Robert Taylor Segraves
The differential diagnosis and treatment of sexual disorders in women is complicated because of their diverse and often interactive biologic, psychologic, and interpersonal etiologies. Few physicians are qualified to be the sole providers of sexual medicine services to female patients with sexual dysfunction, as the requisite knowledge base extends across medical specialty boundaries (see Chapter 17.6 of this book). The ideal solution is a multidisciplinary team approach to diagnosis and treatment, although anomalies in insurance coverage may make this approach difficult to implement in many settings. The treatment team needs to involve a clinician skilled in assessing psychologic aspects of sexual behavior, as the full impact of psychologic and interpersonal forces on female sexuality may not always be fully appreciated by physicians from many specialties. This chapter will focus specifically on how most psychiatrists would approach the diagnosis and treatment of sexual disorders to illustrate what a psychiatric referral or consult might provide. It is important to emphasize that not all psychiatrists are interested in treating or knowledgeable about human sexuality. It is important to select someone with expertise in this area. As well as providing an understanding of the psychologic factors influencing human behavior, the psychiatrist also has expertise in the effects of various psychiatric disorders and their treatment on sexual dysfunction.
The specific contribution of the psychiatric clinician is to broaden the diagnostic and treatment options to include psychiatric and psychosocial etiologies and interventions. In particular, the psychiatrist should be able to recognize and treat female sexual dysfunction secondary to other psychiatric syndromes or secondary to psychopharmacologic interventions, as well as problems related to couple dynamics and individual psychopathology. Similarly, the psychiatrist should be able to target interventions based on the etiologic factors identified. Treatment may include changing medication, treating underlying syndromes, couple psychotherapy, individual psychotherapy, or targeted behavioral therapy (see Chapters 11.1-11.5 and 16.2). In this chapter, the psychiatric approach to diagnosis and treatment of female sexual disorders will be summarized.
The major instrument in psychiatric assessment is the psychiatric interview. The psychiatric interview is central to all psychiatric care and is of the same importance to the psychiatrist as the physical examination to physicians in many other specialties.1 In sexual disorders, a multidimensional assessment is important.2 Each dimension will offer a different perspective from which to view the problem and plan possible interventions. Realizing that many sexual problems have multiple interactive etiologies, the clinician will attempt to identify the most easily correctable factor.3
The primary component will be the differential diagnosis, which will be based on a detailed understanding of the primary complaint, its onset and course, and its relationship to other medical events and to environmental factors. The primary complaint will be classified as global or situational, lifelong, or acquired. These subtypes will help to provide tentative hypotheses as to whether the complaint has a predominantly biologic or psychogenic etiology, and whether it is related to a major psychiatric syndrome or is drug induced. If the problem appears related to a major psychiatric syndrome, it is usually treated first to see whether the sexual complaint will resolve as well.
The next dimension of assessment, particularly if the etiology is hypothesized to be psychogenic, is to examine couple dynamics. As well as overt discord, one may observe that one partner subtly prevents his or her partner from recovering. This diagnosis may be based on a careful assessment of antecedents and consequences of sexual behavior. In these cases, conjoint behavioral psychotherapy with a particular focus on couple dynamics might be the intervention of choice. For example, the author treated a recently married woman with a complaint of low sexual desire in conjoint behavioral psychotherapy. As the woman became increasingly more comfortable in experiencing her own sexual feelings, her husband became increasingly emotionally distant. His withdrawal dampened his wife’s sexual interest. Once the therapist was able to help the husband be comfortable with his wife’s experience of her own sexuality, she was then able to experience a heightened awareness of her own libido.
A third factor in assessment is individual personality traits. If the patient has difficulty with trust and control in interpersonal interactions, it is likely that these issues will also affect her experience of sexual activities, as many behaviors appear to be consistent across different interpersonal settings. These issues may require targeted individual educative psychotherapy as well as behavioral interventions. In this regard, it is of note that the major effect of childhood sexual abuse on women in midlife appears to be on the quality of relationships with the partner rather than on sexual function per se.4 The effects of incest on sexual behavior are reviewed in more detail in Chapter 3.4.
A fourth perspective is the individual’s sexual life story.5 The patient will reveal a sexual narrative in which the inner symbolic meaning and cultural significance of sexual behavior to her are revealed. This information may be utilized in individual psychotherapy or kept in mind as one proceeds with targeted behavioral therapy.
Disorders commonly treated by psychiatrists are difficulties with sexual desire and sexual arousal, orgasm problems, and vaginismus uncomplicated by pelvic pain. Most psychiatrists would collaborate closely with a gynecologist for complaints of sexual pain6 (see Chapters 12.1-12.6). The psychiatrist may help in the multidisciplinary evaluation of sexual pain disorders primarily by excluding psychiatric etiologies of the complaint, thereby reinforcing the need to find somatic solutions to the problem. Referral or collaboration with an endocrinologist or gynecologist would be common in issues concerning hormone therapy or androgen augmentation.7
Subsequent sections will review psychiatric syndromes associated with female sexual dysfunction, psychiatric drugs causing sexual dysfunction, a differential diagnostic approach, and psychotherapeutic approaches.
Psychiatric disorders and comorbid female sexual dysfunction
Studies of sexual function in psychiatric patients indicate that female sexual dysfunction is more common in women with a variety of psychiatric disorders.8 High rates of hypoactive sexual desire disorder have also been found in women with anxiety disorders such as panic disorder, obsessive compulsive disorder,9 and post-traumatic stress disorder,10 as well as in anorexia nervosa11 and in schizophrenia.12 In many cases, treatment of the underlying psychiatric disorder may resolve the sexual problem. Thus, it is important that a differential psychiatric assessment be part of the evaluation of female sexual dysfunction. For example, low desire resulting from panic attacks during sexual activity might be misdiagnosed as hypoactive sexual desire disorder. Depression may also present as low libido as part of generalized anhedonia.
Population surveys have found a high concordance of female sexual dysfunction with relationship discord and symptoms of depression and anxiety.13 For decades, clinicians have recognized that decreased libido is part of the symptomatic presentation of depressive disorders.14 Kennedy et al.15 investigated the prevalence of sexual disorders in 79 untreated female patients with major depressive disorder. Fifty percent reported a marked decrease in libido as well as arousal. Another 15% reported difficulty in achieving orgasm. Kivela and Pahkala16 studied depressive symptoms in elderly citizens in Ahtari, Finland. In women aged 60-70, loss of libido was significantly more common in women diagnosed with depression. After the age of 70, loss of libido was common in the entire population and no longer more common in depressed women than in nondepressed cohorts. Psychiatric disorders that have a high comorbidity with sexual disorders are listed in Table 17.3.1.
Table 17.3.1. Psychiatric disorders highly comorbid with hypoactive sexual desire disorder
Effects of psychiatric drugs on female sexual dysfunction
Psychiatric drugs have a high propensity to cause sexual side effects. The most common side effects are orgasmic dysfunction and decreased libido, although there have been some reports of decreased arousal on psychiatric drugs.17 Case reports and even double-blind studies in the 1980s indicated that antidepressants (see Chapter 16.2), benzodiazepines, and antipsychotic drugs cause sexual dysfunction.18 However, the sexual side effects of commonly prescribed psychiatric drugs were not generally appreciated until these drugs had been in general use for a number of years. The reason for the delayed recognition by physicians has been attributed to the fact that most patients do not volunteer this information unless directly asked by their physicians.19
Considerable evidence establishes that most antidepressants cause sexual dysfunction, especially orgasmic delay. Double-blind studies have demonstrated that phenelzine, imipramine,20 clomipramine,21 and most selective serotonin reuptake inhibitors cause orgasmic delay.22
Controlled studies indicate that nefazodone and bupropion have extremely low incidence of sexual side effects.23,24 The sexual side-effect profiles of mirtazapine and venlafaxine are unclear but are probably close to that of the selective serotonin reuptake inhibitors.25,26 Newer antidepressants and the incidence of sexual side effects are listed in Table 17.3.2. It should be emphasized that one needs to know the spectrum of action of antidepressants prior to substituting drugs. For example, selective serotonin reuptake inhibitors may be prescribed for a depressed patient with comorbid obsessive compulsive symptoms, and bupropion is not effective against obsessive compulsive symptoms. In addition to switching drugs, antidotes can be employed. To date, double-blind studies support the efficacy of 60 mg buspirone27 or 150 mg bupropion28 as antidotes. Case reports suggest that sildenafil may reverse selective serotonin reuptake inhibitor-induced anorgasmia in women, but this has never been demonstrated in a doubleblind study.29
Case reports and clinical studies indicate that antipsychotic drugs can cause sexual difficulty, particularly orgasmic delay and decreased libido. This is important as these drugs are increasingly being utilized to augment treatment of affective disorders including major depressive disorder. These difficulties appear to be more pronounced in older antipsychotic drugs (e.g., haloperidol, thioridazine) as well as the new antipsychotic risperidone, all of which are associated with prolactin eleva- tion.3^32 Large case studies suggest that quetiapine and olanzapine have the lowest incidence of sexual side effects in both sexes.33 Switching from an antipsychotic that causes prolactin elevation to a prolactin-sparing antipsychotic has been reported to resolve sexual dysfunction. Dopamine agonists, such as bromocriptine and cabergoline, have also been reported to reverse antipsychotic-induced sexual dysfunction.34,35 The effects of antipsychotic drugs on sexual function are listed in Table 17.3.3.
Other drugs utilized in psychiatric practice, such as lithium carbonate,36 valproate,37 gabapentin,38 and carbamazepine,39 have been reported to cause sexual dysfunction. One controlled study found that diazepam may cause orgasmic delay in adult women.40 There is minimal evidence concerning the prevalence of sexual dysfunction due to these agents.
Table 17.3.2. Sexual side effects and antidepressant therapy
High incidence Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) S-Citalopram (Lexapro)
Intermediate incidence Fluvoxamine (Luvox) Venlafaxine (Effexor) Mirtazapine (Remeron)
Bupropion (Wellbutrin) Nefazodone (Serzone)
Table 17.3.3. Antipsychotic drugs and sexual dysfunction
High incidence Thioridazine (Mellaril) Risperidone (Risperdal) Haloperidol (Haldol)
Possibly intermediate incidence Olanzapine (Zyprexa)
Unknown incidence Ziprasidone (Geodon) Aripiprazole (Ability)
General issues in the evaluation and treatment of female sexual disorder
The treatment of female sexual disorders will be partly determined by the presenting symptoms and partly by the patient’s life story. The life story may reveal difficulties with trust, control, or past sexual trauma which may direct treatment as much as the formal diagnosis. Although there is considerable overlap between different sexual disorders, assignment to a primary diagnostic group while noting associated disorders will usually guide treatment decisions. A careful subtyping by duration and pervasiveness of the disorder may give clues as to etiology. For example, disorders present from the first sexual experience are thought to be related to sexual attitudes learned in the family of origin, whereas acquired disorders may be organic or psychogenic in etiology. Perhaps the most useful subtyping is whether the disorder is generalized to all sexual situations (global) or specific to one situation alone (situational). In general, situational disorders are more likely to be psychogenic in etiology.
If a psychogenic etiology is diagnosed, treatment is usually symptom-oriented and derived from behavioral models with deviations from this approach when necessary. Situations in which treatment might be altered from a symptom-oriented approach present when significant relationship discord exists or when the resolution of a sexual symptom is blocked by the personal meaning of the symptom.
Lifelong low sexual desire
The psychologic treatment of global, lifelong low sexual desire usually consists of various attempts to achieve attitude change if the problem appears to reside in restrictive attitudes about sexual pleasure. A typical patient may be a young female with minimal sexual experience from a home in which there were strong prohibitions against the experience of sexual pleasure. An exploration of the origins of the patient’s sexual attitudes and reflection on whether her family’s attitudes are applicable in independent adult life can help the patient experience less guilt about experiencing sexual pleasure. In individuals who are highly religious, referral to a well-chosen pastoral or rabbinical counselor may help tremendously. In symptom-oriented treatment, the therapist may give the patient homework assignments of reading romantic/erotic material, bodily self-exploration, or visiting erotic art in a local museum or bookstore. The therapist may also assist the patient to develop sexual fantasies. An example would be to give the patient the assignment of first noticing which male in her office she finds most attractive and then to imagine kissing him. These interventions are usually accompanied by sexual homework assignments. Most therapists share the belief that the patient is more likely to have a positive response to therapy if the patient herself desires change rather than desiring to change in order to please her partner.41 A few case reports suggest organic causes for lifelong low libido, but these have not been confirmed in large studies.42,43 One encounters a subset of women with lifelong histories of low sexual desire whose difficulties are not clearly related to psychologic, psychiatric, or interpersonal matters. One often suspects a normal variation in sexual drive of biologic origin. In these cases, experimental approaches such as androgen supplementation, the use of dopaminergic agonists, or the use of bupropion may be considered.44
An alternative viewpoint is that age-related declines in women in long-term relationships is normative. Situational lifelong low libido may reflect an atypical arousal pattern.45 An example would be a woman in a heterosexual relationship who complains of low libido but masturbates by herself on a frequent basis. Underlying factors may be uncovered by examining the patient’s usual masturbatory fantasies. If the patient desires greater sexual pleasure with the partner, she may be asked to change gradually her masturbatory fantasies to include the partner and to change her sexual activity with the partner to resemble the masturbatory fantasy. An examination of the masturbatory fantasies might sometimes reveal that the woman’s primary sexual attraction is to same sex. In such cases, a frank discussion of this with the patient and consideration of the social and financial consequences of living an openly homosexual life can help the patient resolve life choices, although obviously this will not alter the patient’s sexual attraction pattern. Rarely, one encounters a female patient with an alternative sexual arousal pattern (e.g., involving sadomasochistic activities). It is important to remember that para- philic behavior is not always constant and may wax and wane with external stress and relationship discord. Depending on the particular paraphilia, it may be possible to have a conjoint session with both partners to see whether some of their sexual activity can be adapted to include the specific paraphilic behavior which is arousing to the patient.46 In female patients with a history of repeated sexual abuse, decreased libido may be characterized by extreme ambivalence toward any sexual activity that might be interpreted as aggressive. In such cases, psychotherapy may be useful in ameliorating the aversion to sexual activity.47
Acquired hypoactive sexual desire disorder
Acquired hypoactive sexual desire disorder is an extremely common complaint in most medical practices (see Chapter 11.3).48 One first needs to ascertain whether the problem is situational (occurring in one context) or global (occurring in all situations). A clear example of a situational loss of libido would be a woman who has lost interest in sexual activity with her partner but continues to have sexual fantasies about a past lover. Alternatively, the patient could report absence of sexual interest but daily masturbation. In these cases, it is highly likely that the problem is related to interpersonal issues with the partner.49 Conjoint marital therapy is the treatment of choice.
Acquired global loss of desire can be due to a variety of factors. One first tries to rule out causes that can be treated by well-established therapies. Psychiatric disorders to rule out include major depressive disorder, social anxiety, panic disorder, obsessive compulsive disorder, and post-traumatic stress disorder. For these disorders, one would attempt to treat the underlying psychiatric disorder in the hope that it would resolve the problem with libido.50
As mentioned in another section, a number of psychiatric drugs have been reported to be associated with decreased libido. The influence of nonpsychiatric drugs on female libido has been minimally studied. Hypertensive disease and its treatment may be associated with decreased libido.51,52 It appears that angiotensin-converting enzyme inhibitors are less likely to cause libido problems than other antihypertensive agents. There is some evidence that hypothyroidism and hyperprolactinemia are also treatable causes of decreased libido.53 Evidence from numerous studies suggests that oral contraceptives may decrease libido in many women. There is no definitive evidence of which agents are worse.54 Clinically, it seems logical to assume that any agent might cause sexual dysfunction, and always to consider whether the onset of a sexual problem coincided with the introduction of a new agent or with a dose change. It is also reasonable to do a trial of suspected agents to see whether libido returns.
In postmenopausal women, especially post-oophorectomy, decreased libido is common and has been attributed to decreased androgen production,55 although the evidence for beneficial effects of androgen therapy at physiologic levels is unclear.48 In cases involving hormonal therapy, most psychiatrists would collaborate with a gynecologist or endocrinologist.
Female arousal problems
A important differential in diagnostic evaluation is whether the problem is with subjective arousal, physiologic arousal (vaginal lubrication), or both (see Chapter 11.3). A lack of physiologic arousal in the presence of subjective arousal has a high probability of organic etiology. In premenopausal women, arousal problems are frequently associated with diminished libido as well. Although numerous pharmacologic agents have been reported to cause erectile dysfunction, the effects of these agents on female arousal have been little studied.17 A reasonable approach is to assess whether the onset of the arousal difficulty appears to coincide with drug initiation and to do a trial of suspected drugs. Psychiatrists should also inquire about the sexual relationship and whether sufficient foreplay occurs. Many women require continuous stimulation to maintain adequate lubrication. If a woman becomes aware of diminished lubrication, she may become apprehensive about what is happening and begin self-observation, distancing herself from perception of further stimulation. In many cases, the clinician can help the woman become aware of this cycle and gradually retrain her to stop excessive self-observation.
In postmenopausal women, arousal problems are often associated with atrophic vaginitis due to decreased estrogen. The psychiatrist might begin estrogen therapy, although in most cases he or she would seek gynecologic consultation. For women who choose to avoid any form of hormone therapy, various artificial lubricants may be suggested.56
Female orgasmic disorder
Lifelong anorgasmia is relatively common and usually easily treated (see Chapter 11.4). Most often, it reflects relative inexperience combined with some anxiety about experiencing sexual pleasure, although the scenario may be more complex in women with a history of sexual abuse. Most psychiatrists would treat such problems with symptom-oriented therapy, including masturbatory training and systematic desensitization to sexual pleasure. Most women can learn to be orgasmic with masturbation. Occasionally, the use of a vibrator is needed. Once the woman can reliably experience orgasm during masturbation, the therapist usually attempts to integrate masturbatory activities gradually into partner-related activities. Controlled outcome studies indicate that the woman can usually be taught to reach orgasm by self-stimulation. The transfer of that skill to partner related-activities is more problematic.57 Recent research indicates that bupropion enhances orgasmic capacity in women with a diagnosis of global, acquired hypoactive sexual desire disorder.44 It is unclear whether bupropion would be similarly successful in women with a primary orgasmic disorder. A double-blind, placebo-controlled study of bupropion in premenopausal women found that doses of 300-450 mg per day of bupropion had a statistically and clinically significant positive effect on orgasm completion in a sample of women with global, acquired hypoactive sexual desire disorder.
General psychotherapeutic considerations
Evidence-based approaches form the basis of most sexual psychotherapy. These approaches usually involve a series of “homework assignments” of exercises designed to increase sexual intimacy over a period of weeks, with an absolute prohibition against coitus. These behavioral interventions are often referred to as “sensate focus” and provide a way for each partner to focus on sensual pleasure in the absence of performance pressure. As previously mentioned, orgasmic dysfunction usually also involves masturbation training. In the case of vaginismus, dilators of progressive size may be utilized. An alternative approach is to have the patient insert one and then two fingers into her vagina until the muscle spasm subsides. Subsequently, the patient guides her partners’ fingers for insertion and subsequently allows the partner to insert his fingers without assistance. This method can serve to desensitize the patient gradually to the feeling of loss of control.
These targeted behavioral interventions are usually accompanied by individual and/or couple psychotherapy. Couple psychotherapy usually focuses on communication training. Couples are taught how to express, and coached in expressing, their wishes and feelings clearly in the first person without attributing blame. The other partner is taught active listening skills and may be instructed to repeat what he thinks his partner just said. Individual cognitive-behavioral therapy may be utilized to challenge negative attitudes about sexuality and intimate interpersonal relationships.49 Evidence-based psychologic approaches to the female sexual disorders are covered in more detail in earlier chapters.
Because female sexual dysfunction frequently involves psychiatric issues, it is important to include a psychiatric assessment in the evaluation. A multidimensional approach to diagnosis and intervention can offer an orderly and systemic way to assess psychiatric and psychologic factors involved in the etiology and maintenance of sexual problems. Given the complexity of female sexual dysfunction and the limitations of our current knowledge base, multidisciplinary assessment is critical for effective interventions. The psychiatrist offers a distinct biopsychosocial approach to diagnosis and treatment. In addition, the psychiatrist has special expertise in the comorbidity of sexual dysfunction with other psychiatric disorders and their treatment.
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