Clinical review

Warning: This article contains sexually explicit material

Management of sexual problems

Margaret Ramage. 

Editorial by Adler

Sexual problems present in various ways, many indirect or covert. Patients do not like to come straight to the point. They fear looking stupid by using wrong words, or giving offence by being too explicit, or they have no way of conceptualising what it is that is wrong. A doctor can find himself or herself fumbling around in a slightly mad conversation in which nobody understands what is being said. A common language needs to be established first, particularly in sexual medicine, followed by a good history and a careful examination, if appropriate, before an assessment of relevant management can be made. Recurrent gynaecological or urological complaints, insomnia, depression, joint pains, and other symptoms have all been used as covert presentations of sexual problems.

Man, Woman and Fish by Emily Young

Once the presence of a sexual problem has been established, its severity and importance to the patient need to be understood before the most appropriate course of management can be offered. This can vary from straightforward education, by simply giving accurate information, to referral for psychiatric assessment (fortunately very rare). History taking is therefore the paramount skill underpinning decisions about management, along with forming a positive alliance with the patient. Any course of action has to have complete cooperation. Without that, the best treatment in the world may be useless.

	Overall management

Top Overall management Psychological approaches Physical remedies Use of surrogates Referral onwards

It is worth bearing in mind that, however obviously physical the cause of a sexual problem, there may well be psychological sequelae, if not for the patient then for his or her partner if there is one. Conversely, when the cause seems to be entirely psychological there may be hidden organic factors at work, and it would be irresponsible to miss them. Thus overall management has to take account of both aspects (exclusion of organic factors is covered later in the series).

	Psychological approaches

Top Overall management Psychological approaches Physical remedies Use of surrogates Referral onwards

Giving accurate information
It is useful to give accurate and relevant information. Various books and videos are available that patients may find helpful.

View larger version (25K): [in this window] [in a new window]   The sexual arousal circuit, a schematic representation of the factors that can positively or negatively affect the sexual response in the body, the mind, and the emotions

The sexual arousal circuit
A challenge to clinicians is to enable patients to understand that sexual problems happen in response to something and are not usually located solely in the genitals. Relationships, early learning about sex, trauma, and life stresses can all contribute. A diagram of the sexual arousal circuit is beneficial to show how these factors may all be linked to a sexual problem.¹ When explained to patients, it can help them understand the possible roots of their problem, and thus the appropriate choices for its management.

The third break point in the sexual arousal circuit occurs when the mind is too busy for the individual to relax and become aroused

Counselling can uncover and help resolve hidden conflicts or long denied anger and grief

General counselling
Counselling can uncover and help resolve hidden conflicts or the emotions of anger and grief long denied. Any issues about relationships may also be explored in this context, and communication between partners, often difficult in the presence of sexual problems, can be facilitated. An environment of emotional support and understanding can help patients work out their own solutions, with establishment of realistic goals and support for any changes in lifestyle.

Psychosexual therapy
The assumption underlying this therapy is that the relationship between therapist and patient provides a mirror of the relationship the patient has with his or her partner. It enables understanding of any disturbed interaction with the partner and any hidden conflicts in the patient. Initially, the doctor asks questions only when necessary, to minimise leading the patient. Medical investigations and questioning can sometimes be a way of avoiding painful and important emotional matters that the patient or the doctor may be afraid to face.

Behavioural approach
A man with premature ejaculation can learn to delay his ejaculation by means of a programme of graded masturbatory exercises (the squeeze technique), with or without drug treatment. The aim of the exercises is to enable the patient to recognise the feelings in his penis at different levels of arousal and, by modifying the stimulation, to learn to slow his response.

Sexual and relationship therapy
This integrated therapy incorporates psychodynamic, behavioural, cognitive, and systemic principles. The relationship may be viewed as "the patient," rather than either partner as an individual. After thorough assessment of physical, psychological, and, particularly if a couple comes together, relationship factors, a therapeutic contract is made, with clearly stated goals if possible and sometimes a limited number of sessions. The patient or couple may agree to homework tasks to facilitate and maintain changes. Family influences and cultural and gender issues may also be seen as important, and communication between partners is often fundamental in this approach. With a sexual problem, the relationship will inevitably be affected, but this can commonly offer the very vehicle to ameliorate the situation.

View larger version (154K): [in this window] [in a new window]   In sensate focus the couple explore each other's bodies by touching, stroking, and caressing. (Antoine et Cleopatre (c. 1602) by Agostino Carracci)

Sensate focus
This is a programme of tasks, first described by Masters and Johnson in 1970,² that a couple can undertake in their own time at home. Underlying the programme is a ban on sexual intercourse or any genital contact until anxiety about performance and fear of failure have subsided and trust between the couple has been established. This ban ensures that physical intimacy will not lead to sexual intimacy. The tasks involve the couple setting aside time to explore each other's bodies in turn by touching, stroking, caressing, and massaging gradually introducing sensual, then erotic, and then sexual touch over a period of time.

	Physical remedies

Top Overall management Psychological approaches Physical remedies Use of surrogates Referral onwards

Pharmacological and surgical treatment will be covered in later articles.

View larger version (78K): [in this window] [in a new window]   Tension rings can maintain an erection for up to 30 minutes when placed at the base of the penis

LubricantsKY Jelly and Senselle are generally well tolerated by both men and women and are available in high street stores. Carrier oils as used in aromatherapy, such as peach kernel and sweet almond oils, can be an excellent substitute for those who find water based lubricants are an irritant or messy.

Tension ringsThese are useful when an adequate erection can be obtained but not sustained. A tight rubber band at the base of the penis maintains an erection for up to 30 minutes.

Vacuum pumpsThese promote an erection, which a tension ring can then sustain. Pumps are available in both battery and manual forms.

VibratorsThese are available from sex shops and catalogues. The Clairol Heat Massager is obtainable from high street stores and has the advantage of being useful in other contexts. It is mains operated, which may be a further advantage.

View larger version (106K): [in this window] [in a new window]   Carrier oils, as used in aromatherapy and massage, can be used as an alternative to water based lubricants for facilitating sexual intercourse

	Use of surrogates

Top Overall management Psychological approaches Physical remedies Use of surrogates Referral onwards

Masters and Johnson used surrogate partners for patients who presented with sexual dysfunction but who had no partner, and Cole has described the use of surrogates in Britain.³ With a surrogate, a man might gain a sexual confidence that he could take into another relationship, but all relationships have their own chemistry and dynamic, and the erection might well not be portable. The practice was later abandoned by these workers, as complex legal, contractual, and ethical issues are raised. For example, where would responsibility lie if a patient were or became infected with HIV?

	Referral onwards

Top Overall management Psychological approaches Physical remedies Use of surrogates Referral onwards

Most patients with sexual problems expect to be referred on or at least investigated medically. It is very useful if the referrer has some personal knowledge or contact with the next clinician.

View larger version (180K): [in this window] [in a new window]   With a surrogate partner, a man might gain sexual confidence. (Picture reproduced with subjects' written permission)

A list of therapists can be obtained from the Institute of Psychosexual Medicine (11 Chandos Street, London W1M 9DE) or the British Association for Sexual and Marital Therapy (PO Box 13686, London SW20 9HZ). Relate-Marriage Guidance also gives further specialised training in sexual therapy (a list of local centres can be obtained from its office at Herbert Gray College, Little Church Street, Rugby CV21 3AP).

	Acknowledgments

The picture of Man, Woman and Fish is reproduced with permission of Emily Young, courtesy of the Thackeray Gallery, London (private collection). The cartoon "Sam, the ceiling needs painting" is by Neville Spearman. The photograph of the couple lying in bed is reproduced with permission of Tony Stone. The engraving by Zichy is reproduced with permission of the Bridgeman Art Library Stapleton Collection.

1  Stanley E. Principles of managing sexual problems. BMJ 1981;282:1200-2.

2  Masters WH, Johnson VE. Human sexual inadequacy. London: Churchill, 1970.

3  Cole M. Sex therapy for individuals. In: Cole M, Dryden W, eds. Sex therapy in Britain. Milton Keynes: Open University Press, 1988.

Margaret Ramage is tutor in human sexuality, St George's Hospital, London, and psychosexual therapist, Wandsworth and Lambeth health authorities.

The ABC of sexual health is edited by John Tomlinson, physician at the Men's Health Clinic, Winchester and London Bridge Hospital, and formerly general practitioner in Alton and honorary senior lecturer in primary care at University of Southampton.