The Range of Sexual Difficulties
The range of sexual difficulties can be devastating.
Table of Contents
Potency
The sexual problem in men that is most likely to lead a request for medical assistance is a disorder of erectile function, leading to impotence. This refers to an inability to achieve or to sustain an erection, and may derive from either an organic or psychogenic source.
The organic causes of impotence stem from either problems with the nervous supply to blood vessels of the penis (neurogenic causes), or problems with the blood vessels themselves (vasculogenic causes). There are a number of other illnesses or disorders which may play a part, from local diseases of the penis, Peyronie’s disease, which involves excessive curvature of the penis (few penises are entirely straight when erect) to diseases which affect the whole body, such as liver or kidney disease.
The commonest vasculogenic causes involve diseases which either block the blood vessels, such as atherosclerosis, which is consequent on or associated with excessive smoking, or disorders which destroy the smooth muscle walls of the penile blood vessels, such as diabetes.
The commonest neurogenic causes are consequent on disorders such as multiple sclerosis or diabetes, which may lead to damage to the nervous supply to the sexual organs, or following trauma to the spine or directly to the nerves serving the sexual organs.
There are two neural pathways involved in mediating the erectile response, and either can be damaged separately. One pathway is part of the parasympathetic nervous system which runs from the end of the spinal column and mediates reflex erectile responses, such as when the penis rubs up against material, etc.. It also mediates the spontaneous erections that happen throughout the day and night in a rhythmic manner.
There is another pathway, which is part of the sympathetic system. This has been seen as a more ‘psychogenic’ pathway. This is the pathway leads to erections at the sight of erotic material, for example.
Ejaculation and Orgasm
In the male, climax usually involves an ejaculation. The extremes of pleasure, orgasm, are usually associated with this function. Ejaculation and orgasm, however, need not be tied together. There are a number of possible problems that may affect ejaculation and, as a consequence, orgasm, but there is a separate set of problems that can affect orgasm, indicating that these two functions are not identical. In the female, orgasm as an event is not tied to an obvious ejaculatory event and, as a consequence, the problems presented differ.
Ejaculation depends on the production of seminal fluid from the prostate gland and the mobilisation of semen from the testes. Seminal fluid is produced before ejaculation and may be noticeable on the tip of the penis during arousal, when it appears to add to the sensitivity of the penis and help intromission.
Ejaculation involves a complex set of events in which the bladder neck must be closed off, seminal fluid produced and passed down the urethra to mix with semen coming from the testes, with the lot discharged by a coordinated ‘Mexican wave’ of muscle movements. At any point along this chain of events, a quite minor imbalance or disruption may compromise the whole process.
Problems with ejaculation may involve premature, delayed or retrograde ejaculation. Premature ejaculation involves ejaculation consistently too early in sexual activity, often before intromission is achieved, or else within an unsatisfyingly short time of entry.
Delayed or retarded ejaculation involves an ability to ejaculate within a reasonable period of time, so that no release is achieved. With time this makes for tension and frustration.
Retrograde ejaculation involves the bulk of the seminal discharge passing backwards into the bladder rather than outwards into the vagina. The individual has the experience of ejaculating but not the results. Afterwards, when it comes to passing water, it may be noticed that the urine is cloudier than usual, which is because of the seminal fluid it contains.
Apart from the achievement of ejaculation, which is what is commonly thought of as orgasm, most people will be aware of a certain quality to their orgasms, which varies so that some may be more pleasurable than others. This quality of orgasm may be affected by drugs so that, although ejaculation takes place, it may not be pleasurable thing it once was.
Libido
A third aspect of sexual functioning is libido or degree of interest in sexual stimuli and activities, in lay terms, randiness or sex drive. As with erections and orgasms, this appears to have several components. There are the diurnal and seasonal surges of interest that appear to have no specific trigger but just come on much in the way that hunger comes on, as though something builds up gradually and needs discharge. There is also the specific increase in sexual interest and preoccupation with sexually related imagery that develops in exposure to erotic stimuli.
Sexual Orientation, Objects and Practices
This is what an individual finds erotic. This is, ordinarily, members of the opposite sex. For some it will involve the members of the same sex. This does not depend on whether one is homosexual or heterosexual in practice but what the nature of one’s fantasies are fantasising about sex. If these consistently involve members of the same sex, even though one’s normal sexual partner is of the opposite sex, then one has elements of homosexual orientation.
This distinction points to the fact that a great range of individuals/materials may be used as sexual objects. Sexual intercourse/relief, for example, may be obtained with animals. The fact that this is so does not indicate an individual is necessarily zoo-sexual in orientation, as it most likely that while engaged in such practices, the sexual fantasies which are driving the process are elsewhere.
Related to this is the fact that a wide variety of props/ancillary material my provide a stimulus to the sexual act. If one takes straight forward intercourse between a man and a woman to be the sexual norm, then practices other than this may be said to deviate form the norm. As there is little reliable data on the range of activities that normal individuals engage in, it is often not possible to pinpoint where normal deviation ends and formal sexual deviancy begins.
This blog article will not concern itself with gender orientation, sexual object preference or perversity or otherwise of sexual practices, as the taking of drugs or therapy with drugs reveals little about these issues. It is perhaps worth noting in passing, however, that Roland Kuhn’s first English language article on imipramine and the book Listening to Prozac both describe deviant sexual activity that was transformed by antidepressant treatment into more orthodox behaviour. The reason why this happens is at present a matter of speculation.
The Female Sexual Response
Like men, women have erectile response which involves clitoral engorgement and tumescence. This can spread to involve engorgement of the labia and vaginal walls. As with men, there may potentially be two components to this, a spontaneous rhythmic one and a psychogenic one that arises in response to the presentation of erotic material. Whether or not both are differentially affected is unknown. The extent to which diabetes, multiple sclerosis, trauma or other disorders affect these functions is also unknown, almost certainly because, to a greater extent than with men, a women’s sexual activity can still proceed, even though aspects of function may have become deranged.
In the case of women, there is a wider distribution of erectile tissue in, for example, the nipples, and large area of skin in general may become sensitised to touch in a way that does not happen as clearly in men.
There is also in women a twin component ejaculatory response. The first component involves the release of fluid from the walls of the vagina, which derives from an increasing congestion of the blood vessels to the vagina: it literally transudes into the vagina. This fluid helps sexual conjunction. Its absence is likely to produce dyspareunia – uncomfortable or indeed painful intercourse. A further amount of fluid is released on orgasm proper. An increase in vaginal lubrication is probably the single most reliable and observable component of the female response. It is not clear to what extent drug treatments may inhibit or enhance this.
In women, orgasm proper is not clearly tied to an ejaculatory event as it is in men. It is tied to some extent to a set of sequentially arranged contractions of the pelvic floor and vaginal walls that have their counterpart in the set of muscle contractions in men that lead to ejaculation. Because there is a less clear cut ejaculatory event, there has traditionally in women been a broader focusing on the quality of sexual arousal than on the specifics of orgasm.
As with men, the quality of orgasmic episodes may vary considerably. It is important to distinguish between the physical quality of an orgasmic event and its pleasurable significance. An event may involve an orgasm, be both pleasurable and among the most significant sexual encounters but have a low orgasmic intensity. Conversely, a meaningless encounter may involve an intense orgasmic outcome. It is not clear what factors affect intensity of orgasmic outcome.
For women, the question of sexual libido arises. When in full blood, libido in either sex is easy to recognise because it leads to a mental state dominated by thoughts and fantasies of sexual activity. However, while such mental states happen to all of us on occasion, attempting to judge the state of our normal libido is more difficult. Libido is intact if, when one walks down the street, one finds oneself aware of others as men and women rather than just people. Libido is low if there is little or no spontaneous sexual fantasising.
All of these factors, libido, orgasm and female potency, come together in the case of sexual fantasies, orgasmic dreaming and masturbation, when the various elements of the sexual response can be disentangled from the ‘faking’ that may occur in conjugal situations. Orgasmic dreaming corresponds to the male wet dream or nocturnal emission. It consists of a semi-awakening to find oneself aroused and on the verge of or immediately after orgasm, If it is happening more or less frequently than before, while on some drug, the question arises as to whether the drug may be playing some part in the change. Very much the same thing is true of sexual fantasising. Masturbation, to some extent, offers a chance for an individual to become aware of the various components of their sexual response to determine, in the case of some change, which element is most affected.
