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Treating Sexual Problems
An Interview with Virginia Sadock, MD
Virginia A. Sadock, MD, is the director of the Program in Human Sexuality and Sex Therapy at New York University Medical Center and has been a physician for over 30 years. She has written numerous articles and book chapters on sexuality with a focus on sexual disorders, and earned an MD from New York Medical College.
What are some of the sexual problems you see in men and women?
Dr. Sadock: In both men and women, there is hypoactive sexual desire, which is low desire. In women, there's anorgasmia, which is a lack of ability to have an orgasm. There's inhibited excitement, and vaginismus, which is a medical term describing a spasm of the muscle surrounding the vagina, which makes it impossible for penetration to occur. And dyspareunia is pain associated with intercourse. Now, men can experience that, too. But, it is almost invariably a physical problem when a man experiences that. For a woman, up to 30% of the time her problem is physical. For women, there are a lot of psychological issues.
Why don't you see psychological issues with men?
Dr. Sadock: Because most men demonstrate their psychological issues with their ejaculation or erection problems.
It sounds like there's quite a range of potential problems. What are the most common and why?
Dr. Sadock: Low desire for both sexes. In women, orgasm problems, and in men, erectile problems. These areas are what seem to be where men and women are most vulnerable. For one thing, a woman's lack of ability to get excited doesn't stop the sex act. It may not make it pleasant, but it doesn't stop it in terms of intercourse.
A man's inability to get an erection prevents intercourse, and they are vulnerable. Most men climax at least up to a certain age every time they have intercourse. Some will ejaculate more quickly than they like, and about 3% of men that I see have a problem with ejaculating, but most will ejaculate.
What causes these problems to happen?
Dr. Sadock: Some are physiological causes, for instance, following genito-urinary tract surgery. Certain medicines can interfere with the ability to get excited, even some over-the-counter products. A woman may feel excited in her head, but suppose she's taking an antihistamine? The same way it dries out the mucous membranes of the nose and the mouth, it can dry out the vagina. Also, some antidepressants, anti-anxiety agents, and antihypertensives can interfere.
If a woman goes through menopause and is not taking any kind of hormone replacements, she will take much longer to lubricate and her vaginal wall is actually thinner. Men past age 55 or 60 take a longer time to get excited. It doesn't mean they won't. It just takes a longer time. It's the same way that they can't run as fast. Some men may have very subtle vascular problems. What causes an erection is blood flow into the penis. If there's a problem with the flow in or if it leaks out, that can also cause problems.
There are also psychological problems. Those can be intra-psychic; by that I mean because of something that happened in the person's development. They may feel inhibited about their sexuality. Or, sometimes they grew up and had no problems with their sexuality but they're going through depression, either male or female. One of the first things to disappear with a serious depression is libido. Desire drops. Sometimes it's a reflection of difficulty in the relationship.
Most of the dysfunctions are the result of an inhibition that comes from the way one was brought up, where sex was associated with sin, or connected with guilt, or considered dirty or taboo under certain circumstances.
How do you treat different dysfunctions?
Dr. Sadock: In terms of men, premature ejaculation is the easiest to treat, partially because it seems to be a learned dysfunction. When a young boy is masturbating or having sex, what's the point of prolonging it? He learns to do it quickly if he's having sex in situations that would be embarrassing if he were caught.
The other thing that's easy to treat is if a woman has had orgasms in the past, but now, for some reason, does not. It's not something you forget how to do, so once you know how to do it, you know how to do it. But if something is blocking it, you can work on what is blocking it.
Low desire is a harder one to deal with. It's more complicated. And many dysfunctions are inhibitions of function. So, it's not being able to do something that you were able to do before, or that a lot of people can do.
Hypersexuality, or compulsive sexuality, or sexual addiction, is hard to treat. It's not just a strong sex drive, which is fine, but it's when the need to have sex interferes with the rest of your life. For instance, there is the impulse to climax frequently, like five or six times a day, so you leave your work, and go to the rest room, or you get up at four in the morning so you can masturbate. And that is sex not just for the pleasure of sex or the intimate bonding that occurs with it, but it's usually to relieve painful feelings, whether they are anxiety or depression.
What should people look for if they feel they need to see a sex therapist?
Dr. Sadock: The best thing would be to look for physicians that are accredited and affiliated with a medical center. There are certifying sex therapy organizations, such as the American Association of Sex Educators, Counselors and Therapists and the Sex Information and Education Council of the United States. Ask your family physician, internist, or general practitioner for a referral. Don't just go to anybody off the street because anybody can put up a shingle and say, "I am a sex therapist."
By and large, most people feel initially comfortable with the same sex people. But, some men do not feel comfortable talking to other men about their sexual inadequacies. What is important is what the patient is feeling. Who does the patient feel comfortable with?
To sum up, can you pinpoint the different ways men and women respond sexually?
Dr. Sadock: Women are more complex—they just are! In one study, men and women were asked what turned them on visually in terms of movie scenes. Almost all the men said that explicit pornography would turn them on. Most women felt that a physical scene, accompanied by romance and a hero of some type, would turn them on.
The men and the women were hooked up to physiological monitors. The men that said they would be turned on by pornography were turned on. And the women who said they would be turned on to the romantic scenes sometimes were and sometimes weren't. When they were shown pornography—which they said they would not be turned on by—physiologically, they were turned on to it, but in their heads, they still weren't. So, it doesn't matter if the woman's body is saying yes, if her head is saying no. So women are more complex.
To give you another example: most men don't mind if you go directly for their genitalia in terms of stimulation. Most women do; they'd rather be kissed, held, caressed, stroked first. It's just different.
Interviews were conducted in the past and may not reflect current standards and practices in medicine. Talk to your doctor to learn more about how sexual conditions are diagnosed and managed today and what treatment approaches are right for you.
American Association of Sex Educators, Counselors and Therapists
Sex Information and Education Council of the United States
Sexuality and U
Malatesta VJ. Sexual problems, women and aging: an overview. J Women Aging. 2007;19.
Stimmel GL, Gutierrez MA. Counseling patients about sexual issues [review]. Pharmacotherapy. 2006;26:1608-1615.
Wang WF, Chang L, Minhas S, Ralph DJ. Selective serotonin reuptake inhibitors in the treatment of premature ejaculation. Chin Med J (Engl). 2007;120:1000-1006.