Sex addicts on Internet

Contraceptive skinplaster

Children of lesbic couples

At the End a chapter from the Textbook of Medical Communication:

              Communication about  problems of Sexuality

                   (In: Pilling J. (Ed.): Orvosi kommunikáció.  2008, Budapest, Medicina) 

                                       Vilmos Szilágyi, sexologist

Introduction

The persistent taboo of sex, and how to counteract it

The framework for discussing sexual problems

Contexts to be explored

Guidelines for diagnosis, advice and therapy

Summary

Review questions

Appendix

Bibliography 

Introduction 

Most people who come to their doctor with psychosomatic symptoms are unaware of the deeper reasons for their condition. What lies in the background is often a sexual or relationship disorder. If the true causes are not recognised even by the doctor, treatment can become superficial or even fruitless. Many such problems still go undetected.

An illustration of how serious the consequences of such failure can be is a letter from a middle-aged man who sought help after several years of treatment and the prescription of about forty different drugs, none of which rid him of his complaints (anxiety and depression). In the meantime, he had realised that his sexual problem was a bigger problem than any disease, but had never really been talked about. “I find that every doctor or psychologist who asks about it demurely moves on to the next subject after a few questions.” He then went on to write that his sexual problem was also responsible for his “strained nerves” and so obviously needed treatment, but this had never been done. He did not know who to turn to for help with his main problem, and for some time he had been seriously thinking about suicide.

Such severe consequences can be prevented if, present with various different complaints, the doctor pays greater attention to sexual relationship problems and does not avoid discussing these in detail. This of course requires some preparation. Hidden sexual problems are common and significant, but are not always easy to detect and can be difficult to discover and treat. 

The persistent taboo of sex, and how to counteract it 

The reader is no doubt aware that despite the deluge of sex in advertisements and pornography in recent decades, sexual inhibitions persist, especially when it comes to discussing “intimate questions” openly and in detail. This mostly applies to older generations, but is not rare even among young people (except among friends of the same sex, who like to flaunt their lack freedom from inhibition).

Of course, how open people are prepared to be about these issues depends a lot on who they are speaking to and how they relate to that person. In this respect, the doctor-patient relationship is a special one: patients can be inhibited from being completely candid by fear of putting themselves under the doctor’s control and by the circumstances which typically prevail in a doctor’s surgery (not enough time, presence of others, etc.). They expect, quite understandably and reasonably, that the doctor should help them in this, but doctors themselves are not always free of inhibitions in communication on sexual matters, and some find pretexts to avoid the subjects of sexuality and partner relationships. Common pretexts of this kind are that the doctor does not wish “to put the patient in an uncomfortable position” or “to bother the patient with “indiscreet questions,” or he wants to avoid misunderstandings, or has no time for such conversations.

The real reason for such responses is that most doctors feel unprepared for the task, not having been trained at university or anywhere else, and so that they not know where to start with patients’ sexual problems. This deficiency is not unique to Hungary; the pattern is similar in other European countries and throughout the world, if not to the same extent as here. A British researcher has found, for example, that the sexological training of health professionals is highly deficient; medical students do not consider themselves capable of taking a sexual anamnesis or examining sexual organs. University training should prepare students for this, just as it should help them to approach patients without prejudice.

Patricia d’Ardenne, editor of the British journal Sexual and Marital Therapy wrote (in issue 2 of 1992), “Sexually transmitted diseases and sexual functional disorders occur everywhere in medical practice, and should have a place in medical training. Several different branches of medicine… could have a part to play in training doctors in sexual therapy.” The British Medical Journal recently published a series on protecting sexual health, which covered the taking of a sexual anamnesis, examination of patients with various sexual disorders, etc. The authors drew attention to the importance of sexual communication and sexological studies, noting that training in these areas is a neglected area in Britain. In Hungary, doctors and psychologists get no sexological training whatever, and traditional sexual taboos persist very strongly. As a result, obsolete views and prejudices are stronger than in Western countries, where sexology is now a compulsory subject in university medical courses.

Most patients coming to the doctor feel it is “inappropriate” to bring up sexual problems with the doctor. They prefer to present with organic complaints, sometimes because they actually see these as the cause of their sexual problems. They think that if the doctor can help free them of their organic problems, then there will be no trouble with sex. The doctor is happy to accept the symptoms which the patients present, puts them into some diagnostic pigeon-hole, and writes a prescription or refers the patient for a test.

As a result, sexual problems often do not come to light, let alone find a solution. If the patient does timidly make some reference to sexual matters, the doctor often responds with something like, “Let’s not complicate things,” or “We can come to that later.” (The subject somehow never arises again.) Or, “You should perhaps take that to a specialist,” which means a gynaecologist for women or a urologist or andrologist for men, or a psychiatrist or psychologist for both. Whether the patient actually does approach the recommended “specialists” and whether he or she actually gets help from them, is highly questionable, because they have not received any training in sexology or sexual therapy either. So passing on the patient usually just means avoiding the problem. (Until there are very few trained sexual therapists in Hungary.) 

The framework for discussing sexual problems 

If we do in fact want to help – something that might be reasonably expected from a doctor – there are some things we should know. Sexuality is still a “sensitive area” for many people, and we must take care not to offend the patient’s sensitivities or moral viewpoint. Secondly, we must speak in plain language about sexual matters and sexual problems. First we should establish a reasonably direct and confidential relationship by talking about neutral subjects, probe the patient’s level of education and value system, and adjust questions on sexual life accordingly.

To enable problems to come to the surface, we must adapt to the patients. In general, and above all, this means avoiding extremes: either medical expressions used among doctors, or either euphemisms or vulgarities. A commonly-heard complaint is that there are no acceptable “polite” expressions for the more sensitive areas of sexuality. This is just a pretext to get out of the task, because there are in fact suitable words for everything. There is no sexual act or phenomenon which cannot be expressed in plain words (and without vulgarity!).

This of course does not mean that we should avoid the better-known medical terms, but we should always – at least initially – add an explanation.

We should of course only start asking questions on sexual life after securing the patient’s confidence in the preliminary conversation. Even then, rather than launching a stream of specific questions, it is advisable to encourage the patient to tell us his experiences and troubles in his own words. If he finds this difficult, then we can make things easier with assisting or leading questions. These are aimed at clarifying the problems and avoiding any misunderstandings. Something like, “If I understand correctly, the situation is that…”

In framing questions we should always bear in mind patients’ sociocultural background, because this can strongly influence how much patients understand of what we say, how they take our questions, and how – and how fully – they answer them. Sometimes we have to put the question in several different ways, because the answers we get complement each other and make the interconnections clearer. There is a particular need to put questions in a modified way (better adapted to the patient) if the patient is clearly struggling with the answer. It is important not to force an answer to the question. If necessary, put it aside and return to it later, or try to approach the same subject from another side or in another sense.

A productive discussion of sexual problems can only take case in the proper conditions, which we must take care to provide. First there are the objective conditions. Chief among these are privacy and freedom from interruption. It is obvious that most people will only be prepared to talk about intimate issues if they are alone with the doctor, in calm surroundings, in the right kind of place and with sufficient time available. The usual surgery conditions – presence of an assistant or other staff member, restricted time, constant interruptions – make effective communication almost impossible So we have to provide a more suitable place and much more time than usual. The time cannot of course be unlimited, but within the constraints it might be extended, especially for the first interview.

Most specialists and GPs are limited in the time they have for thorough discussion of problems. But they should not be avoided even if we only have 5-10 minutes available. A brief intervention can still be productive, especially if it is repeated at several consultations. Certainly, doctors should be aware of the limitations of their own competence and skills, and be able to judge accurately what they can help patients with (e.g. listening to problems, dispelling misunderstandings, etc.) and when they should refer patients to specialists who have more time and greater skills in this area.

The essential environmental conditions are a quiet and comfortable place, where the interview can proceed with no external sources of distraction, if possible, and both patient and doctor can feel relatively at home. Seats (which should be comfortable) should not be placed directly opposite but in the “consultation position”, i.e. the doctor’s chair behind the desk and the patient’s at the side. There should be enough space on the desk to put out any documents or reports.

Perhaps even more important than these objective conditions are the subjective conditions, most of all the atmosphere of confidentiality which we have to establish. This of course depends on how long we have known the patient, what our previous conversations were like, and whether we are talking alone or in the presence of another person. The patient’s partner, for example, may wish to attend the consultation, and this should not be excluded, in fact may be beneficial, because sexual problems usually arise in a relationship, and so the partners involvement may be needed for proper diagnosis and giving advice.

Additionally, modern sexual therapy is basically couples therapy. This does not mean that we should not speak to a patient alone, especially in the initial stage of discovering sexual problems. Speaking to the patient alone may facilitate adaptation, the attainment of empathic attunement with the patient, which is the most important subjective condition for productive work. This is accompanied by an accepting attitude of friendly enquiry, refraining from negative judgement and appraisal, in both the verbal communication and metacommunication. Patients are usually very sensitive to this, and become blocked if they do not receive complete acceptance and encouragement. We should therefore avoid incongruent situations (when our words and our gestures are not in harmony).

What this does not mean is approving everything that the patients say. Empathic listening involves receiving patients’ prejudices, false ideas and inappropriate habits with the intention of understanding them, but by saying “We’ll go back to that later,” or putting clarifying questions, we indicate that we want to clarify the causes and functions of unfavourable factors.

Another important condition is that the doctor be calm and relaxed, and does all he can to help the patient be so. It is unproductive and inadvisable to talk about sexual problems in a tense state. In such conditions it is better to postpone the interview or temporarily talk about other things. After talking about a more neutral and reassuring subject, we can try again after some time to return to the sexual problems. One way of relieving tension is to display genuine interest in patients and ask about important events in their lives. Most people are happy to talk about their own lives, and this can provide a guide for exploring sexual problems and clarifying their background. In addition, talking about their recent history can create a more intimate atmosphere which also helps the discussion of sexual problems.

It is important to give patients (or couples) constant feedback, indicating we have understood what they said, that we appreciate their candidness, and that it will be very useful in resolving the problems. If something is not completely clear, ask about it immediately and then, in our own words, summarise what was said (asking them to confirm or correct it). When speaking with a couple, it is important to ask the opinion of one partner about what the other has said, and thus discover differences in attitude that can be key causal factors in sexual problems. The purpose here is not to support one partner against the other, but to make it possible to discuss differences of opinion. Clients have a tendency to assign therapists the role of arbitrator and support them against their partner. Any concession to this leads to difficulties in persuading them that partners are usually equally responsible for the development and solution of the problem, and so must help each other. This underlines the need for the therapist to take a position, and engage in communication, which is helpful to both parties.  

Contexts to be explored 

Understanding of sexual/couples problems demands a knowledge of their sociocultural background. This is partly of a cultural history nature, like the historical dominance of male sexuality, the still-persistent patriarchalism, whose most pregnant manifestation is “machismo”, sexual conquest, exploiting women and treating them as objects. There are, however, many other factors that can generate sexual disorders.

These include circumstance inhibiting psychosexual development, like the sexual coarseness and ignorance deriving from lack of sexual education, the frequent lack of male models in the family and in school, strong mother-son bonding (especially with only children), and the extreme “macho” male ideal conveyed by pornography (and mass communication in general), largely accepted and propagated by peer groups and frequently engendering the feeling of diminished sexual worth.

The contexts that have to be explored in order to understand sexual problems include the sociocultural background (place in society, qualifications, religious affiliation, lifestyle, leisure pursuits, etc.) and the sexual history of those involved. An assessment of this for diagnostic purposes requires a knowledge of the general features of psychosexual development, concepts such as sexual identification, i.e. identification with and acceptance of the person’s biological gender (which does not always happen), the gradual learning of the gender role, and sexual orientation, i.e. preference for partners of the opposite or the same sex. These form the basis of psychosexual development, one of the principal strands of personality development. It pervades the individual’s whole life, and should culminate, by adulthood, in partner selection, i.e. readiness for marriage and the parental role.

This development can easily be blocked if the necessary conditions are not in place, getting stuck in childhood and youth and inhibiting the emergence of the ability to love and reach psychosexual maturity. Young people, and even young adults, still become preoccupied with guilt-ridden masturbation and hardly dare to initiate sexual relations or accept the approach of a possible partner. A “sexual relationship” does not necessarily, of course, mean coition, because “petting” can be satisfying to both partners and can help avoid unwanted pregnancy and sexually transmitted diseases. (Those who disapprove of early “sexual experience” often forget that the concept is not necessarily equivalent to coition, because it also covers such things as kissing and petting.)

Many problems derive from concentration on sexual performance. In our performance-oriented age, it is common for both men and women to aspire to certain levels of performance even in sexual relationships, and are liable to make a strained effort, which very often leads to failure. This pursuit of performance can take the form of determination to attain maximum pleasure, to reach quick and/or multiple orgasms, or simultaneous orgasm. This prompts women especially to “fake” pleasure, and simulate orgasm.

It is therefore important to determine whether couples are straining in their sexual relations. Since straining is usually driven by various fears, we should try to make these fears explicit. One of the most common is fear of failure. Nearly everybody sometimes experiences that the sexual experience does not live up to expectations (because of tiredness, for example). Where there is sufficient self-confidence and a harmonious relationship, the partners do not make an issue out of this. Otherwise, one or other partner can quite easily start – consciously or unconsciously – to be afraid of repeated failure, and worriedly monitor themselves even during foreplay, which can disturb sexual excitement and distract from its usual pleasurable course. Fear of failure thus becomes dominant.

Fears can concern other matters than failure. There are many other real or imagined dangers. For example, unwanted pregnancy, sexually transmitted disease, a partner's “excessive” expectations or bonding, loss of freedom, etc. For some, the latter can lead to fear of intimacy itself and the accompanying imagined control, because they do not trust their partner. (This is usually associated with lack of self-confidence.)

Then there are the circumstances of sexual encounter: whether there is a suitable, untroubled place and enough time, and what state of mind and body it takes place in. An uncomfortable place (e.g. a car), absence of washing facilities, fear of being disturbed, or need to hurry can cause sexual problems just as much as exhaustion, diseases, or intoxication. Problems can also arise if one partner has, for some reason, not had any form of sexual life for an extended period, and is “out of practice”, or “not in training” and this is not taken proper account of by either partner. Other components of lifestyle like smoking or addiction can also seriously impair sexual abilities.

Sexual partners’ attitudes to each other are also important, particularly how long they have been seeing or living with each other, and what their motivation is. Clearly, sexual disorders in a recently-begun relationship have different causes than in one that has been going for many years. In new and promising relationships, love can be a very strong motivating force, especially if it is mutual and of similar intensity, and this makes adapting to each other much easier. The desire to conform can prompt people to strain themselves sexually, and this may lead to failure. Love therefore does not in itself guarantee sexual harmony. (The author has several times encountered sexual problems between loving couples. Here, the worries and straining are the problems to be overcome, not the love.)

Straining is not necessarily absent even from long-standing relationships, the result of compensating for libido deficit or lack of interest caused by boredom or emotional cooling. Much more common is for sex to become tedious, and for variety seeking, usually with another partner. A person may “cheat” only on the plane of fantasy, and cause either guilt, which has a negative effect on married life, or the reverse, a temporary revival of sexual desire towards the person’s partner. The same dual effect is observed in real extramarital affairs, whether or not they are discovered. The relationship and sexual life of couples with a traditional outlook can collapse from an extramarital affair, whether it is a one-night stand or a sustained liaison, or result only in a mild temporary crisis for others. “External relations” do not therefore unavoidably create serious sexual problems. In such cases it is important to asses any exaggerations in the perception of an affair.

This may be the most difficult aspect of appraising the situation. Firstly, it is difficult to get honest and reliable answers, and secondly even a subjectively honest answer frequently twists the facts under the influence of unconscious game (see Eric Berne’s game theory), or are the products of tacit agreements and compromises (see Jörg Willi’s collusion theory). In such cases, it may be worth requesting the help of a competent psychologist.

It is only possible to properly interpret these, however, if we have the basic facts. These include: the age, sex, occupation, educational level, address, marital status, current or past medical conditions (especially diseases with a bearing on sexual life). The answers can lead to all sorts of questions, like whether they have children, have had an abortion, etc.

Guidelines for diagnosis, advice and therapy 

Since sexual problems arise in every area of medical practice and are associated with the most diverse organic complaints, it would be neglectful of our medical calling to skirt around these or deal with them by giving trivial advice (e.g. “Have a strong one beforehand.”) Although treatment of sexual disorders is a branch of medicine requiring special training, this is as yet not available (at least not at a state-recognised level) in Hungary, and so it is not possible simply refer patients to the “appropriate specialist”. (The only apparent exception to this is with men with erectile disorders, who may be referred to an andrological clinic, but they are only likely to get drug treatment there, what is not a  modern sexual therapy.)

Most doctors are unable to offer sexual therapy in the narrow sense, but even to give advice they need some basic knowledge of sexology. The World Health Organisation first drew attention to the need for training health workers in sexology in 1974, and drew up Recommendations for protection of sexual health at another international conference in 2000 (see Sexological Documents, 2004). This defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (The Declaration of Sexual Rights is given in the Annex to this chapter.)

The basis of sexual well-being is naturally a cared-for body free of disorders and diseases, and functioning of sex organs appropriate to age. Its maintenance requires proper attention to the possible risks and damaging factors, especially sexually transmitted infections, which can be difficult to treat or even fatal if not detected early – the most striking example being HIV and AIDS. There are many other diseases or conditions which endanger or restrict sexual health, often without the sufferer being aware of them. A doctor must be familiar with these and check them as a matter of routine in the course of medical examination.

A doctor nowadays must also know, for example, that sexual behaviour in humans is not instinctive, but learned, and develops in the course of socialisation – which means it may be formed, developed and corrected. Neither is sexual preference (hetero-, homo- or bisexuality) something we are born with, but develops under influences which come to bear during the individual’s psychosexual development, and is usually finalised in the teenage years. (It seldom changes later, although this cannot be excluded.)

Sexual orientation disorders (known colloquially as “perversion” and in medical language as “paraphilia”) are relatively rare. Sexual problems are much more often caused by sexual dysfunctions of which the most common are, in men, erectile dysfunction and orgasm disorders, most prominently premature ejaculation (ejaculatio praecox); and in women, failure to achieve orgasm (anorgasmia), pain during coition (dyspareunia) and  impossibility of penetration (vaginismus). It should also be known that impotence can only be considered a dysfunction in relatively healthy men who, despite making attempts, do not achieve erection sufficient for penetration for an extended period (several months). Frigidity is not identical to anorgasmia, but means that the woman is completely incapable of sexual excitement regardless of the nature and period of sexual stimulation (this is quite rare).

All these should be borne in mind when diagnosing presented sexual disorders. Without detailed exploration and taking the anamnesis with the patient alone, it may be possible to reach an approximate diagnosis, but not to give useful and effective advice. Although there are some auxiliary methods which make diagnosis easier and quicker (such as questionnaires), but they are not sufficient in themselves and need at least verbal confirmation and augmentation.

Some eminent medical sexologists have developed a brief and reliable method of measuring erection function, one that can be performed by the client, has been used in various cultures and is reasonably psychometrically sensitive to changes elicited by treatment. The method is based on findings in the medical literature, and information obtained by interviewing erectile dysfunction patients and their partners, on the main characteristics of sexual functioning in various cultures. A questionnaire was compiled and tried out on a large population of patients, after which the results were assessed by experts. The final 15-item questionnaire, the International Index of Erectile Function, has been translated into 10 languages and checked in many countries for reliability, structure and validity.

The findings are that there are five main factors in male sexual life: erectile function, orgasm, sexual desire, satisfaction with coition and satisfaction with sexual life in general. It was found in trials that there is a close association among all five factors, and repetition of the test reliably shows up changes occurring during therapy in all five areas. The questions cover sexual experience in the previous four weeks. Some of them are:

 “When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?”

“When you attempted intercourse, how often were you able to penetrate (enter) your partner?”

“When you attempted sexual intercourse, how often was it satisfactory for you?”

“How much do you enjoy sexual intercourse?”

“How satisfied are you with your sex life?” etc.

The client had to select one out of five predetermined answers for each question. the Hungarian version of the test, which consists of only five questions, was accessible in GPs waiting rooms (until it ran out). What Hungarian GPs were able to make of men’s answers to these is another matter, apart from possible prescribing them some “potency enhancing” drug. (Not to mention that the questionnaire itself seems somewhat obsolete, because it identifies sex life with sexual intercourse.) This international index has made diagnosis easier, but gives not guidance for therapy and has not helped to change the traditional doctor’s attitude that most erectile dysfunction is due to somatic causes and that the proper and effective treatment must by with drugs (or some kind of prosthesis).

Surveys in Hungary in recent years have found that erectile dysfunction affects nearly half a million men. The prevalence is 30% in the 40-49, 50% in the 50-59 and 80% in the over-60 year age groups. Erectile dysfunction means basically inability to penetrate the vagina or maintain sexual intercourse for at least 4-5 minutes.

The possible reasons for erectile dysfunction include all of the following: 

Somatic disorders

• Cardiovascular disorders (heart problems, stroke, high blood pressure, high cholesterol level)
• Diabetes
• Nervous system disorders
• Side effects of other drugs (some blood pressure drugs, antipsychotics, antidepressants, some tranquilisers)
• Low level of male hormone production

Lifestyle risk factors for erectile dysfunction

• Heavy drinking
• Exercise-poor lifestyle
• High body weight (overweight, obesity)
• Smokin

Psychic risk factors for erectile dysfunction

• Stress, fears, anxiety
• Compulsion to perform
• Depression
• Partner relationship problems

As a first step in determining the causes of erectile dysfunction, it is advisable to ascertain whether the man has night-time erections, during sleep. This can be checked in a sleep laboratory using an instrument with special circumference-measurement band placed on the penis for the sleeping time and this register when there is an erection. (In Hungary, this band is often replaced by a strip of small stamps which break along the perforations when there is an erection.) The occurrence of night-time erections proves that the erectile dysfunction is not of biological origin. In this case what is needed is not drug treatment but psychotherapy (couples therapy, cognitive behavioural-based sexual therapy) or counselling.

The situation is similar with the premature ejaculation which is frequent among young men, for which drug treatment is rare (indeed can be harmful). The reason here is usually bad conditioning, often through hurried masturbation, and this persists in the partner relationship. The solution is therefore deliberate conditioning to slow down stimulation and learn to delay orgasm and ejaculation. For this, it is advisable to omit sexual intercourse for a while and practice retarding with modes of stimulation which are easier to control. Another orgasm dysfunction which occurs more rarely in men is difficulty or inability to achieve orgasm in intercourse. Organic causes can be easily excluded if there is no problem in other ways, like petting or masturbation, and the psychic causes must be explored.

Women’s sexual problems are mostly linked to the fact that orgasm is not something that appears by itself in adolescence, as with boys, but has to be learnt and developed (which happens most simply and surely by masturbation). Even nowadays, this is not usually pointed out to them by anybody, and many expect bliss “automatically” from their partners and a loving marriage.

Men, however, are usually unaware if women are “disadvantaged” in their lack of orgasm capability, and immediately aim for intercourse, in which women, who are otherwise mature but have a weaker orgasm capability, find it much more difficult to achieve orgasm than by direct clitoral stimulation. (Especially if foreplay and intercourse together only last a few minutes.) This is why a great many women remain unsatisfied in ordinary sexual intercourse, and if they do not dare to admit this and do not discuss it immediately with their partners, they may be tempted to fake orgasm, to simulate the experience. This only aggravates the sexual problem. But if a woman’s lack of orgasm (anorgasmia) occurs only in intercourse, then it cannot be regarded as pathological in any sense (unlike the false beliefs of early psychoanalysis).

It is important to know that there are many similarities in the sexual reactions of men and women. As sexology developed during the 20th century, and particularly in the classic laboratory experiments by Masters and Johnson, it was found that the sexual reactions of both sexes fall into four phases: 1. Excitement, 2. Plateau, 3. Orgasm, 4. Resolution. The orgasm – the climax of pleasure – is from a physiological viewpoint a reflex-like phenomenon: spontaneous muscle contractions around the urinary tract, or in the lower third of the vagina, at the climax of sexual excitement. In men, it is usually accompanied by ejaculation, although research in recent decades had found that women can also have secretions from the urinary tract as a result of stimulation of the G-zone. (The G-zone is named after its first observer, Gräfenberg.) The explanation of the phenomenon is that the female urinary tract passes beside, and in parallel with, the vagina, and so can be stimulated via the front wall of the vagina. In response to this, the wall of the urinary tract swells just like the clitoris and the lips and vasocongestion causes a few little glands to secrete fluid which passes into the urinary tract and is ejected in the spasms of the orgasm reflex. Studies have proved that this secretion is unrelated to urine (although many people mistake it for that), and its composition is more like semen (naturally without the sperm). Not every woman displays this feature, but it is important to mention because it is also mistaken for a sexual dysfunction or “wetting oneself”. Explanation of the phenomenon can be very reassuring for women.

Women’s sexual dysfunctions, like men’s, can be traced to biological, psychological and sociocultural causes. The biological causes include diabetes, various neurological conditions, side effects of some medicines and psychotropic drugs, and hormonal changes related to menses or menopause. Psychological causes can be childhood trauma (e.g. sexual abuse), partner-relationship conflicts or estrangement, and sociocultural causes include over-strict, conservative, anti-sexual upbringing that results in ignorance, false beliefs and severe inhibitions, and revulsion from, or fear of, sex. Such women do not desire and mostly do not enjoy sex. In medical jargon, this is known as libido deficit or hypoactive sexual desire, and various studies have found it to occur in 20-30% of women. In the extreme case it can degenerate into sexual aversion.

Pain in sexual intercourse – dispareunia – and vaginismus, can have both physical and/or mental origins. Any somatic causes of dispareunia can easily be excluded by a gynaecological examination. A negative result strongly implies mental causes: if the woman fears that intercourse will be painful or there will be other unpleasant consequences, then the vagina remains dry and causes painful friction (dispareunia) or the vaginal muscles go into spasm and resist penetration by the penis (vaginismus). This is unpleasant for both partners, but with another form of stimulation and omission of penetration, the woman is also capable of orgasm. In such cases, therefore couples are advised to set aside coitus-centrism and practise “petting” and gradual relaxation of the vaginal muscles (“Kegel exercises”).

The discussion of sexual problems must in every case include clarifying misunderstandings and providing information on possible sources of dysfunction. We must also talk about what couples can do to ensure normal functioning, the need to be calm in mind and body so as to “get in the mood” and to avoid straining. To reduce stress, the therapist can recommend various relaxation exercises (which are often used in sexual therapy in general). In counselling, it is worth pointing out to clients that if either party detects the other is straining any sexual act, they should stop their partner and talk about it, so that and love-making can continue playfully, in a relaxed mood, without straining.

The most important factor – indeed a precondition – for solving problems and also in developing sexual relationships is absolute trust and honesty towards each other, and talking in detail about sexual wishes and worries. The primary task of the doctor is therefore to assist in this – by encouragement, reinforcement and providing an example of communication during the discussion of sexual issues.

Difficulties and dysfunctions are not restricted to sexual behaviour in the narrow sense, i.e. erotic behaviour, and can show up in starting and raising a family, and also in social gender roles. These are all of course closely interlinked, because for example differences of opinion surrounding having children or inability to fertilise or conceive, i.e. sterility, can severely endanger the emotional-erotic harmony of a sexual relationship. It is known from many studies that such problems have more than merely organic causes, and can stem from psychic factors which can necessitate psychotherapy.

It was pointed out that human sexual behaviour is not instinctive, but influenced by circumstances, sociocultural factors, age, lifestyle and various stimuli, i.e. it is learned. The dysfunctions that develop in an individual’s psychosexual development can be solved if we are capable of discussing them with sufficient knowledge and honesty. This requires some training and communication ability, the main factors in which were presented in the chapter.

Through a medical interview, it is possible to discover sexual problems, and correct false ideas, if we talk with the patient alone, take proper account of the still-persisting sexual taboo and the inhibiting effects of other circumstances, and make use of active listening, auxiliary questions and leading questions. If insufficient time is available, shorter discussions can also be effective if repeated on several occasions, where possible involving the patient’s partner, because the problem is shared and the solution demands the partner’s cooperation. It was also mentioned that modern sexual therapy is psychosomatic-oriented and does not depend purely on medication and invasive procedures.

In more complex cases, it is definitely advisable to involve professionals who are more experienced in sexual therapy, and possible refer the patient to them. Literature on the subject written in plain language, attitude-forming information and self-help advice can also often be of help to patients.

Review questions 

·        What is required for unimpaired sexual behaviour?

·        What are the most common forms of sexual dysfunction among men and women?

·        What are the main principles of the medical interview about sexual problems?

·        What kind of therapy should be preferred for sexual dysfunction?

·        How can willingness to solve sexual problems be raised?

·        What does the WHO recommend to provide sexual health?

Appendix 

World Association for Sexual Health

Declaration of Sexual Rights

Sexuality is an integral part of the personality of every human being. Its full development depends upon the satisfaction of basic human needs such as the desire for contact, intimacy, emotional expression, pleasure, tenderness and love. Sexuality is constructed through the interaction between the individual and social structures. Full development of sexuality is essential for individual, interpersonal, and societal well being. Sexual rights are universal human rights based on the inherent freedom, dignity, and equality of all human beings. Since health is a fundamental human right, so must sexual health be a basic human right. In order to assure that human beings and societies develop healthy sexuality, the following sexual rights must be recognized, promoted, respected, and defended by all societies through all means. Sexual health is the result of an environment that recognizes, respects and exercises these sexual rights.

1. The right to sexual freedom. Sexual freedom encompasses the possibility for individuals to express their full sexual potential. However, this excludes all forms of sexual coercion, exploitation and abuse at any time and situations in life.

2. The right to sexual autonomy, sexual integrity, and safety of the sexual body. This right involves the ability to make autonomous decisions about one's sexual life within a context of one's own personal and social ethics. It also encompasses control and enjoyment of our own bodies free from torture, mutilation and violence of any sort.

3. The right to sexual privacy. This involves the right for individual decisions and behaviors about intimacy as long as they do not intrude on the sexual rights of others.

4. The right to sexual equity. This refers to freedom from all forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability.

5. The right to sexual pleasure. Sexual pleasure, including autoeroticism, is a source of physical, psychological, intellectual and spiritual well being.

6. The right to emotional sexual expression. Sexual expression is more than erotic pleasure or sexual acts. Individuals have a right to express their sexuality through communication, touch, emotional expression and love.

7. The right to sexually associate freely. This means the possibility to marry or not, to divorce, and to establish other types of responsible sexual associations.

8. The right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation.

9. The right to sexual information based upon scientific inquiry. This right implies that sexual information should be generated through the process of unencumbered and yet scientifically ethical inquiry, and disseminated in appropriate ways at all societal levels.

10. The right to comprehensive sexuality education. This is a lifelong process from birth throughout the life cycle and should involve all social institutions.

11. The right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders. 

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