Nia Pryde

Dr. Judith Longstaff

MSc, Dip. Psychother.

Lecturer in Clinical Psychology,
Department of Psychology,

MB ChB, MRCP.
Deputy Head,
Department of Medicine,
United Christian Hospital,

University of Hong Kong,

Common Psychosexual
Disorders : Presentation
And Management

Summary

Problems With Desire

The major psychosexual disorders are

examined with respect to presentation
characteristics and principles of management. Psychological and relationship factors
are emphasised in causation and treatment.
Conclusions may be drawn by the GP, who
may wish to participate in treatment, in
suitable cases, or refer when the problem
is more complex.

In Men (Absence of Sex Drive) and Women

(Frigidity)

Introduction
During the last decade effective, shortterm treatment of the major psychosexual
disorders has become a reality. For the
general practitioner, who seeks to provide
developing standards of patient-care, this
may bring new expectations and responsibilities, for which he or she may feel illequipped by virtue of training.
In this paper we will be considering
the main categories of dysfunction, in terms
of established characteristics and principles
of treatment. It is hoped that this outline
will provide a source of information to the
GP, who may wish to participate in aspects
of management, in suitable cases, or refer
when special expertise is required.
Psychological and relationship aspects of
aetiology will be considered first on account
of their prominence as causative factors. The
discussion will, again, be limited to
heterosexual problems in couples.
Classification of psychosexual disorders
is, broadly speaking, either by function (eg.
erectile impotence, premature ejaculation)
or by phase (e.g. desire, excitement, orgasm)
affected. A simplified representation of
the main disorders, with outlines of treatment, is presented in Table 1.
The Hong Kong Practitioner, July 1982

Psychosexual dysfunction in the area of

'desire', 'arousal', or 'feelings' is more
frequently recognised in women than in
men, although it is actually quite common in
both sexes. In men, problems with desire'are
sometimes confused with impotence. So
far as women are concerned, it is probably
the most frequently reported psychosexual
symptom.
The disorder may be characterised as
'hypoactivity' or 'inhibition' of sexual
desire.1 The man or woman concerned
loses interest in sexual matters, as though
their sexual circuits had been 'shut down'.
Some of the people affected refuse to engage
in sex and avoid sexual situations, even to
the extent of developing a phobic avoidance.
Others will participate, but for reasons other
than sexual desire, for example, to avoid
offending their partner.

Aetiology
Psychological and relationship factors
Anxiety and conflict over sex are
prominent and may be deep-seated. Sexual
feelings and desires are unconsciously
suppressed and avoided.
The
marital relationship is often
discordant. Hostility towards the partner is
frequently
noted and there may be
particular problems over communication and
intimacy.
Inadequate stimulation may be a
feature, particularly in relation to women.
Depression and stress may also play a part.
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Common Psychosexual
Disorders : Presentation
And Management

Physical factors
These are less frequently found in
women than men. Causes include drugs
(for
example, hormonal
medication),
hormonal changes and physical illness.

Treatment
The object is to modify the client's
tendency to inhibit erotic responses, thus
allowing the natural emergence of these
feelings. This normally requires that some
insight is gained into the causes, particularly
underlying sexual conflicts and relationship
problems.
Initially, the client and partner engage
in sensual pleasuring exercises. If anxiety is
severe, less intimate experiences may be
prescribed first, such as, holding hands, or
taking a bath together. When a favourable,
sensual response begins to occur, the couple
proceed to genital caressing and, eventually,
non-demand coitus (gentle penetration
without aiming at 'satisfaction'), which
focuses on pleasurable stimulation of the
problem partner and is under his or her
control.
Open communication with the spouse
about sexual feelings is encouraged. Erotic
stimuli, such as films or books, may be used
to augment the sensual experience.

Unconscious conflicts and resistances,

which frequently begin to appear during
the course of treatment, require specific
attention and discussion. Focus on the
general quality of the emotional interaction
between the couple is important, also the
resolution of particular problems in the
relationship.
The Hong Kong Practitioner, July 1982

In cases where anxiety and avoidance is

marked, it may be necessary to deal with the
phobic element first, by means of anxietyreduction procedures.
Unfortunately, desire dysfunction tends
to have the poorest prognosis of the problems considered here, and may require
more prolonged treatment in order to effect
a satisfactory improvement.

Problems With Entry

In Men (Impotence)
Erectile dysfunction, or impotence,
has been defined as "a persistent
inability to obtain a sufficiently firm
erection, or to maintain this during
intromission and intercourse" (Jehu).2
It is termed 'primary' if erection has
never occurred, and 'secondary' if there
is loss of potency following a period of
normal
functioning.
Impairment
of
erection may or may not be accompanied
by other sexual difficulties, such as, lack
of desire, or inability to ejaculate. It may
also, in common with other dysfunctions,
occur in certain circumstances and not
others, for example, with a particular
partner.
The incidence of impotence rises
gradually with age. Primary impotence
is less common than secondary. The
experience
of
occasional,
transient
incapacity (perhaps in relation to tiredness,
stress, or illness) is quite common, and need
not constitute a problem, as such.

Aetiology
Psychological and relationship factors
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Common Psychosexual
Disorders: Presentation
And Management

'Performance anxiety', in general, and

fear of failure, in particular, are considered
to be highly significant factors. These may
be associated with a range of deeper causes,
including conflict over sexual pleasure and
success. Phobia of the female genitalia may
also be a feature.
Destructive interactions between the
man and his partner are often important,
particularly when the response to his
difficulty is one of criticism and anger.
Physical factors
These are rare in primary impotence
and relatively uncommon in secondary
impotence. However, a thorough medical
history and examination is important.
Physical factors include
hormonal,
neurological and vascular disorders, stress,
fatigue and debilitating illness. Drugs,
such as narcotics, alcohol, oestrogenic and'
hypertensive medication may be implicated,
also local disease (e.g. of the penis).

Treatment
The aim is to enhance stimulating aspects
of the sexual interaction, whilst diminishing
anxiety, particularly in relation to 'performance' and 'failure'.
Initially, both coitus and ejaculation are
prohibited. Non-demand sensual pleasuring
is instituted, extending to include gentle
stimulation of the man's genital area. When
incipient erection-responses begin to occur,
the partner proceeds to stimulate the penis
directly, and stop by turn, allowing the
erection to come and go (Masters and
Johnson call this 'teasing'), until the man
The Hong Kong Practitioner, July 1982

begins to experience some confidence in

his ability to recover it again after 'loss'.
The couple move on to brief intromission with the woman on top, moving in an
undemanding way (this permits the man to
relax and concentrate on his own feelings),
then to ejaculation in this position, followed
by the same with the man on top.
The man is encouraged, throughout, to
focus on his own needs and feelings, and
go at his own pace. The tendency to
obsessive thoughts and self-observation
may be dealt with by means of distraction
techniques, for example, the use of favourite
sexual fantasies. Interpersonal problems,
specific anxieties arising and resistances may
also require attention during treatment.
Other procedures employed include the
use of vibrators, drug treatment (eg.
testosterone), which is controversial, and
prosthetic implants, when all else fails.
Desensitisation of anxiety (individual and
group) and training in assertiveness have
also been used.
The success rate for the treatment of
impotence is approximately 60% overall,
with a better prognosis for simple secondary
(about 80%) than for primary impotence, or
where there are more severe conflicts
underlying.

In Women (Dyspareunia

and

Vaginismus)

Entry difficulties in woman generally

involve the experience of pain, as in
dyspareunia,
and/or
the
involuntary
constriction of the vaginal passage, as in
vaginismus.
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Common Psychosexual
Disorders : Presentation
And Management

Dyspareunia
Dyspareunia refers to the experience of
pain on intercourse in the vaginal entrance
or passage, clitoris, or internal pelvic organs.
It may be associated with other sexual
difficulties, such as lack of interest and
arousal.
Since organic factors may be relevant
with this disorder, a detailed gynaecological
history and examination is important.

Aetiology
Psychological and relationship factors
General psychological factors include
miscellaneous stresses and partner discord.
Anticipation of pain arising from past
experience (when physical factors were
present) is also important. Underlying sexual
conflict undoubtedly plays a part in a
number of cases.

Physical factors
Pain at the entrance to the vagina
may be due to, for example, problems
with the hymen, tender
scars and
vaginismus. Causes of clitoral pain include
lesions, scar tissue, and excessive manual
stimulation.
Pain or irritation in the vaginal passage
can arise from insufficient lubrication, (for
instance, if penetration is occurring before
the woman is aroused), atrophic vaginitis,
infection, or allergic reactions (e.g. vaginal
chemical contraceptives, feminine hygiene
sprays). When pelvic pain occurs, infections,
tumours, endemetriosis and scar tissue
may be the cause, also vasocongestion due to
prolonged stimulation without orgasmic
release.
The Hong Kong Practitioner, July 1982

Vaginismus
Vaginismus is a relatively rare condition,
which is characterised by
involuntary
contraction of the muscles at the vaginal
inlet whenever an attempt is made to
introduce an object into the vagina. This,
effectively, prevents sexual intercourse (also
gynaecological examination) and attempts
at entry may cause considerable pain. When
it is severe, it can result in an unconsummated marriage of considerable duration.
In addition to the muscle spasm, there
may be fear of penetration and coitus,
amounting to phobic avoidance: Inhibition
of desire or orgasm may or may not be a
feature. Many of these women are, in fact,
fully responsive to sexual stimulation, so
long as it does not lead to intercourse.

Aetiology
Psychological and relationship factors
There is some agreement that vaginismus
is a conditioned response, which probably
arises from the association of pain or fear
with attempts or even fantasies, of penetration3. The original unpleasant stimulus may
have been physical or psychological.
Specific
traumatic
experiences include
vaginal examination, catheterisation, sexual
assault, or distressing first attempts at
intercourse.
Guilt, conflict and anxiety over sex may
be contributing factors, also hostility to
the partner and sexual ignorance. Spouses
may be collusive (for example, overly
considerate).

Physical factors
Anything

which

causes

pain

on
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Common Psychosexual
Disorders : Presentation
And Management

intercourse may result in the conditioned

response of spasm. Although the condition
may no longer exist, the woman continues
to respond as if it did.

Problems With Orgasm

In Men (Premature and Retarded Ejaculation)
Premature Ejaculation

Treatment
Physical causes of pain should always be
investigated and treated first. When the
aetiology is psychosomatic, as it often is, the
condition should be dealt with psychotherapeutically.
If phobic avoidance of entry is present,
this must be tackled at the outset, for
example, by systematic desensitisation (the
woman is required to relax, then to visualise
varyinq degrees of penetration, until it
becomes less threatening to her).
When vaginal muscle spasm (vaginismus)
is present, the treatment focus is on
eliminating the spasm by progressive deconditioning. This, normally, involves the
progressive insertion into the vagina of
graduated vaginal catheters (fingers may be
used as an alternative), whilst the woman is
relaxing, which may be carried out by the
husband, the therapist, or the woman
herself. In this way, the involuntary contraction loses strength and the woman sees
that intercourse is possible.
When the larger catheters can be
tolerated, insertion of the penis is attempted, under her guidance, initially without
thrusting. Later, normal movements are
allowed.
Vaginismus is one of the most rewarding
problems to treat. Rates of cure are sometimes quoted at 100%.
The Hong Kong Practitioner, July 1982

Premature ejaculation is probably the

commonest of the male sexual disorders.
Different criteria of 'prematurity' prevail,
defining it by the length of time between
entry and ejaculation, the number of thrusts,
or the satisfaction of the partner. The
crucial aspect, however, appears to be the
absence
of
voluntary
control
over
ejaculation.
The pattern of prematurity is usually
found to have existed from the outset of
sexual experience but, in some cases, there
is a late onset, often associated with erectile
incapacity.
Aetiology
Psychological and relationship factors
Failure to perceive erotic sensations
just prior to orgasm is considered to
be significant probably arising as a result
of anxiety and conflict over sexuality and
sexual pleasure. Performance anxiety may
also be important.
Relationship difficulties can be relevant,
and responses of impatience and anger by
the partner may compound the problem
further. Unconscious hostility towards the
partner, or women in general, may be a
feature. Early, rushed sexual experiences can
also contribute.
Physical factors
These are rarely involved, but should be
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Common Psychosexual
Disorders : Presentation
And Management

investigated when there is a later, acute

onset,
for
example,
urological
or
neurological systems may be involved.
Treatment
Treatment focuses on developing voluntary control over ejaculation, by enabling
the client to discern and tolerate the
sensations preceding ejaculation.
Therapy normally begins with sensual
foreplay, including direct stimulation of
the penis. When the man indicates that
he is nearing climax his partner, either,
stops stimulating him ('stop-start' method),
or squeezes the penile shaft between finger
and thumb ('squeeze' technique) until the
sensation disappears. The procedure is
repeated several times (during which the
man makes no attempt at conscious control)
until, finally, orgasm is permitted.
Once improvement in control has been
experienced with manual stimulation, the
stop-start procedure is continued intravaginally, with the woman on top, moving
and stopping, by turn. When control has
been gained in this way, the man is
instructed to thrust. Subsequently, stopstart coitus continues on the side, then
with the man on top, changing finally to
a stop-slow format.
Once again, interpersonal issues and
unconscious resistances may require attention. Group treatment has also proved useful
with this disorder.
Overall, the cure rate is about 90%.
Retarded Ejaculation
Retarded ejaculation (also known as
The Hong Kong Practitioner, July 1982

ejaculation incompetence) is a relatively

uncommon problem in men, in which
ejaculation fails to occur, or is retarded,
whilst erections are unimpaired. Although
unable to ejaculate in coitus, the man can
often succeed with manual or oral
stimulation. When unable to ejaculate under
any circumstances, the condition is termed
'absolute'.
The symptom may have been present
from the outset of sexual functioning, or
follow a period of normal activity. If
untreated it can lead to impotence.
Aetiology
Psychological and relationship factors
The basis to the disorder appears to
be an unconscious (conditioned) inhibition
of the ejaculatory reflex, resulting from
its association, in, the past, with traumatic
factors (such as punishment for sexual
activity). Inadequate penile stimulation and
excessive self-observation during arousal
may also be significant issues.
Unconscious fear and sexual conflicts
are believed to play a part, also hostility
(which may be suppressed) and lack of trust
in relation to women. Partner discord may
be implicated.
Physical factors
Physical factors are uncommon, but may
include neurological disease and drugs.
Treatment
The aim is to identify and manipulate
inhibitory factors, whilst building on existing ejaculatory capacity.
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Common Psychosexual
Disorders : Presentation
And Management

The couple first engage in sensual touching, after which the man ejaculates under
whatever circumstances are possible for him
eg. masturbating alone. Subsequently, he
progresses to 'self-stimulation in the partner's presence, then 'stimulation by the
partner, and, eventually, insertion of the
penis into'the vagina close to the moment
of orgasm. Finally, normal coitus resumes,
with the partner supplying additional
stimulation to the penis-base, until it is
no longer required.

lation (some need more direct and prolonged

stimulation than others to climax), adequacy
of sexual technique is always an important
consideration.. It may be noted, in this
connection, that most women have achieved
orgasm, by some means, after 5 years of
marriage, although not on every occasion of
coitus.

If the client has never ejaculated, the

initial aim is to have him first experience
orgasm on his own, by means of intense selfstimulation, perhaps combined with distracting erotic imagery.

The essential pathology appears to be

the involuntary inhibition of the orgasmic
reflex, which may represent a kind of
'over-control' in response to anxiety.
Obsessive 'self-observation ' is often a
contributing factor.

Concurrent psychotherapeutic sessions

serve to foster insight into anxieties, resistances and interpersonal issues that maybe
reinforcing the inhibition. Other procedures
employed include anxiety-reduction and
imaginary rehearsal techniques, and the
use of a vibrator.
The success rate varies with the severity
but may be as high as 80%. Clients who
have never ejaculated are generally regarded
more pessimistically.

Aetiology
Psychological and relationship factors

Inadequate stimulation may be a

significant issue, particularly if the partner
lacks knowledge of a woman's anatomy and
sexual response. Unconscious conflicts and
fear of loss of control may be implicated in
addition, also partner discord.

Physical factors
If intercourse is painful for any reason,
orgasmic capacity may be impaired.

In Women (Orgasmic Dysfunction)

With orgasmic difficulties in women,
orgasm either occurs infrequently in coitus,
or not at all. Some are, in addition, unable
to climax under any circumstance, for
instance, in masturbation. Desire and arousal
may be affected but, normally, only
secondarily.
Although there is a wide range of
response amongst women to sexual stimu-

The Hong Kong Practitioner, July 1982

Treatment
The aim is to reduce involuntary overcontrol of the orgasmic reflex, by diminishing inhibitory factors, whilst fostering
abandonment to erotic feelings. This is
achieved by building on orgasmic capacity,
under conditions of effective clitoral
stimulation.

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Common Psychosexual
Disorders : Presentation
And Management

The couple.first engage in sensual touching, after which the woman stimulates herself to orgasm under circumstances of her
choice (eg. alone). Self stimulation to
orgasm is next transferred to the partner's
presence, followed by stimulation by the
partner. Non-demand coitus follows, in
which the woman is instructed to be 'selfish'
and to surrender to her sensations. Clitoral
stimulation may be employed simultaneously as many women need more intense (e.g.
manual) stimulation during coitus than is
provided by thrusting alone.
When inadequate stimulation is suspected, information regarding sexual technique,
particularly clitoral stimulation, is an important preliminary. If the client is totally
anorgasmic the initial aim is to have her
first experience orgasm when she is alone, by
means of instructions in self-stimulation,
combined with the use of a vibrator, if
necessary, and erotic material (e.g. fantasy)
to distract.
Psychological and relationship conflicts
may be attended to concomitantly.
Approximately 90% of women in
this category are able to attain orgasm
during intercourse after treatment.
Other Psychosexual Presentations
Apart from the main disorders which
have been described, other psychosexual
problems which occur include complaints
of pain on intercourse in men, and sexual
phobias.
Psychosexual dysfunction may appear
in combination with other pathological
phenomena, such as psychiatric problems,
physical illness, or perverse sexual practices
(e.g. transvestism). It can also occur in
The Hong Kong Practitioner, July 1 982

both partners simultaneously, for example,

premature ejaculation and female orgasmic
dysfunction.
Chinese Cultural Syndromes
Cultural factors may be represented in
the kinds of problems that prevail in
different settings. Koro, for example,
which is a condition characterised by acute
anxiety and delusion of penile retraction,
is believed to be peculiar to the Chinese in
Asia. It appears to be related to folk belief
about the grievous consequences of
masturbation.4
Attitudes to sexuality and to sexual
symptoms may also vary in the cultural
context. One study, in this connection,
noted a decline in sexual interest in Chinese
men with renal failure, apparently as a result
of popular belief that the kidney is an
important sexual organ.5 Another study
found that Chinese men with retarded
ejaculation considered their dysfunction
more of an asset than a complaint, in line
with traditional ideas about the desirability
of conserving semen.6
Conclusion
A number of common psychosexual
disorders have been considered and
principles' of management outlined. Some
aspects of these problems the GP may wish
to handle him or herself. Referral for
specialist treatment is advised, however, if
the problem is severe, or longstanding, or if
there are deeper psychological and relationship difficulties involved.

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Common Psychosexual
Disorders: Presentation
And Management

Table I
Major Psychosexual Disorders and Principles of Management
Problems of

Male

Female
DEFECIT FEMALE
SEXUAL RESPONSE
Frigidity

DESIRE

DEFECIT MALE
SEXUAL RESPONSE
Absence of sex drive

Management:

i. An attempt is made to create a situation which reduces anxiety and inhibition

and promotes pleasure ie. a relaxed and sensual setting in which the sexual
response can begin to manifest itself naturally, without the demand to
'perform',
ii. Sensual and erotic experiences are prescribed, leading to non-demand coitus,
iii. Attention is given to the general quality of the relationship, particularly the
emotional interaction.

ENTRY

Management:

ERECTION DIFFICULTIES
Impotence

i. The situation is manipulated so as

to
enhance stimulation and
diminish anxiety,
ii. Intercourse is initially banned,
combined with exposure to 'teasing', erotic stimulation,
iii. The erection-response, when it
begins to occur, is gradually
shaped towards the act of
intercourse.

ORGASM

EJACULATORY DIFFICULTIES
A. Premature ejaculation

Management:

i. Learning of voluntary control is

facilitated by increasing awareness
and tolerance of pre-orgasmic
sensation,
ii. Controlled response learned with
manual stimulation is gradually
shaped
towards
normal
intercourse.
B. Retarded ejaculation

Management:

ENTRY DIFFICULTIES
a) Dyspareunia
b) Vaginismus
i. Physical causes are treated first.
ii. Attention is paid to any phobic
element.
iii. Physical inhibition and avoidance
is progressively deconditioned.
iv. The vagina is dilated, in graduated
steps, leading to penile insertion
under the client's control.
ORGASMIC DIFFICULTIES

Orgasmic Dysfunction

i. Inhibitory factors are identified and modified whilst abandonment to erotic

feelings is fostered,
ii. Attention is paid to adequate stimulation under relaxed conditions,
iii. The orgasmic response, such as it is, is built upon towards its occurrence in
intercourse.

The Hong Kong Practitioner, July 1982

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Common Psychosexual

A cknowledgements
We wish to thank Dr. D.Y.F. Ho and Dr,
M.L. Ng for information relating to cultural
aspects.

' ' : '***"

,MtpX^;|^ft;^fe

3.

Kaplan HS. The new sex therapy: a c t i v e

treatment of sexual dysfunctions, B r u n n e r /
Mazel, 1974.

4.

Yap PM. Koro ~ a c u l t u r e - b o u n d depersonalization syndrome. Br J Psychiatry

1965; 111:43-50.

5.

Ng KL, Kung YT, Hua SP. Sexual f u n c t i o n i n g

of Chinese patients with chronic renal failure.
Presented at the World Psychiatric Association
Meeting; New York, Nov. 1981.

6.

Lieh-Mak F, Ng ML. F j a c u l a t o r y i n c o m petence in Chinese men. Am J Psychiatry

1981: 138; 5: 685-86.

Further Reading
\.

M u n j a c k D, Oziel Li. Sexual medicine and

counselling in office practice, a comprehensive t r e a t m e n t guide. Boston: L i t t l e .
Brown & Co., 1980

2.

K a p l a n HS. The new sex t h e r a p y , op. cit.

3.

Belliveau F. Richter L. U n d e r s t a n d i n g h u m a n
sexual inadequacy. Coronet Books, 1 9 7 1 .

4.

Chang J. The tao of love and sex: the ancient

Chinese way to ecstasy. New York: Dutton,
1977.

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