Sexual Dysfunctions and Sex Therapy
"To find pleasure in one's own body strenghtens self-confidence and improves quality of life.
No one should be barred from that." (Source: Alphanova.at)
Nowadays, the scientific understanding of sexual dysfunctions is one that considers them as forms of sexual behaviour or sexual experiences which are perceived as disturbance by concerned persons. Such a disturbance might not always be recognized by the affected persons, because they don't even know about the potential of their sexual evolvement (so that they consider their sexual experiences as 'normal'). The wide scope of what could be considered as 'normal' today has resulted in a situation where even conditions like long-time singleness can be seen as states of affliction (if unintentional) but also as neutral or even positive (if intended). However, if the person in question doesn't consider her sexual disposition as a disturbance, but if society or the partner is doing so, this might still result in a conflict and the disposition being seen as a problem. So it's generally difficult to define the borderlines between sexual deviances and 'normal' sexual behaviour in a scientifically exact way.
Frequent causes for diagnosable sexual dysfunctions are disturbances in early childhood, violative experiences in one's personal history, relationship issues, physical causes or intrapsychical conflicts in an area of tension between demands, desires and feasibility.
Experience and diagnosis of 'sexual problems'
Despite all difficulties to draw the outline of sexual 'dysfunctions': just a tiny fraction of people are really happy with their sex life, and the number of dissatisfied ones seems to be rising, as related studies are suggesting. People who only had unsatisfactory sexual contacts or not any sexual contacts at all for some time, often feel that this reduces their quality of life remarkably, and very often, sexual dissatisfaction comes along with depression and other strains. But it's solely up to every affected person to look for professional support on overcoming these issues. Because psychological and sexual problems are still regarded as 'embarrassing' by most, it is also still extraordinary if people decide to use counseling. Thus, an overhwelming majority of affected persons are suffering for years or even decades without achieving any remarkable or sustainable change.
However, clients who undergo sex therapy with professional therapists, are usually advised to start with a medical examination of their issues. It is not enough to verbally enquire about the manifestation of the dysfunction, as insufficiently trained (or untrained) sex therapists often do - this might foil any therapeutic success, because the actual causes of the problem remain vastly untouched. Indeed, often this was the reason if on a purely psychological approach (often the case with counselors, psychologists or therapists) the client is quickly fobbed off with 'hints' or tricky 'homework' lessons, or if only tablets or other substances are prescribed (often the case with medical doctors or alternative practitioners).
A sex related therapeutic diagnosis consists of
- sexual anamnesis (sexual history and experiences)
- family anamnesis (relationship to father, mother and siblings, relationship of parents, role models, values and standards, handling of fear and guilt, formative experiences,..)
- questions about current relationship (acquaintance, course of development, current state)
- questions about current sex life (sexual desire, arousal, contact, orgasm)
Sex Therapy / Sex Counseling
It's pretty normal to lose joy of sex if frustration replaces desire in a couples' bed. Sexual counseling helps to reveal the wide and complex range of psychological causes and to resolve them if possible. Because of the strong interplay between our sexuality and the psyche, sex therapy and psychotherapy can sometimes even help to control or reduce the symptoms of purely physical symptoms.
Sexual issues are far from being something extraordinary during the average person's history: statistical data shows that everyone has problems of sexual nature at least once during their lifetime! In order to avoid having to wait for years or the rest of one's life for the symptoms to 'disappear' by themselves (if they do), it is advisable to take them seriously after some weeks going by without any noticable improvements, and to look for support by a sex therapist if one is available.
Most frequent range of symptoms
- appetence disorder (lack of appetence, low libido) - appetite for sex has remarkably reduced or completely disappeared (, )
- sexual inhibition ('Sexual Shyness') - inhibition or blocks against one's own body or the body of the partner, sexual activities can't be enjoyed because of uncertainty (, )
- sexual aversion - thinking of sex is perceived uncomfortable and repugnant, "no desire in sex".. (, )
- absence of orgasm ('Anorgasmia') or difficulties to achieve an orgasm (, )
- orgasm or ejaculation with absence of satisfaction (, )
- sexual desires or problems that can't be addressed in the relationship (, )
- fetishism or distinctive other sexual preferences that are hard to integrate in one's life (, ) [list]
- sudden loss of arousal (, )
- erectile dysfunction (chronical) [see Online Self Test on Erectile Dysfunction], also known as 'impotence'): the penis doesn't stiffen (sufficiently) anymore ()
- absence of sexual arousal and lubrification disorders (aka 'vaginal dryness', the vagina doesn't lubricate sufficiently enough) ()
- premature ejaculation (Ejaculatio praecox) - occuring before or soon after insertion into the vagina ()
- delay or absence of ejaculation (Anejaculation) - despite erection and intensive stimulation, no ejaculation can be achieved ()
- Vaginismus (vaginal spasm) - due to a conditioned reflex of certain muscles, any form of vaginal penetration, including sexual penetration, is impossible or painful ()
- pain during sexual intercourse (Dyspareunia) - (, )
- post-coital disorders (post-orgasmic depression) - depression, huffiness, feeling uneased, crying fit or fit of laughter, headaches etc. after sexual intercourse (, )
- other disorders related to sexality (disturbances of sexual preference or paraphilias or sexual deviations according to the international diagnostic scheme ICD-10 or DSM IV, like:
- Gender identity disorder (a man wants to be a woman and vice versa), if it is considered as disturbance or reduces quality of life for the affected person (read more under "sexual variations")
- troublesome differentness (see below)
- sexual offences (all kinds of sexual abuse, harassment, assaults,.. - see below)
- Automasochism (, , )
- BDSM / 'Sadomasochism' (, )
- Telephone scatalogia (most often , )
- Exhibitionism (most often , )
- Frotteurism (most often , )
- Gerontophilia (, )
- Cleptomania with sexual elements (most often , )
- Coprophilia, Coprophagia (, )
- Necrophilia (, , )
- Pedophilia (, , )
- Zoophilia (aka: Sodomia, sodomistic sadism) (, , )
- Transvestic fetishism ()
- Urophilia (, )
- Klismaphilia (aka: Klysmaphilia) (, )
- Voyeurism (often , )
An important role for the assessment of the manifestations listed as 'other' disorders is the severity of the behaviour, whether the person is suffering from it, if there already exists some kind of dependence (= without the sexual behaviour, no sufficient arousal and/or orgasm can be achieved), whether the behaviour might be harmful or punishable, like when resulting in sexual offences, or in other kinds of problems in one's social environment.
According to 'Criteria A' of the DSM-IV, the activity must be the sole means of sexual gratification for a period of six months, and either cause 'clinically significant distress or impairment in social, occupational, or other important areas of functioning' or involve a violation of consent to be diagnosed as a paraphilia. Forms of paraphilia appear as arousing phantasies, urging sexual desires or behavioural patterns dealing with
1. non-human objects (fetishism, zoophilia,..),
2. suffering or humiliation, pain or degradation of the partner or oneself (masochism, sadism,..),
3. sexual attraction to prepubescent or peripubescent children (pedophilia) or non-consenting or non-competent persons.
As a form of complemental variation and with a concordant attitude of curiosity, certain kinds of sexual deviations can add well to the quality of sex life, and with the right partner, even build the main focus of a sexual relationship. On the other hand, as time goes by and sexual deviations are taking shape, some people develop downright compulsive behaviour in regards of exercising and realizing it. Thus, within an elightened society, a paraphilia might socially accepted but still hard to be considered as 'healthy' (as this term is defined by the WHO1), especially if it results in a constriction of a person's sexual spectrum. That's especially the case if this variant is tending to dominate one's sex life or if sexual arousal can only be achieved if the paraphilia is practiced.
= paraphilia is harmful and/or punishable (always or under certain circumstances)
No sexual dysfunctions, but often accompanied by them:
- Sexual addiction & Hypersexuality
- Pornography addiction
- Brothel addiction / Prostitute addiction
- Difficulties to find a partner or long-time solitude
- psychological disorders with side effects on sexual experience or sexual behaviour
- Infertility or other kinds of disturbed or reduced fertility. Especially long-term unsuccessful desire for a child can put enormous burden on a relationship - sex therapy or pair therapy / relationship counseling may have an important an relieving impact, adding to support in regards of eliminating potential causes.
Other sexual variations:
Homosexuality (an enduring pattern of or disposition to experience sexual, affectional, or romantic attractions primarily to people of the same sex) and Lesbianism () are still object to social (i.e., 'moral') judging, not considered as morbid behaviour anymore and thus not listed in modern medical classification systems of mental disorders anymore.
Transgender (non-identification with, or non-presentation as, the gender one was assigned at birth). Transsexual people identify as, or desire to live and be accepted as, a member of the gender opposite to that assigned at birth. The terms "transsexualism", "dual-role transvestism", "gender identity disorder in adolescents or adults" and "gender identity disorder not otherwise specified" are listed as such in the International Statistical Classification of Diseases (ICD) or the American Diagnostic and Statistical Manual of Mental Disorders (DSM) under codes F64.0, F64.1, 302.85 and 302.6 respectively. Understanding Transgenders as persons with a sexual preference deviating from predefined norms is considered as inexact and is rejected by the affected.
The 'image' of both sexual variations saw a significant metamorphosis during the last decades, today, homosexuality is widely accepted especially in Western countries. However, they often result in severe psychological burden for the involved people, especially during their 'coming out' (at first, realizing their sexual preference, then to talk about it), that's why counseling can almost always play an important supportive role during this process. If transgenders are planning a sex change, psychotherapy is regulated by law.
The basic causes for both forms of sexuality are not exactly definable as of today - neither are there any solid psycho-causal explanatory models, nor a prove of causally determined biological/genetic factors.
Causes for sexual issues
Men usually experience a decline of the intensity of their sexual needs after about their 30s, and after 50yrs, of their sexual performance as well. These are completely normal physical processes of which their first signs of appearance may be influenced by environmental, psychological, genetical factors and others, and of course physical condition. Due to the chance of physical causes, a medical examination done by an urologist/andrologist is almost always an advisable first step to break down on possible reasons. If no clear explanation was found, sex therapy is indicated - rather sooner than later, because the symptoms of most sex issues tend to increase and to develop psychological dynamics that can't be called helpful.
Even at purely physiological causes, sex therapy can prove supportive and often reduce the symptoms, because the psychological impact of the issues will most often have significantly aggravated them.
Women rarely show physiological causes for sexual dysfunctions - apart from pain or other obviously physical symptoms, almost always sex therapy or psychotherapy is indicated.
Experts generally agree upon that - similar to the whole range of psychosomatic disorders - for most kinds of sexual dysfunctions, psychological causes are at least jointly responsible to the organic irregularities showing up, while these organic symptoms often turn out as the result rather than the cause after a careful evaluation. And it's indeed a widely shaped range of causes: often they show up as pressure to perform or a feeling of having to comply with certain expectations or norms - many people have forgotten to listen to their own needs or don't take them seriously enough. Especially men often have a downright tantalizing want to make everything "work" in bed: thus, more and more of them are already frequently using drugs supporting their erectile function like Viagra or Cialis even at ages of 45 years and below, which often results in an at least psychological dependence on their intake after many years of use.
Women, in turn, often have difficulties related to low sexual drive or sexual oder to reach a sexual climax, under which they are sometimes suffering for decades - usually, because they aren't taking the problem seriously enough, or out of constraints to openly talk about their issues even with professional advisors.
Relationship issues as a cause
Sooner or later, conflicts in the relationship will usually irritate sex life as well. However, a couple doesn't necessarily have to deal with open fights - unresolved issues, different ideas about sex (frequency, variants, desires, needs) may contribute to the development of sexual issues for one or both partners, especially if talking about sex is difficult or only possible within a very limited range. In such a situation, joint sex therapy or relationship counseling sessions may build up some space in which - under professional moderation and support - those difficult topics and issues can be talked about and be dissolved.
Structure of Sex Therapy
Contents and structure of professional sex therapy will always be based on the diagnosis, but rarely just consist of only psychologically-based 'hints' or a prescription of drugs.
If psychological reasons are apparent causes of the sexual issues (like after infantile disorders and burden, neuroses, attendant psychological symptoms etc.), an exclusively psychotherapeutic approach will usually be the most promising one, but an assisting treatment of the functional sexual dysfunctions might be useful. While the approach itself is of subordinate relevance, choosing the "proper" therapist is essential. If a patient suffers from traumata (PTSD), it's also important to look for a therapist who has experience in trauma therapy.
Generally, a holistic combination of guided, behavioral approaches (like erotic massage, pampering and desire days, communicating and realizing phantasies, erotic movies, role play, special places etc. etc.), systemic (especially if relationship issues have also occured) and communicative approaches (communication training, communication practice and/or attendance of related seminars) is considered as most effective. The sex therapist will emphasize the most promising approaches based on his/her experience and on the diagnosis, support the couple or the individual by getting over the usually unavoidable hitches at the beginning of the process and offer a protected atmosphere to exchange and reflect upon what both partners have experienced. Most people quickly see sex therapy as interesting and exciting process and something that can broaden not only their relationship but also their very own sexual experience and joy as soon as the first obstacles (like talking to a 'stranger' about their private issues) have been overcome!
Approaches aside of integrated methods
In Urology, sexual dysfunctions are usually considered as 'malfunction'. Urologists are medical doctors and thus specialized in surgical, medical and hormone treatments (like prostate surgery, treatment with sildenafil ('viagra') or testosterone). Sex therapy - understood as outlined above - is rarely offered by urologists.
For Clients without relationship partners or sex partners, some sex therapists are cooperating with prostitutes who have therapeutic competence as so-called 'compensatory partners'. However, if sexual dysfunctions are diagnosed or especially if shyness or social phobias have turned out as a co-cause for singleness, the mere visit of prostitutes (as it is often suggested by friends or on some Internet websites) will rarely solve these inhibitions, but might even aggravate the underlying complex of problems: by increasing the sexual drive, producing additional frustration (often the case with ED) or increase the pressure to find a 'real' partner. Additional experiences of frustration usually just increase the feeling of being even more stuck with the problem. Women usually have it easier to find sexual partners - but just that alone might hardly 'train' them to establish truly satisfying and sexually fulfilling relationships on a long-term basis. Thus, it's usually more meaningful to at least complementary work on the problem on a relationship level (like "why can't I find a partner?").
For the sake of completeness, it should be mentioned that any form of sexual contact between psychologists, psychotherapists and (professionally trained and working based on scientific standards) sex therapists and their clients is condemned as abuse by any established professional associations and are punishable in many countries2. In specific cases, physicalness can be a helpful complement or method in psychotherapy (body-oriented appendages in psychotherapy like bioenergetics or holotropic breathwork, but not such of sexual nature.
Sexual dysfunctions or sexual issues in the relationship are not life-threatening - in principle, one could spend all of his/her years accompanied by them. Hhowever, they are derogating quality of life -at least in certain phases of life- substantially. Concerned persons are telling about themselves, that they really try hard and often also read a lot about their problem, but just with little or short-term success. Often they are giving an impression as if they would like to pull themselves up by their bootstraps ..but without the outcome they hope for. This especially applies to men orientated on 'classic' gender roles - to solve their problems all by themselves.
Sex therapy often is a complex process that might not allow results right after the first few sessions - way too long many clients were bearing their issues, too deep are those causes already 'wired' within their organism. But if one seriously goes in to sex therapy and bears up with it for some time, first improvements will often show up already after 3-5 meetings.
1 "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (official definition of 'health' as in the Constitution of the World Health Organization (WHO) signed on 22 July 1946 by the representatives of 61 States; this definition has not been amended since 1948.)
2 Austria: § 212 Abs. 2 StGB, Switzerland: Art. 193 Abs. 1 StGB, Germany: § 174 c StGB
Related keywords and terms: Sex Therapy, Sexual dysfunctions, sexual problems, low sexual drive, appetence disorder, Orgasmusprobleme, Orgasmusstörungen, vorzeitige Ejakulation, Ejaculatio praecox, Vaginismus, Beratung, Supervision, Therapie
Appendix: literature about this topic, with reader comments: