When significant organic factors are present, a useful distinction can be made between sexual symptoms that arise directly from organic disorders, such as structural disorders of the urogenital system, neurologic disorders affecting the innervation of the sexual organs, and endocrinopathies that influence sexual physiology, and those that are secondary to changes in general health, such as sexual disturbances associated with rheumatoid arthritis, malignancies, renal failure, and other chronic diseases, or those that occur with acute debilitating conditions, such as myocardial infarction, major surgery, and hepatitis. Patients with primary organic disorders may need counseling to help them adjust to permanent losses of sexual function if medical measures cannot reverse the process. Although libido may be affected adversely by a general loss of vitality and by toxic and metabolic factors, the sexual disturbances associated with physical illnesses can also be the expression of hopelessness, depression, or anxiety and may be perpetuated by psychological factors long after the organic problems have disappeared. Persistent sexual dysfunction after a heart attack may reflect fear of sudden death during sexual excitement.
The apparent absence of an organic etiology does not necessarily mean a sexual dysfunction is psychogenic. Subtle vascular or neurologic changes not found on routine evaluations of impotence may underly some instances of erectile dysfunction. The diagnosis of psychogenic impotence should be reserved for cases in which positive evidence of emotional disturbance can be found. Psychological factors that can interfere with the sexual response include fears and conflicts about sex, emotional disturbances that are antithetical to sexual excitement, and anger or dissatisfaction with a partner. Once a sexual failure has occurred for any reason, performance anxiety can develop and lead to further impairment by worry about subsequent encounters. In one study of impotence only 14 percent of cases were diagnosed as psychogenic. In many instances of sexual dysfunction, psychological factors interact with an organic vulnerability to produce overt symptoms.
Primary psychogenic disturbances, those that have been present since puberty, can be distinguished from secondary disturbances, those that represent decompensations from previous adequate levels of function. The former often reflect chronic and deep-seated sexual conflicts. When a patient seeks help for a chronic disturbance, the key diagnostic issue may be why help has been sought at this particular time. A secondary decompensation may be the presenting symptom of a psychological defeat or a disturbance in a relationship. Some sexual problems occur in connection with life stresses or transitions, such as retirement, pregnancy, work crises, or bereavement.
Other sexual disorders are manifestations of major mental disorders and respond only to treatment directed at the mental disorders themselves. Diminished sexual responsiveness, impotence, or ejac-ulatory disturbances may be indications of depression. Bizarre sexual complaints with increased or diminished sexual activity can indicate incipient psychosis. The strange qualities of the symptoms or the intensity of the associated feelings may be the best diagnostic clue to the presence of a psychosis. Hypersexuality can also occur with the onset of mania or as a manifestation of depression, especially in postmenopausal women.
Alcohol may play a significant role in impairment of potency. Often the first episode of secondary impotence is associated with the on counselors for the evaluation of emotional problems rather than carrying through the diagnostic phase themselves. If physicians keep in touch with patients through the process of therapy, it enables them to evaluate the efficacy of the treatment program and to provide support and reassurance.
A few examples will illustrate some of the principles involved in the treatment of patients with sexual disorders.
A.R., a 56-year-old attorney who had recently suffered a myocardial infarct, complained to his physician of loss of libido. He was an energetic, competitive, aggressive self-made man, who enjoyed athletics and was “top man” in his firm. The physician asked him about the details of his daily life and found that the loss of libido was only one of many inhibitions. He avoided arguments, stopped playing handball, reduced his work load, lost weight, and developed insomnia and anorexia. Further questioning revealed fears of sudden death and the fatalistic belief that his days were numbered. He assumed that strict reduction of activity was mandatory. His wife shared his fears and urged him to avoid stress. Together they had decided not to have sexual relations during the period immediately after his heart attack, and he had no desire to resume. In the course of several sessions of counseling the physician reassured him that his fears were exaggerated and that many patients with heart trouble experienced similar feelings, clarified the extent of his disability, and helped him and his wife to plan realistic resumption of many of his previous activities, including sexual relations.
L.D., a 26-year-old woman, consulted a physician because of frigidity. She had left her husband after 6 years of an unfulfilling marriage and had sought satisfaction in a series of brief affairs. The interview revealed a restless, competitive, chronically dissatisfied person who was unhappy in her career and experienced disappointment in close relationships. After careful evaluation of the physical aspects of her sexual difficulties and experiences, the physician decided that her problem reflected long-standing psychological conflicts and referred her to a psychiatrist.
M.B., a 34-year-old salesman, complained to his physician of impotence. He was a nervous, insecure, ineffectual man who worked for his older brother. His wife, an active real estate broker, had become withdrawn and bitter, and his two adolescent children were involved in minor delinquency. The impotence was confined to his relationship with his wife; in a recent extramarital affair he had performed adequately. He said he was unable to satisfy his wife in any way; she was either withdrawn or overly demanding. The physician determined that the impotency had no organic basis and referred the patient to a service agency where the family could be worked with as a unit. Here the wife was found to be depressed and received psychiatric treatment. Later the patient reported that when her depression improved, his potency returned.
C.W., a woman with breast cancer, was asked about her marriage. She reported that her husband had stopped having sexual relations with her when it was discovered that she had metastatic disease. The physician then saw the husband, who confessed to an extramarital affair and the wish to leave his wife. He also described irrational anger directed to his wife and feelings of shame and worthlessness. It emerged that the marriage had been an unusually close one and that he could not bear the anticipation of his wife’s death. Sexual contact with her reminded him of his impending loss. His anger and the extramarital affair were responses to grief. The physician met with him for several sessions. By avoiding a moralistic position and by indicating that many spouses of patients with serious diseases have similar feelings and may even find solace in extramarital relationships, the physician helped him to overcome his shame and to share his grief. The process brought dramatic relief, and with occasional contact with the physician he was able to remain with his wife and be helpful to her throughout her terminal illness.