INTRODUCTION
Discussions about sex and sexual problems have always been
shrouded by secrecy. Even though the ancient Indian culture and literature has
provided adequate provision to gain the appropriate knowledge, in the modern
India there is still a lot of taboo associated with seeking knowledge about sex
and help regarding sexual problems.
Estimates show that up to
50% of couples experience sexual difficulties at some point in their lives of
which nearly 80% of the problems are psychological. This may be the
psychological problems experienced by one or both the partners, the problems in
interpersonal marital relationships and other emotional problems which also have
a secondary effect on the sexual life.
CLASSIFICATION
Sexual Disorders may be divided into
three broad categories:
ØSexual
Dysfunction
ØDisorder
of Sexual Preference (Paraphilias)
ØGender Identity Disorders Based on the primary etiology it
may be categorized as
ØPsychological
ØPsycho-physiological
ØPhysio-psychological
Psycho-sexual
dysfunctions are those dysfunctions that occur
ØIn
spite of the patient having adequate sexual physiological fitness
ØEven when he/she is devoid of any physical illness that can contribute
to sexual dysfunction
ØDue to Psychogenic factors that develop secondary to physical
condition or illness or treatments that does not contribute to sexual
dysfunction
Psycho sexual dysfunctions include
ØImpairment
of normal sexual interest, enjoyment.
Øloss
of pleasure in sexual activity
ØAvoiding or being afraid of sex.
ØInability
participate in a sexual relationship as he/she would wish
ØInability
to perform satisfactorily
ØInability
to get desired orgasm at the desired time
ØFeeling
intense negative emotions when touched, such as fear, guilt, or nausea.
ØHaving
difficulty with arousal and feeling the sensation.
ØFeeling
emotionally distant or not present during sex.
ØHaving
disturbing and intrusive thoughts and fantasies, that interfere with
performance.
ØEngaging in compulsive or inappropriate sexual behaviors to compensate
sexual inadequacy
ØHaving
difficulty establishing or maintaining an intimate relationship
Most cases of sexual
dysfunction arise from a combination of emotional, Psychological, interpersonal
relationship and cultural factors.
Emotional
factors:
ØInability
to experience and express positive emotions
ØFear of
failure, exacerbated by pressure to perform,
ØOver
concern about pleasing one's partner
ØFeelings of
embarrassment or awkwardness
ØFear of
performance, intimacy and excitement
ØFear of
being perceived as sexually weak or vulnerable
ØWorries
about rejection and criticisms
ØConscious
or unconscious emotions of helplessness
ØSuppressed
emotions of anger or frustrations
ØHabituated
dependence negative emotions to gain advantage in relationships
ØFears of
impregnation, pregnancy, diseases.
ØEmotional
trauma associated with past sexual experiences
Psychological
factors
ØType
A personality
ØBody
image concerns
ØHigh
expectations
ØLow
self esteem
ØDoubt
and guilt harbored about sexual feelings or behavior.
ØA tendency to erect defenses against erotic pleasure
ØPerformance
anxiety
ØCritical
thoughts leading to monitoring of one’s own sexual responses
ØExcessive
distractions or psychic preoccupation that precludes or happens during sexual
activity
ØPsychological
conflicts and Stressors and inability to manage them appropriately.
ØInhibitions
about nakedness and displaying ones body
Relationship Factors
ØNormal expression of impulses being inhibited through excessive shyness
or harboring
ØDifferences
in sexual needs and the refusal of partners to respond
ØFailure Difficulties to communicate openly and without guilt and defensiveness about feelings,
wishes and responses
ØAvoidance
of or failure to engage in sexual behavior which is exciting and stimulating to
both partners
Ølack
of attraction towards a partner
Øissues
of trust, and commitment
Ødifficulty
with authority and concerns about being dominated
ØConflicts
in relationships
ØFears
of ostracization by or discrimination
ØLack
of knowledge regarding sexual life
ØMisinformation
ascribed by traditional healers, to “loss of semen”.
ØCultural beliefs that contribute to anxiety or guilt, based on a common attitude that sex is shameful,
dirty or sinful.
ØMyths
associated with gender roles, age and appearance or performance expectations.
ØConflicts regarding normal recurring sexual feelings especially during adolescence and
parental / social sanctions against sexual
enjoyment
ØMyths
associated with masturbation, nocturnal emission, sex with elderly women etc
ØStrong
social stigma of open discussion on sexual matters, expression of sexual
knowledge etc
ØReluctance
to discuss and preference to be discreet and secretive about sex life
Psychotherapy
Psycho-sexual
case history taking
Areas
covered should include:
ØThe exact nature of dysfunction in relation to the phases of the sexual cycle and what conditions
produce or reduce it.
ØDuration
of the problem.
ØPast
and current sexual experiences
ØRecent
stress or adjustment difficulties
ØVariation
with different settings, partners, erotic fantasies
Øthe
level of trust, understanding, love and commitment with the partner/spouse
ØIndividual
attitudes to coital frequency, birth control, having children, etc.
ØThe
existence of other psychological problems
ØThe
existence of a psychiatric disorders
ØA
concomitant medical disorder
ØConsumption
of drugs or alcohol
Psychometry
Detailed psychological assessment is done to identify etiology of the
problem. Psychometric tools and projective tests are used to evaluate
Ø
the nature of the couples’ relationship
ØPersonality
ØThe conscious
and unconscious desires, needs, drives, conflicts, passions etc on the intensity
ØThe
incongruence between the conscious and unconscious needs, drives and motives
ØCo-morbid
psychological problems or psychiatric disorders
ØAreas and
intensity of psychological conflicts, difficulties or stress.
ØThe motivation
level, Communication skills and ability to resolve conflicts.
Treatment
The treatment programs are individually
tailored based on principles of various psychological approaches. These are
often incorporated parallely in the initial phase and concurrently as the
treatment proceeds.
The psychotherapeutic treatment involves
treatment of the four major domains
ØThe
Behavioral domain
ØThe
interpersonal domain
ØThe
emotional domain
ØThe
cognition domain
Behavioral domain: Altering the sexual activity and associated behavior
This
is done by combining the Behavioral and Masters & Johnson sex therapy
techniques. The focus is on training the patients in effective sexual activities
and behavioral techniques that can aid in better participation.
The steps involve
ØTraining
in anxiety control techniques such as progressive relaxation, controlled
breathing etc
ØTraining
in stress inoculation techniques for persons who find stress unmanageable
ØCovert
sensitization to sexual needs and
pleasures
ØGuided
Self exploration of the stimulating physical, psychological and environmental
factors
¯Physical factors by self stimulation
¯Psychological and environmental factors by
fantasizing
ØThe
partners physically exposing to each other their physique.
ØHeightening
sensory awareness to sight, touch and smell.
ØSensate
focus in which the partners focus on mutual pleasuring by massage, caressing etc.
ØCreating
arousal by touching the appropriate erogenous points.
ØFondling
and caressing the genitals.
ØSpecific
techniques for specific dysfunctions such as.
¯The stop-start technique .
¯Squeeze
technique .
¯Graduated dilatation of the vaginal path
with the fingers or prescribed dilators .
ØNon
intrusive penetration.
ØAltering
the time and environment to understand the most stimulating and satisfying ones
Penetration in various postures to understand the
most satisfying ones.
ØFull
unbound sexual intercourse.
The aim is to establish proper verbal, nonverbal
and sexual communication between partners
ØTraining
in appropriate verbal and nonverbal communication techniques
ØFacilitating
the establishment of social ties with the opposite sex using social skills
training.
ØDiscussing
their sexual needs, stimulating environments, fantasies etc
ØExpression
of mutual needs and establishing the goal at various stages.
ØCommunicating
the positive emotions that the partners experience for each other
ØCommunicating the negative emotions in an appropriate unoffending way without suppressing
or masking
ØInvolving
in positive talks to overcome the misperceptions and develop trust
Øproviding
permission or reassurance whenever deemed necessary.
ØUsing
problem solving and consensus approach to solve the conflicts
ØUsing
humor whenever deemed appropriate
Emotional constructs
are enduring emotional structures built by a systematic repeated combination of
felt, perceived and expressed emotions which mutually interchange and determine
a person’s emotional reaction to an event or a domain
Love-
Possession - Envy
Helplessness
- Fear - Anger
The
steps involved are
ØIdentification
of the dysfunctional emotional constructs
ØVentilation
of the suppressed emotions associated with past experiences
ØUnderstanding
the incongruence between the felt, perceived and expressed emotions
ØLearning to express positive and negative emotions in an acceptable way pertaining to
the environment
ØReducing
the incongruence by using these methods to express the felt emotions in an
appropriate manner
ØGeneralization
to various related areas
Cognition
domain: cognitive restructuring
Treating the cognitive area involves changing cognitive distortions by
changing the associated negative schemas or dysfunctional beliefs using
cognitive behavior therapy which uses systematic approach of collecting
evidences and implementing alternate positive beliefs. Some such negative
beliefs are
ØIts
difficult to enjoy sex unless one is physically strong, good looking,
intelligent and successful
ØIf
I don’t do well all the time my partner will not respect me
ØMy
value as person depends on what others think of my sexual capacity
ØIf
my partner disagrees it means that he/she does not like me
ØI
am always responsible if my partner is not satisfied
ØI
have failed once and will fail every time
ØI
should do every activity myself or vice versa
ØIf
I do not act correctly I will be ridiculed and my position will be threatened
ØI
can have healthy/ happy life only if I avoid sex
ØThe
sex life is full of risks and dangers which I cannot cope with
The other area of cognitive restructuring is altering the goals of sexual
relationships from - involving in coitus, achieving orgasm, satisfying the
partner, reproduction, emotional intimacy & involvement, having a thrilling
experience, a work profile of marriage, ventilating the erotic energy and stress
reduction to just enjoying the
pleasure of the process.
Conclusion
Medical
practitioners are still perceived as the most appropriate people to turn to for
advice.
The onus rests on the medical practitioners to prepare the patients
presenting with psychosexual problems to psychological interventions.
When psycho-sexual disorders are detected the patient should be referred
to a competent psychologist for specialized evaluation and psychotherapy.
Avoiding the dichotomous paradigm of sexual dysfunction being either
organic or psychogenic or holding the assumption that organic factors
necessarily take precedence over psychosocial factors or vice versa and adopting
a multimodal approach of treatment can be the most beneficial treatment for any
patient.