Behavioral treatment of sexual disorders Part 5

Ethical considerations

Therapeutic efforts either to stop unwanted sexual behaviors or to start wanted sexual behaviors should raise ethical questions—for individuals in treatment, clinicians, and ultimately society as a whole. While sexual behaviors are vehicles for some of the most exquisite of life’s pleasures and intimate joys, they also account for a considerable amount of pain, suffering, and violence inflicted by some individuals on others. The legal, religious, and cultural institutions of a society have a vested interest in providing norms for sexual behaviors. The norms promote the society’s stability and preserve the values treasured by the particular institutions. How this is done, especially in the context of Western culture that treasures individualism and unfettered free choice, is the nub of the ethical debate on sexual behaviors.

The subtleties of this question cannot be addressed in any detail here. What I can suggest is that the discussion of ethical considerations of sexual behaviors be framed in the context of the dialectic of social constructionism versus essentialism. In brief, social constructionism posits that all behaviors have meanings and values constructed and attributed to them by the context of the culture in which they operate. Essentialism holds that there is an innate order, or ontology, in the human system that is the source of values attributed to behaviors. In general, social constructionism is a value-relative system; essentialism is a valueabsolute system. In sexual behaviors, social constructionism speaks of varieties of sexual behavior that are chosen by individuals, while essentialism sees some sexual behaviors as positive or good and others as negative or bad, depending on whether or not they are consistent with the vision of the good society that the essentialism holds.

The primary ethical considerations in working with the behavior perspective are twofold:

  1. the clinician and patient should be aware of their own positioning in the social constructionist versus essentialist continuum;
  2. from this basis, the two should agree on a treatment contract that does violence to neither party’s values.

In practice, this requires the clinician, in his or her own mind, to frame the goal of the behavioral treatment as promoting sexual behaviors that

  1. both clinician and patient (or patients) value positively (e.g., intercourse between a happily married couple);
  2. the clinician values positively for others but not for himself or herself, and can assist others who do value such behaviors to express (e.g., same-sex sexual intimacies);
  3. the clinician values negatively and does not want to assist in an individual who values the behaviors (e.g., behaviors involving infliction of pain on nonconsenting partners or vulnerable persons such as minors).

While the first and third situations are relatively straightforward, the second situation poses the greatest ethical challenge for the clinician. The challenge often involves walking with the patient down a path of erotic expression that the clinician would never choose but which he or she has judged to be a valid and meaningful path for the patient. This experience can often give the clinician a broadening view of the human condition that is enriching. It can also be a self-deception under the influence of financial reward, voyeurism, or increased self-esteem about being a highly tolerant clinician. Prevention of such self-deception is possible through a healthy review of one’s motivation, conducted alone or with a trusted colleague. It serves the welfare of neither the clinician nor the patient if the two enter a behavioral program marked by a high degree of ambivalence on both sides about the value of the behavioral goal. Values, like sex, eventually will out.

Treatment in the behavior perspective aims at stopping unwanted sexual behaviors or starting wanted sexual behaviors. To accomplish this, the antecedents of the behavior, the behavior itself, and the consequences of the behavior are the main foci of treatment. The common modalities of treatment are couple therapy to start successful sexual behaviors and group therapy to stop unwanted sexual behaviors. Adjunctive interventions such as antiandrogen medication for sexual disorders and prosexual medications for sexual dysfunction are examples of using the disease perspective with the behavior perspective as base. Similarly, adjunctive individual therapy that explores issues of value and meaning is an example of the complementary use of the life story perspective. In all treatment involving sexual behaviors, the clinician should have a clear understanding of the ethical positions that guide his or her work with the individuals seeking assistance.

Behavioral treatment of sexual disorders Part 4

Relapse Prevention: Monitoring and Managing the Consequences

No behavioral treatment program for a sexual disorder consisting of unwanted sexual behaviors is complete without a relapse-prevention component. The model here is the AA “recovering alcoholic” who lives “one day at a time.” Individuals with a compulsive sexual disorder or a paraphilic pattern of sexual arousal are well served if they view themselves as persons who will always be inclined to that particular expression of sexual behavior. In terms of the perspectives, they should work daily to control the behavior rather than assume they are cured of disease.

– The first element in a relapse-prevention program is the ability to identify the “trigger” circumstances of the unwanted sexual behavior and to take steps to avoid or ameliorate them. To do this, the individual must have or must develop in treatment a self-monitoring vigilance and an ability to be critical of his or her behaviors and assumptions. A special trigger today is use of the Internet. If individuals use the Internet to engage in forms of unwanted sexual behavior, they have already pulled the “trigger” and returned to the pattern that brought them into treatment in the first place.

– The second element in relapse prevention is regular consultation with a clinician who can assist the individual in observing and managing the consequences of his or her behaviors. The frequency of these consultations may range from monthly, immediately following the initial treatment, to annually, when both patient and clinician see the tension and risk for expressing the behaviors as low.

The consultations should be scheduled at an agreed-upon frequency and address at least three topics:

  1. Assessment of how the “triggers” are being managed;
  2. Assessment of whether the replacement behaviors (e.g., relationship with spouse) are being developed;
  3. Completion of a mental status examination.

In some cases where there is risk of harm to others or incarceration, a polygraph evaluation can ascertain whether any of the problematic behaviors have occurred since the previous consultation. For patients whose regimen includes antiandrogen medication, compliance can be assessed by checking testosterone levels. Any concerns that arise from these three points indicate a need for more frequent consultation or the resumption of regular therapy.

There are several forms of the twelve-step program, as originated in AA: Sexaholics Anonymous, Sex and Love Addicts Anonymous, and other variants.

In general, these organizations support participants in their work of avoiding unwanted sexual behaviors. As locally directed, nonprofessionally led groups, they vary in their effectiveness. Before making a referral to a particular group, the clinician should inquire about how it is organized, what its rules are, and what its position is on therapy for its members. In practice, this information can be obtained by listening to new patients who have participated in these groups.

Relapse prevention is also a component in the treatment of sexual dysfunction. In these cases, the individual is trying to initiate and maintain a wanted sexual behavior. Relapse from successful treatment occurs when the behavior is again absent or dysfunctional. A bit of commonsense advice for couples who have successfully completed a course of sexual therapy is that they should expect the dysfunction to appear again in the future. They are vulnerable to sexual dysfunction. They should take the reappearance of the dysfunction not as a sign of failure but as an invitation to review the conditions that, as they have learned in their therapy, are the likely causes. The partners then can directly address the conditions (e.g., general communication lags) and their sexual life with the methods learned in their sensate focus therapy.

Behavioral treatment of sexual disorders Part 3

Treatment Stage Two: Stopping the Behavior

Unlike other compulsive behaviors, such as alcohol or drug abuse, which commonly occur in social settings, compulsive or paraphilic sexual behaviors often have a massive wall of secrecy around them. The behaviors have for years been practiced in secret, out of shame or fear of arrest and incarceration. One of the initial steps is to destroy this protective wall of secrecy.

Eroding the wall of shame and secrecy can be accomplished by inviting the individual, now a patient in therapy, to explain the behavior in minute detail, describing the external circumstances, the behaviors themselves, and the internal responses and fantasies. If initially the recounting becomes sexually exciting for the patient, this sexual response should be remarked on and processed in the therapy. Arousal may occur if the patient is allowed to “hide” in the semidissociative state of the behaviors rather than recounting the behaviors in the real-life circumstance of the individual or group therapy session. For the most part, however, repeated elaboration will have the effect of providing a realistic appraisal of the behavior as a pattern that is a maladaptive effort to respond to subjective and objective antecedents. It will, in some cases, assist the patient to see the effects of the behavior on the lives of others, including, as in Rob’s case, his loved ones. It can open the door for the development of empathy.

Group therapy is the preferred treatment modality for stopping unwanted behaviors, including unwanted sexual behaviors. Both the twelvestep programs modeled on AA and behaviorally focused group therapy accomplish the twofold task of challenge and support. Members are challenged primarily by other group members to “get with the program” or stop deceiving themselves about the antecedents of the behaviors. The AA saying, “It takes one to know one,” applies to those who are struggling with unwanted sexual behaviors. Denial, rationalization, deception are sooner or later labeled as such in a group setting far more effectively than in individual therapy.

In addition to challenge, groups also provide support for individuals who are trying to change deeply ingrained behaviors. Sponsors or group therapy members who have reached some level of control over their behaviors offer role models for the new members. Words of encouragement after a relapse or of praise after an achievement help the individual to progress in his or her program to stop the behaviors. Last, but perhaps most important, are the unspecific curative factors in any group process. Through engagement in the group as a microcosm of the human community, an individual is given the opportunity to become more deeply human. In most group processes, therefore, the unwanted sexual behaviors are viewed as obstacles to this process of becoming a fuller and more effective human being.

For those who are able to understand themselves in terms of their own psychosocial history and the role of this history in their behavior and attitudes, individual therapy that addresses the life story may be helpful in preventing relapse. It may serve also as an effective complementary treatment to group therapy. However, individual therapy, especially insight-oriented therapy, is not recommended as the sole modality to stop unwanted sexual behavior. Even for the psychologically minded patient, insight into the putative causes of the behavior and emotional cathexis to the insight or memory are often not sufficient to stop the behavior. For those who have difficulty in understanding themselves psychologically, stressing an insight-oriented treatment will not be successful in stopping the behavior. It may worsen it by providing the opportunity for another “failure” at correction, thus increasing the frustration of patient and therapist alike. This delivers the message to the individual that he or she is not able to stop the behavior, even with the help of psychological experts. Individual therapy, insight-oriented or cognitive-behavioral, should be used as an adjunct to the primary modality of group therapy to stop unwanted behaviors.

Medication for Behaviors

Pharmacological interventions may be necessary for some individuals to gain control of their sexual behaviors. In terms of the perspectives, the use of medication in the treatment of behavioral disorders employs the disease perspective. This is not to say that a disease process is occurring in the individual with a compulsive or paraphilic disorder, but rather that the clinician and patient have elected to control sexual behaviors by modifying the body’s physiological functions. This is a reminder that the use of the perspectives in therapy is not a disjunctive process in which it is either this perspective or that perspective. Treatment using the perspectives methodology is conjunctive: using this perspective and that perspective. It is a selection of one perspective as the primary treatment modality, then the integration of the other perspectives as appropriate for the understanding and treatment of the particular case.

Pharmacological treatment should be considered when any of the following conditions exist:

  1. there is a clear and present danger that others may become the victims of sexual violence, as in pedophilia and sexual sadism;
  2. behavioral methods have proven unsuccessful when used independently;
  3. the sexual behaviors are excessively driven, as measured by their frequency, duration, intensity, and lack of attention to consequences;
  4. a comorbid condition (e.g., depression, bipolar disorder, dementia) is augmenting the expression of the sexual behavior.

Unless the behavior’s frequency and intensity indicate the need for an antiandrogen medication, the first line of pharmacological treatment is the use of selective serotonin reuptake inhibitor (SSRI) medications. The advantages of these medications are that they can treat an affective disorder (even subclinical in its symptom level) and that their secondary effects of reducing sexual drive and obsessions with sexual content are positive effects in treating the sexual disorder. The disadvantages are that the SSRIs may not be potent enough to counter the physiological components of the sexual behavior or that the common side effect of anorgasmia may contribute to the patient’s noncompliance.

The second-line pharmacological treatment is the use of medications that have an antiandrogen effect. In both men and women, the injection or ingestion of substances such as medroxyprogesterone acetate, cyproterone acetate, and depot leuprolide acetate lowers the testosterone levels and through this mechanism greatly reduces sexual drive without necessarily making the individual unable to have sexual intercourse. With the diminished drive and reduced preoccupation with the unwanted sexual behavior, the individual is able to employ the strategies developed in the behavioral treatment. The advantage of the antiandrogens is their powerful effect on decreasing libido. The disadvantage is that there may be medical effects such as reduced bone density, weight gain, and feminization. Regular monitoring of bone density, glucose levels, and liver function tests is advised in cases of chronic use.

Other medications have been and undoubtedly will be used as adjuncts for controlling behavioral problems. Paul Federoff reported a case in which he was treating a man for anxiety disorder. The patient also cross-dressed, although this was not the object of treatment. To treat the anxiety, Federoff prescribed buspirone, an antianxiety medication. The patient reported that after a few weeks his anxiety was reduced and that, strangely, he had not felt the urge to cross-dress. When the medication was stopped, both the anxiety and the cross-dressing behaviors returned. When resumed, the medication again had the effect of reducing the anxiety and, without intending it, stopping the urge to cross-dress. In another case report, naltrexone, an opioid agonist, was used in the successful treatment of a man who had been engaged in kleptomania and compulsive sexual behaviors. The naltrexone controlled both behaviors and, when stopped, the behaviors returned. For individuals with dementia, neuroleptics have been used to manage sexual behaviors that are nonresponsive to behavioral treatments and remain disruptive to residential living.

Thus, medications such as SSRIs, antiandrogens, antianxiety drugs, or neuroleptics are used to control problematic sexual behaviors. In the perspectives methodology, the employment of such medications is the welcome integration of the disease perspective with behavior perspective treatment.

Behavioral treatment of sexual disorders Part 2

Pretreatment: Assessing Motivation

For all three groups, however, assessment of motivation for change is the first step in the treatment for stopping unwanted sexual behaviors. In most cases, a third party (e.g., a partner, an employer, the courts) has brought a person with problematic sexual behaviors into treatment. In some cases the individual voluntarily initiates treatment, with no external threat, but these cases are rare. More often that not, the individual with compulsive, paraphilic, or injurious sexual behaviors has been brought to evaluation and treatment by the demands of a third party. It is crucial for determining an individual’s resources for treatment, there fore, that the clinician assess his or her motivation for change and report this information to the patient and to the parties requesting the treatment.

One of the most useful triage constructs that has emerged from the addiction treatment field is the Transtheoretical model of James Prochaska and Carlo DiClemente. Their stages-of-change model consists of six stages: precontemplative, contemplative, preparation, action, maintenance, and termination stages.

Using this model regarding the behavior in question, the clinician evaluating a patient for treatment assigns the individual to:

  1. the precontemplative stage (not thinking about stopping or controlling the behavior);
  2. the contemplative stage (considering stopping but ambivalent about “losing” the gratifications that the behavior brings);
  3. the preparation stage (making adjustments to take action in the next month); or lastly,
  4. the active stage (having made a subjective decision and having taken at least one step to stop the unwanted behavior).

Granted that motivational states may be difficult to assess, it is nonetheless important that both the individual and the treatment team or therapist have an accurate appraisal of the true motivation for change of the individual. The individual should be assisted to progress to the active stage, if necessary using the threat of loss of relationship or incarceration, so that the treatment then can effectively begin. Treatment from the behavior perspective assumes that, at some rudimentary level, in every behavior the individual is choosing to act. In controlling and stopping unwanted sexual behaviors, the ability to behave consistently with verbalized (and in some cases believed) intentions may be compromised by habit, attitude, and physiological dependence. Nevertheless, the individual must make a decision to stop the unwanted sexual behaviors. Without this active stage of decision and action, no successful treatment of sexual disorders can be achieved, regardless of the duration of treatment or the reputation of the treating facility or provider.

Treatment Stage One: Identifying and Controlling the Antecedents The circumstances that initially caused a behavior to occur are usually not the conditions that promote its maintenance and continuation.

As a young boy, Rob was dressed as a girl one Halloween by his older sister, and as he made his door-to-door trick-or-treat journey, he was praised by his mother and neighbors for “what a good girl he would have made.” The initial Halloween cross-dressing was not sexually exciting but it was ego-gratifying. Subsequently, as a young boy, Rob cross-dressed in order to repeat the ego gratification. He would admire himself in the mirror. When he became pubescent, the crossdressing became eroticized and he would become sexually aroused and masturbate. Now in his early thirties, Rob reported cross-dressing both for sexual excitement and release as well as for relaxation. His wife had discovered the behavior and was afraid for the sexual safety of their children, and she had threatened to leave the marriage. This threat brought Rob into treatment with an ambivalent request to help him stop the behavior.

Clearly, the factors that started the behavior of cross-dressing on Halloween twenty-five years ago are not the factors that reinforce and maintain the current cross-dressing behavior. While it might be interesting and intellectually satisfying for Rob to remember that first crossdressing incident and his emotional reaction to it, that recollection and insight will do little to stop the present goal-directed behavior of crossdressing, looking at himself in a mirror, becoming sexually excited, and masturbating to the vision of himself as a woman. If the behavior is to be stopped, the antecedents that are effective in maintaining Rob’s practice of cross-dressing today must be altered.

The antecedents are all those factors that proximately precede the behavior:

  • physiological drives,
  • behaviors, and acquired influences,
  • both internal (e.g., drugs, beliefs, attitudes) and external (e.g., environment, relationships).

A subset of antecedents can be considered “triggers,” circumstances that immediately precede the behavior.

Rob’s antecedents were any set of circumstances that challenged his sense of worth. His supervisor putting pressure on him at work, the children disobeying him, but especially his wife criticizing or disagreeing with him caused him to feel both demoralized and anxious. He had the assumptive belief that his cross-dressing in secret was his “little island of repose,” and he would strategize about how to arrange for the necessary privacy. When his wife left the house for an extended period of time with the children, the “trigger” was there. Rob would unpack his hidden stash of female clothing and engage in the cross-dressing behavior. Except for the last incident, he was able to return the clothing and, with some shame, resume his day “as if nothing happened.” During the last cross-dressing episode, his wife unexpectedly returned home earlier than planned and caught him in the midst of his cross-dressing ritual.

Applying Prochaska and DiClemente’s motivation-for-change model, we see that Rob was between the contemplative and action stages of behavior change. He wanted to stop the behavior and had cooperated fully with the evaluation. Altering the antecedents of the cross-dressing behavior would involve Rob’s stopping some behaviors as well as developing others. He should remove the stash of clothing. To manage the identified trigger, Rob should have a plan for activities when alone. It may initially be necessary to leave the house when his wife does (e.g., work in the yard, run errands). Psychologically, Rob has to develop an internal vision of himself as a more competent employee, parent, and spouse and must be able to assert himself in life situations as a more competent person. He and his wife may need marital therapy to adjust to the personal changes that Rob must make in terms of assertiveness.

Behavioral treatment of sexual disorders Part 1

Если характерные поведенческие цели лечения сексуальной дисфункции является содействие поведения, поведенческие лечение сексуальных расстройств, чтобы остановить нежелательное сексуальное поведение или ограничить его в определенных обстоятельствах, которые являются менее вредными или проблематичным.

Четыре поведенческих характеристик сексуального расстройства, возможно, и часто делаем, перекрытия:

  1. с приводом, обязательного сексуального поведения (например, человек, который два или три раза в неделю подвергает себя для женщин);
  2. импульсивный сексуального поведения (напр., человек, который реагирует на сексуальные стимулы без какого-либо обдумывания);
  3. paraphilic сексуальной поведения (например, тот человек, который привлек сексуально для детей);
  4. сексуальное поведение, не управляемый ни paraphilic но вредны для себя или других в их возможные последствия (напр., женщина, которая участвует в еженедельных случайных половых контактов с незнакомыми людьми и без защиты от заболеваний, передающихся половым путем).

Обязательного сексуального поведения отмечены за их частота и почти обыденным, автоматизм. Они были поведения, которые были routinized на свое обычное выражение. В некоторых случаях, лицо с обязательного сексуального поведения описываются “на автопилоте”, как он идет через узорчатые поведение. Там может быть даже чувство ангедония, или отсутствие приятным участие в сексуальном поведении. Импульсивный сексуального поведения характерны спонтанность, и, в определенной степени, по интенсивности поведения. Джеральд Мюллер и его коллеги предложили построить из импульсивность, что состоит из трех элементов:

  1. снижение чувствительности к негативным последствиям поведения;
  2. быстрый, незапланированных реакции на раздражители до завершения обработки информации;
  3. отсутствие связи для долгосрочных последствий поведения.

Однако, Moeller тройное определение матчи и клинические характеристики лиц с импульсным сексуального поведения.
Данные опроса доступны по обоюдному согласию взрослых сексуальных взаимодействий и взрослых мастурбации, но нет эпидемиологических исследований на частоте других видов сексуального поведения (напр., использование Интернета для эротических целях), что позволит врачу, сказать, что количество поведение для человека является статистически нормальной частоты. В этих случаях, это до врача и пациента, чтобы определить частоту сексуального поведения такова, что она препятствует пациента профессиональных, социальных, или реляционных цели и ценности. Например, человек, который занимается серфингом Интернет для эротических сайтов, на десять часов в неделю, а на работе есть частота, продолжительность и это снижает его производства на работе. В дополнение к высокой частоте, управляемых качества поведение, его интенсивности, часто очевидна, когда в отдельных докладах некоторых вариант compulsivity после того, как поведение началась. Хотя могут быть некоторые попытка уйти от ответственности за поведение, ссылаясь на “автопилоте” или semidissociative государства, сообщили если последовательно, то это-надежный индикатор того, что egocontrol поведения является более субъективным сил обобщенно именуемые“, мотивируя диски”.

Paraphilic поведение характерно своего объекта, то есть, на цель их эротическое влечение или инсценировка сексуальная фантазия на сексуальное поведение. В paraphilic цель-неодушевленный предмет (напр., нижнее белье), частичный (человека) объекта (например, ногу), или ничего не подозревающий или nonconsenting человек (как в выставления напоказ, копролалия, frotteurism, или педофилия). В paraphilic сексуального поведения, индивидуальных сексуальных фантазий является первичной. Это может быть выражено в мастурбации, но с фантазией и возбуждение, как правило, жаждет большего стимулирования, предусмотренных в азарт и риск, действовали, во внешнем мире, paraphilic фантазии, в конечном счете, предполагает реальный человек, соглашаясь или нет.

Третья группа-те, кто занимается nondriven и nonparaphilic но, безусловно, проблемное сексуальное поведение, является особенно сложной группы, чтобы описать, не говоря уже лечить. Их поведение не имеют частоту или диссоциативной растормаживание приводимой поведения. Они явно не paraphilic по критериям DSM-IV-TR. Но поведение, все же представляют собой серьезную опасность для себя или других лиц. Заболеваний, передаваемых половым путем, потерю стабильности семьи, потеря работы, возможные последствия, но часто недостаточно, чтобы изменить или остановить сексуальное поведение. В то время как все три группы поведения прибыль от поведенческого лечения вмешательства, эта третья группа, в частности, как правило, требует терапии, которая полагается на информацию, предоставленную измерение перспективы и стратегии, предусмотренных жизни, история, перспективы. Для этой группы едва ли не больше, чем двух других групп, проблем, решений и личных ценностей и смысла, может быть, наиболее важных факторов в терапии.

Sexual Behaviors and Group Personality Profiles

The relationship between personality traits and sexual behavior has been examined repeatedly in personality and sexual research, with only modest results in terms of finding correlations between specific sexual disorders and specific personality traits. For the most part, studies have reported on the personality characteristics of sexual offenders. Despite multiple attempts to establish a correlation between personality and specific sexual dysfunction, there have been no robust findings such that any specific sexual dysfunction can be associated with any personality profile.

Comorbidity studies of sexual disorders and dysfunctions using Axis II (personality disorder) diagnoses of the DSM-IV-TRexamine the question of personality from a pathological perspective. For example, among a sample of pedophilic men, 60 percent met the criteria for a personality disorder, the chief among them being:

  • obsessive-compulsive (25%),
  • antisocial (22.5%),
  • narcissistic (20%),
  • avoidant (20%).

Although diagnostic categorical data provide information about personality limitations, they cannot provide the more comprehensive view that a dimensional personality group profile might supply. Knowledge of personality strengths, not merely vulnerabilities rooted in the disorder, are helpful in developing a treatment plan.

An example of a dimensional examination of personality and sexual disorders is found in a study completed in our Sexual Behaviors Consultation Unit (SBCU) at Johns Hopkins. In this study, we found that men with paraphilic behaviors who presented for evaluation and treatment had a distinct group profile as measured by the five-factor personality model of the NEO-PI-R. The clinical sample (N _ 51) had high Neuroticism, high Openness to Fantasy, low Agreeableness, and low Conscientiousness. Interpreting these domains suggests that the paraphilic group has a higher than average vulnerability to negative affect. This may have been an artifact of studying a sample from a clinical population, but in any case, the participants in the study described themselves as being chronically distressed. The paraphilic group also had a rich fantasy life. This supports the belief that paraphilia is primarily a cognitive phenomenon that may or may not be amenable to change. The treatment challenge is to assist the patient to avoid acting out the fantasy in criminal or otherwise harmful behaviors. The paraphilic group tended to have a more narcissistic focus and, last, had difficulty in performing consistently and conscientiously in their activities. These latter traits posed distinct treatment challenges that I discuss below.

In contrast to the men with paraphilia, who had a group personality profile with scale scores outside the average range, age-matched men with erectile dysfunction had a group personality profile that was in the average range for each of the five major factors. While certainly many of the individual men had facets and factors that were above or below the average range, for the group no factor was high or low. The pooling of their individual profiles resulted in a regression to the mean. As a result, one cannot predicate any personality traits that may be held in common by men with sexual dysfunction, as was done for the group of paraphilic men.

Two conclusions were drawn from the finding that the paraphilic group had a distinct personality profile and the men with sexual dysfunction did not:

  1. some sexual behaviors (e.g., paraphilia) might be correlated with personality traits;
  2. when no distinct group profile emerges (all scale scores are within the average range), then clinical attention should be directed to the individual personality profile of the patient to see what traits may be contributing to the response of the sexual disorder or behavior.

To this task I now turn.

Sexual Behaviors and Individual Personality Profiles Although sex is usually relational in its expressions, individual persons express that sexual behavior. The individual person has enduring qualities and traits that, however they may have developed, shape sexual behaviors and attitudes. Likewise, these same traits may influence the person to react in patterned responses to various influences—both internal and environmental. It is important to assess the relative strengths and vulnerabilities of the traits in the individual with a sexual disorder, so that one can design a treatment program that uses the strengths and minimizes as much as possible the limitations.

While group profiles are helpful in terms of generating hypotheses about the personalities of individuals with a shared sexual behavior, for the most part the contribution of the dimension perspective lies in the attention it pays to the unique array of traits within the individual. Over the past fourteen years, at the SBCU we have used the NEO-PI-R to measure the personalities of individuals with sexual disorders and problems. The NEO-PI-Ris not an instrument, such as the Minnesota Multi – phasic Personality Inventory (MMPI), that measures psychopathology. It is, rather, a self-report inventory that yields a profile of the five factors of normal personality structure. The five factors of Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness provide a comprehensive assessment of normal personality dimensions. It gives the clinician a picture of the personality of the individual who is seeking help for a sexual problem. Employing a personality inventory such as the NEO-PI-R at the initial evaluation permits the clinician to hypothesize what trait strengths and vulnerabilities may have been involved in the genesis of the sexual problem and what personality resources are available for treatment.

Sex and the dimension perspective

The dimension perspective holds that traits and characteristics are usually normally distributed throughout a population and therefore can be measured dimensionally. An individual may have high, average, or low extraversion, intelligence, and a host of other such traits. When individuals interact within environments that tax the limits of their traits, problems and inadequate responses, including sexual disorders or sexual problems, may result. The dimension perspective calls on the clinician to pay attention to these traits, the particular strengths and vulnerabilities of the individual, in formulating the cause of the disorder and in developing a treatment plan.


The dimension perspective is interested in measurement (see Table). As such, its logic is one of generating numbers and converting them to scores on scales for interpretation by the clinician. The dimension perspective counts and concludes in numbers rather than in categories. For example, the disease perspective is concerned with categories: does this person have hypertension or not? The dimension perspective prefers to ask the question: what are the person’s blood pressure readings? The response to the disease question is a categorical yes or no.

The answer to the dimension question is 130/80. Clearly each type of question and response is valid. But each serves a different purpose. Some specific information is lost in the categorization of an individual as, say, “hypertensive” or “normotensive.” The exact numerical values are combined into groups according to predetermined cutoff points. There are times when categorical groups facilitate communication—for example, between clinicians who are discussing a patient and between researchers in study design.

In the evaluation and treatment of sexual disorders, the dimension perspective measures three principal domains: personality, intelligence, and the sexual behaviors themselves.

Sexual diagnoses

Given that the sexual diagnosis must be the product of a full formulation of the case before beginning treatment, I note here some special features of sexual diagnoses in particular. While these diagnoses share the DSM structure, with its aim of empirically verifiable and replicable criteria, some qualities in sexual behaviors and problems warrant comment.

Not All Sexually Disordered Behavior
Has a Psychiatric Diagnosis

Many problematic sexual behaviors are not currently considered psychiatric disorders. Rape and sexual aggression are examples. Rapists are a heterogeneous group, and some commit rape not because it is the preferred sexual expression and therefore paraphilic but because of other factors (e.g., antisocial personality). Unwelcome sexual contact or sexual aggressiveness has been reported by more than 50 percent of women, a prevalence that argues more for cultural factors (interactions between genders) than for paraphilic disorders in males. Using the Internet access at the workplace for erotic exchanges and sexual release may show extremely poor impulse control, poor judgment, and deficient employee integrity, but it may not be a sexual disorder. Sexual harassment and multiple extramarital affairs may cause loss of employment and divorce, but they are not necessarily sexual disorders. If we were, then, to limit our discussion of sexual disorders to those thus classified by the DSM-IV-TR, we would be omitting many of the pressing sexual questions of the day.

This is not a plea to pathologize such behaviors and give them a DSMIV- TR diagnosis. It is a recognition that many problematic sexual behaviors are brought to the attention of mental health clinicians with the request that they assist in correcting or stopping them. These behaviors require a means of formulation that is adequate to hypothesize about the probable causative influences and maintaining factors and to propose treatments. The perspectives methodology guides the clinician and treatment team in this process by structuring their use of established approaches and stretching their thinking to consider yet other perspectives.

Sexual Diagnosis Does Not Imply Causality

The explicit aim of the DSM series is to avoid in its criteria any assumptions about the causality of the sexual diagnoses. Thus, for example, Inhibited Sexual Desire (DSM-III) was changed to Hypoactive Sexual Desire in DSM-III-R. The editors rightly felt that the word inhibited implied a causal factor. Accordingly, the editors of DSM-III-R changed inhibited to hypoactive, on the grounds that this term is more descriptive without any etiological bias. Persons with the diagnosis Hypoactive Sexual Desire may or may not be inhibited by biological, psychological, or cultural factors. To make this distinction or to imply this influence in the disorder is not the function of the diagnostic category. The clinician employing the perspectives as a methodology to guide thinking about sexual disorders is interested in the genesis, course, and treatment of sexual disorders. The perspectives certainly assist in establishing diagnoses, by describing the cluster of symptoms and quantifying the behaviors evident in the individual patient. Responding to the question of etiology, the clinician using the perspectives methodology strives to avoid ascribing to one factor the entire causal variance. If there is a bias in the perspectives, it is one of assuming multifactorial causality.

For those who want “single cause, single solution” according to diagnosis protocols, the perspectives will seem to unnecessarily complicate a simple process. For those who use a perspectives methodology, the categorical diagnosis is the result of a complex review of clinical data and impressions from several approaches. Sexual Diagnosis Is an Alterable Construct Diagnoses have changed and will continue to change in terms of their criteria. New diagnoses will be developed—though, it is to be hoped, only after they have been justified as a distinct clinical entity in research. DSM-IV-TR diagnoses, therefore, cannot be the final word on the phenomenology of disorders. Diagnoses are certainly helpful, as noted previously, but they should not be counted on for the ultimate statement about a condition.

In sexual function research, many are dissatisfied with the application of the human sexual response cycle as the basis for sexual dysfunction in women. Rosemary Basson developed a theoretical model of female sexual response, and Ellen Laan and colleagues offered experimental research support for the model. The Basson model basically says that the sequential desire-arousal-orgasm-resolution model that has been fairly normative for the past forty years does not fit the arousal patterns of women, especially those in long-term relationships who may not have spontaneous thoughts about sex but may be quite able to respond sexually to their partners out of a desire for intimacy. Laan’s research supports the centrality of the arousal function in women and that the woman’s subjective sense of sexual arousal is often not correlated with vaginal lubrication and swelling.

The point of mentioning the Basson and Laan works is to note that sexual diagnoses are alterable constructs. Yet clinicians and researchers must continue to use the present diagnostic nomenclature while at the same time marshalling theoretical arguments and data for the alteration or abandonment of specific diagnoses. This requires a breadth of vision that can coordinate information from many quarters. It requires an abil ity to listen to those whose paradigms of organizing data are quite diverse. Clinician and researcher alike are stretched to consider data and constructs from different perspectives. It is helpful to have a methodology that enables one to consider and eventually integrate the different perspectives. Some would say that it is more than helpful—it is imperative. In this latter spirit, the perspectives are presented here for the reader’s consideration.

Как Импотенция, Диагноз?

Patient History

Medical and sexual histories help define the degree and nature of impotence. A medical history can disclose diseases that lead to impotence. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire. A history of using certain prescription drugs or illegal drugs can suggest a chemical cause. Drug effects account for 25 percent of cases of impotence. Cutting back on or substituting certain medications often can alleviate the problem.

Physical Examination

A physical examination can give clues for systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be a cause.

Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean the endocrine system is involved.

A circulatory problem might be indicated by, for example, an aneurysm in the abdomen. And unusual characteristics of the penis itself could suggest the root of the impotence–for example, bending of the penis during erection could be the result of Peyronie’s disease.

Laboratory Tests

Several laboratory tests can help diagnose impotence. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. For cases of low sexual desire, measurement of testosterone in the blood can yield information about problems with the endocrine system.

Other Tests

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of impotence. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then the cause of impotence is likely to be physical rather than psychological. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination

A psychosocial examination, using an interview and questionnaire, reveals psychological factors. The man’s sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

Premature Ejaculation Diagnosis


Masters and Johnson wrote that the object of the sex therapy is not the individual with the sexual problem, but the couple; however, most new medical and surgical therapies for erectile dysfunction, premature or delayed ejaculation, female sexual disorders, androor menopause, and hypoactive sexual desire are based on the symptoms of an individual, rather than the couple as a unit. The exclusive focus on the patient or on the symptom may be reductive and therapeutically dangerous.
Diagnosis of the psychological causes of PE should include extensive interviewing, possibly with standardized psychological tests such as the Chinese Index of Premature Ejaculation (can Be treated with Viagra Online Australia + Dapoxetine Au) and Patient-Reported Outcome measures in order to establish the history of the dysfunction and the circumstances under which it occurs. This must be performed alongside a thorough physical examination and medical tests to assess organ functions that may interfere with ejaculation. When medical tests are normal, a diagnosis of psychogenic PE is considered likely; however, this “diagnosis by exclusion” may lead to unreliable conclusions for various reasons:

  1. it is impossible to demonstrate that a case of PE is generated by the mind (psychogenic),
  2. as stated above, all cases of PE have a psychic and/or relational aspect,
  3. while research is continuously growing, there is still a severe lack of knowledge on central mechanisms of ejaculation.

It can be surmised that in the near future, there will be new tests capable of discovering subjects with purely organic PE. On the basis of these arguments, the authors propose here that when the organic cause for PE (as for other sexual problems) is not identifiable, the term “idiopathic” [“denoting a disease or condition the cause of which is not known”] should be used instead of the term “psychogenic.”

The possibility that PE may involve marital problems should always be considered, even though it may be difficult to discern if the couple’s troubles are the cause or the effect of PE. Whenever possible, sexual symptoms should be assessed in the context of the couple. Thus, it is essential to compare the male’s description of the symptoms with those of his female partner. Perception of penetration time is in fact very subjective.

In the classic Masters and Johnson’s setting, a dual team comprised of both a male and a female therapist treated the “marital unit”. This rarely occurs nowadays, as each individual member of the couple typically receives separate treatment by a single therapist. Structured questionnaires for PE have not been standardized, and attempts to distinguish organic versus functional sexual failure using the Minnesota Multiphasic Personality Inventory or historical data have generally proven unsuccessful.

As PE can be found in the absence (primary) or presence (secondary) of other sexual symptoms, the possibility of coexistence with other sexual problems should always be investigated. Hypoactive sexual desire may lead to PE, due to an unconscious desire to abbreviate the unwanted penetration. Additionally, reduced time to ejaculation is a common early manifestation of erectile dysfunction that may occur with an unstable erection due to fluctuation in penile blood flow. In these cases, the subject may ejaculate early to hide the weakness of the erection, and this type of PE will respond successfully to the appropriate treatments for impotence.

Finally, female sexual dysfunctions (can be treated with female Viagra Australia) such as anorgasmia, hypoactive sexual desire, sexual aversion, sexual arousal disorders, and sexual pain disorders, including vaginismus, should also be taken into account.

These may be secondary to the male PE and can be considered a frequent complication of this condition. In other cases, PE may result from hidden female arousal difficulties. This emphasizes the need for the diagnosis and treatment of the couple as a combined unit.

Physical Exam and Laboratory Testing

The physical examination for PE is usually normal. Penile biothesiometry, however, has been proposed as a useful method to evaluate and quantify penis sensitivity in PE. The biothesiometer is a vibrating device with a fixed frequency of 50 Hz and variable amplitude that is placed on the penile shaft, the glans penis, and the mid-scrotum. The patient is asked to inform the examiner of the first sensation of vibration as the amplitude is slowly increased.

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This includes prostate evaluation by transrectal ultrasonography and standardized Meares and Stamey protocol. Inflammations/ infections of the prostate have been found with high frequency in PE, and the presence of PE has also been demonstrated with high frequency in cases of prostate disease. These epidemiological data, together with the anatomical contiguity of nerves controlling ejaculation with prostate, as well as the role of this gland in the machinery of ejaculation, suggest a causal or concausal relationship between some subclinical prostatic pathologies and PE. Thus, urethral and midstream bladder urine, expressed prostate secretions by prostate massage, and postmassage urine samples are collected, examined microscopically, and cultured bacteriologically. Prostate inflammation is diagnosed if 10 or more white blood cells per high power field are present in the expressed prostate secretions. Nonbacterial prostatitis is defined by evidence of prostate inflammation together with negative urine and prostate fluid cultures. Prostate infection is defined by a colony count 10 times greater in the expressed prostate secretion or postmassage urine sample than in the urethral urine sample. Careful screening for the presence of Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma hominis, Candida species, and Ureaplasma urealyticum should be performed.