humiliated,
bound or otherwise made to suffer; sexual sadism in which the physical
suffering of another individual is perceived as sexually arousing;
transvestic fetishism in which a heterosexual male experiences intense
needs for cross dressing and voyeurism in which the goal is to observe
an unaware individual disrobing or engaging in sexual activity. The
large commercial market in materials pandering to these
needs/disorders suggests that their prevalence may be quite high, and
these problems appear to begin in childhood. Often the criteria of
"six months" is used in which the problem is considered a
disorder if the drive lasts for more than six months and is not,
therefore, merely the result of some transient (passing) stressor. The
problems, very often can transgress legal boundaries, and most often
create impairment in social and occupational functioning.
September 7, 1998
Q I have always wished I were a
male. I have no desire to dress like one, and as a woman, I certainly
do not feel attraction toward females. A girlfriend told me that I
have an identity disorder and need help. There are many advantages in
my culture to being a male. I believe the same is true in the United
States. Do I have a psychological problem because I would prefer the
advantages accorded to a male?"
A There is a disorder in
which a child, adolescent or adult has a strong and persistent
cross-gender identification in which the person may insist that they
desire or actually are the other sex . The may chose to dress and
behave as if this fantasy is their reality. These individuals may seek
to live within the role of the opposite sex, engages in the activities
traditionally associated with the opposite sex, and peer group
identification with members of the opposite sex. The person may insist
at times that they are the opposite sex and that their thoughts,
feelings, beliefs and attitudes demonstrate that their true gender is
the opposite sex. This is accompanied by a desire to rid themselves of
the characteristics of their biological sex and to alter their sexual
presentation.
This is not the same as preferring the advantages that you perceive
are held by the other sex and envying their comparative benefits. What
you describe is feeling culturally oppressed in that your female role
is not accorded with the benefits granted a male in your society. What
you describe is not a clinical disorder but a cultural imbalance
within your society.
September 14, 1998
Q I was involved in an auto
accident recently (fell asleep at the wheel). I have what they are
calling diffuse pain. One university clinic said I have reflex
sympathetic dystrophy, and another clinic said that this was a
somatoform disorder. Is reflex sympathetic dystrophy a somatoform
disorder?"
A Disorders in which there
are subjective (patient) complaints that exceed all physical findings
are referred to as somatoform disorders and are believed operated by
considerations such as secondary gain (attention, affection, and other
forms of reward). A person with a somatoform disorder believes that he
or she has a problem that doctors merely cannot diagnose. However,
reflex sympathetic dystrophy is not a somatoform disorder. If it is
accurately diagnosed, and you have true clinical findings reflecting
this disorder, then what you least need to be told is that the
problems are entirely emotional in nature. Now it is possible that
what they are trying to communicate to you is that you have a
verifiable physical condition but that your emotional response to that
condition may be complicating your capacity to deal with it. They are
not likely saying that your response is inappropriate, merely that it
is adding another problem to that which you already have.
September 21, 1998
Q I was reading recently about
something called conversion hysteria in which people go blind
or become paralyzed because of their emotions. I have trouble
understanding this and wonder if this really occurs or is some rare
condition.
A When a patient has symptoms or
deficits involving sensory functions (vision, hearing, taste, etc) or
voluntary motor control, and there are no physical basis for the
complaints, the patient is described as suffering from a conversion
disorder. Psychological factors are believed to be at the root of
the problem as demonstrated by trauma, conflict or stressors occurring
prior to the onset of the symptoms. These symptoms are not under
voluntary control or would be referred to as malingering or factitious
disorder and are not due to substance use/abuse or the result of
subcultural behavior (for example religious experiences in some
societies). Symptoms may include paralysis, localized weakness,
difficulty speaking or swallowing or even urinary retention.
Individuals may have symptoms of loss of sense of touch or pain,
double vision, blindness, deafness or even hallucinations. Some
patients may have conversion seizures. Naive individuals
often have extremely implausible symptoms whereas a medically
sophisticated individual may have symptoms that more strongly resemble
a true neurological problem. Often the differentiation between a true
neurological problem and a pseudoneurological (conversion) disorder is
based upon the symptoms being physically illogical in a person with
conversion disorder. The symptoms may be maintained by what is called
primary gain in which the patient removes himself/herself from an
aversive situation (relationship, etc) by having the symptom(s).
September 28, 1998
Q Is the conversion disorder
discussed last week the same as a pain disorder. What I mean is: is a
pain disorder a kind of conversion disorder or is this something else,
and when they talk about pain disorder do they mean that the pain is
"imagined"?
A Pain Disorder (like
conversion disorder) is a form of somatoform disorder. However, they
are not the same. As previously noted, conversion disorder involves
sensory or motor functions and suggests a neurological disorder that
does not, in fact, exist. Please see again last weeks discussion.
Pain Disorder does not mean that the person has no biological reason
for pain. It suggests that there are psychological factors that appear
to have contributed to the onset, severity, maintenance or
exacerbation (amplification) of the pain. That is, the individual may,
indeed, have a valid reason for the pain, but the individual's pain
may be worse in association with life events and/or internal emotional
conflicts. In (somatoform) pain disorder, it is important that the
patient be assisted in determining what factors play a role in the
experience of the pain. This may include the way in which they and
others respond to their complaints of pain. In order for there to be a
diagnosis of pain disorder, the pain must disrupt social and/or
occupational functioning. An example of such a disorder would be an
individual who sustains a back injury during the course of financial
difficulties arising from a divorce. Perhaps it is noted that the pain
is more severe when resolution of the divorce or the financial
situation is expected of the individual. In such a case, we would be
concerned that the pain is being amplified by these external factors.
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