Psychosocial interventions for sexual dysfunction in addictive disorders.

Substance abuse and addictive disorders are very common in the community. Patients with addictive disorders frequently experience sexual dysfunctions and chronic use of substances tends to adversely affect all stages of sexual response, in both male and female abusers. An important aspect in the management of sexual dysfunction is psychosocial intervention. In addictive disorders, sexual dysfunction is of high clinical relevance, as it often leads to treatment non adherence and sexual or marital disharmony. Instead of a disease-centred approach, a couple and relationship centred approach of management is desirable. A detailed history about the sexual dysfunction, the addictive disorder and enquiry into various psychosocial aspects is mandatory for adequate management of the same. Sexual therapy, behavioural techniques, systematic sensitization and desensitization are some of the techniques used in the management of sexual dysfunction in addictive disorders. The assessment and treatment need to be tailored depending upon the various psychosocial aspects of the individual.

INTRODUCTION

Sexual dysfunction is a problem that affects many men and women in their lifetime. In a large epidemiological survey done in the United States, it was reported that > 40% of women and 30% of men suffer from some form of SD, with low sexual desire in women (22%) and premature ejaculation in men (21%) being the most common.[1] These are figures similar to those from European countries where 34% women and 15% men reported low sexual desire.[2] These are trends similar to what found in our country also. A study conducted at Chandigarh, India by Natera, Wig andVerma in 1977, found sexual problems in 10% of males attendingpsychiatry and medical Out Patient Department (OPD).[3] In a study done at a village in South India it was found that among those above 60 years of age and sexually active, 43.5% of the male subjects had male erectile dysfunction, 10.9% male premature ejaculation, 0.77% male hypoactive sexual desire disorder and 0.38% males had anorgasmia. Among females, the prevalence of female arousal dysfunction was found to be 28%, female hypoactive sexual desire disorder 16%, female anorgasmia 20% and female dyspareunia 8%.[4] It is not uncommon for people to use alcohol and other substances to tackle sexual performance anxiety, enhance sexual performance, or overcome sexual dysfunction.[5] However, contrary to the common belief, substance use disorder impacts sexual functioning negatively and it may also lead to the onset of sexual disorders.[6] Various types of substances tend to negatively impact sexual functioning in every stage (desire, arousal, orgasm) and over time in both males and females.[7] Even though the initial connection between drugs and sex was one that attempted to enhance sexual functioning, there is evidence that in the long run, substance use disorder hamper the sexual functioning and may also lead to the onset of sexual dysfunction or disorders.[68] It has been reported that male smokers have a 1.5 times greater chance of developing erectile dysfunction, as compared to non-smokers. The duration and amount of smoking are also significant risk factors for sexual dysfunction.[7] In another study it was found that 86% of smokers have an abnormal penile vasculature on testing and structural damage in the corporal tissues.[8] Excessive alcohol consumption leads to erectile problems and inhibition of orgasm in males and in women may cause difficult lubrication, menstrual irregularities and dyspareunia.[7] It is also found that the amount of alcohol consumed was significantly associated withthe number of sexual dysfunction complaints reported.[9] With respect to cannabis use, studies report a mixed picture, with a few studies suggesting it can cause erectile dysfunction in men and others showing no significant negative impact on sexual functioning.[7] In a study of opioid users, its use was associated with decreased libido in 68% women and 75% of the men. Similarly, 60% of the users reported difficulty in achieving orgasm. Another study in which chronic use of opioid was evaluated found that erectile dysfunction was seen in over 50% of the patients.[7]

While recovering from the substance use disorder, the patient may face continuation or recurrence of sexual dysfunction, leaving the therapists perplexed about whether to address the addiction or the sexual problems of their clients.[10] In addictive disorders sexual dysfunction is of high clinical relevance, as it often leads to treatment non-adherence and sexual or marital disharmony. Yet, it is often neglected and unexplored in routine clinical care.[5] Addictive disorders may impact sexual functioning in its entirety, or may impact a particular phase of sexual functioning. Psychosocial treatment of sexual dysfunction in addictive disorders is not only restricted to the disturbed functions, but it also places the couple and the quality of their relationship at the centre of management.[11] The presence of addictive disorder often colours the underlying sexual dysfunction and the diagnosis is often missed. It is important to acknowledge and treat sexual dysfunction as sometimes the only underlying cause for ineffective treatment of addictive disorder can be a sexual dysfunction and the various psychosocial stressors associated with it.

Evaluation

In sexual medicine, diagnosis and therapy are interrelated more closely than in other medical fields. From the very start, the importance is on the diagnostic-therapeutic process, because the assessment of the patient is indicative of the therapist's perspective about sexual dysfunction.[12] This becomes even more important in addictive disorders due to the associated comorbidities and also the duration of illness. Emphasizing on the diagnostic-therapeutic process a detailed history is vital before management of sexual dysfunction in addictive disorders. While taking a sexual history, the clinicians should make the patient comfortable, ensuring adequate privacy. Maintaining confidentiality is of utmost importance and the clinicians should inform the patient regarding the same. Both the clinician and the patient should be comfortable with the language in which the patient is interviewed. Developing rapport, being empathic and non-judgmental are important and a physical examination is a must in all the cases.[13] Differences in socioeconomic level, age, gender and culture between the clinician and the patient can be barriers for adequate history taking.[14] When we address sexuality related issues, we are opening a window to the patient's psyche. This gives us information regarding the individual's capacity to be psychologically intimate, love and be loved and give and receive pleasure.[15] Patient's current complaint, duration, associated symptoms, mode of onset, frequency and severity of the problem should be noted; whether the problem is generalized or situational, life-long or acquired needs to be enquired into. Enquire regarding sexual practices, fantasies and goals, intimacy issues with partner, relationship problems affecting the current sexual functioning, sexual addictive disorders and paraphilia. The clinician must ask regarding any other associated factors aggravating the current problem and life stressors, if any. Past sexual history, mode of gaining information regarding sexual functioning, history of first sexual activity, history regarding masturbation, sexual orientation and past history of sexual abuse need to be noted. It is also important to note any guilt associated with sexual self-stimulation, premarital and extramarital sexual activities, live-in relationships.[16]

Management

The focus of psychosocial management for sexual dysfunction in addictive disorders is not solely disease-centered, but couple and relationship-centered. An important aspect of such a therapy is the dual role of therapist as an expert and an attendant. The therapist is required to build a partnership with the couple in order to administer effective psychosocial management. It requires the therapist to not only to be an expert-observer-educator with his/her knowledge about the subject but also an empathic companion, a patient-listener and an attendant to the couple undergoing therapy.[12] Initially passing on the knowledge about the addictive disorder, sexual dysfunction and the association of the two is essential. As elaborated by Masters and Johnson in 1970, sex therapy (dual sex therapy) ideally includes both the patient and the partner for satisfactory outcome. Information regarding anatomy and physiology of sexual function is explained and any myths or doubts are cleared through counseling the couple. Therapy should include educating the partners, to avoid blaming one's partner or oneself for the sexual problems. The basic concept about sexual intercourse, that it is a mutual act between two individuals, and is not something a man does to a woman or woman to a man has to be conveyed to the couple. Sexual intercourse can be a form of interpersonal communication at a highly intimate level.[17] Educating the couple, improving the communication, heightening sensory awareness, and sensate focus exercises can be taught to the couple. Behavioral exercises include non-demand pleasuring or sensate focus, to allow the individual to re-experience pleasure without any pressure of performance or self-monitoring (spectatoring). The assessment and treatment need to be tailored depending upon one's setting, profession, specialty and most important of all, the type of the problem encountered in the client, wherein different approaches may be helpful.[16]

Sexual dysfunction is considered as a maladaptive behavior by behavioural therapists. Using a hierarchy of anxiety provoking sexual interactions the client is systematically desensitized.

Different approaches include Masters and Johnson's approach, Kaplan's approach and the PLISSIT MODEL with some variations in the treatment process. Annon (proposed a graded intervention popularly called as PLISSIT MODEL wherein the individual letters stand for: P: Permission giving, LI: Limited information, SS: Specific suggestion and IT: Intensive sex therapy.[18]

Permission giving: In this phase, the client is assured that their thoughts, feelings, fantasies and behaviours are normal till they are not affecting the partner in a negative manner. In ‘Limited Information’ phase, the client is given limited and specific information related to his or her sexual problem. In ‘Specific Suggestion’, suggestions related to specific situations are given. The intensive therapy is needed only in selected cases and involves detailed sex education, sensate focus exercises and, behavioral exercises like start- stop technique, home assignments etc., These help in improved communication between the couple and in learning new arousal behaviours., Selected cases may need insight oriented psychosexual approaches to make the client aware of their feelings.[192021]

Sex therapy involves primarily Sensitization and desensitization techniques.[22] The general principles are applicable to majority of the inadequacies encountered in clinical practice. The major guidelines to be followed are:

Educating the couple -The couple is advised to talk on issues bothering them in a nonjudgmental way, encourage partners to see, hear and understand each other's perception and teach verbal and nonverbal communication skills,[23] in general and during sexual activity in particular.

Setting the framework for the therapy -Inform ground rules of the therapy, dispel negative and sensational images of sex therapy and allow the couple to recognize and take responsibility for much of their treatment. The treatment has to be tailored towards the couple which acts as a marital unit, focusing in particular on the problems associated with the marital unit.[24]

Proscribe sex -To take off performance anxiety and pressure.

Sensate focus exercises -These are structured exercises, about 3-5 sessions assigned between the visits. Help couple recognize that sexual activity is not limited to sexual intercourse and that ‘Pleasuring’ and ‘Receiving Pleasure’ can be enjoyable without being regarded as foreplay or a preliminary to sexual intercourse. Slow progress from non-demanding pleasure i.e. pleasing to explore one's own feelings about the experience from non-genital area to breasts and then to penile pleasuring.[25] Various stimulation methods are taught and the couple is advised to try different intercourse positions which may not necessarily lead to completion of sexual intercourse. One of these stimulation methods is, using fantasies for stimulation, to avoid obsessive concerns termed 'spectatoring’.[26]

Systematic Sensitization and Desensitization -‘Start-Stop Sensitization’ technique used for premature ejaculation is one of the most common and useful techniques under this heading. Here one partner provides manual stimulation to the other and is stopped at a signal from him when orgasm becomes imminent. Repeating this activity for certain duration of time, leads to some degree of control over ejaculation. Further the partners are advised to should then try intra vaginal containment, usually in Female Superior Position. Partners should increase the rhythmic movements until the man gives the signal to stop. After a pause and they should repeat the act. With repeated attempts, the partners learn how to prolong the pleasure of intercourse while containing the urge to ejaculate.[16] Similar desensitizing and sensitizing techniques are utilized in treating psychogenic erectile and orgasmic dysfunctions in men and arousal and orgasmic dysfunctions in women. In women, with progressive stimulation of clitoral and other genital areas by partner, arousal is experienced without demand or pressure of intercourse.

CONCLUSION

In addictive disorders, sexual dysfunction is of high clinical relevance, as it often leads to treatment non adherence and sexual or marital disharmony. Although very commonly seen in the community, this is often a neglected and unexplored area. There is also a dearth of research in this area.[5] The presence of addictive disorders clouds the sexual dysfunction and the involvement of various psychosocial factors make it a difficult area of research. There is a need for specific research in the field of management of sexual dysfunction in addictive disorders. The various specialities of medicine like urologists, andrologists, gynaecologists, psychiatrists and psychologists dealing with such patients need to have specific training with regard to effective psychosocial management of sexual dysfunction. A holistic and comprehensive perspective, including the importance of a diagnostic-therapeutic process is the way forward. Dealing not with the individual but the couple and enhancing the relationship of the client is to be given outmost importance in the effective management of sexual dysfunction. Various psychological and behavioural techniques are available and the management needs to be individualised, based on various factors. Maintaining a healthy lifestyle and exercise are very important in any case of sexual dysfunction. In cases when psychosocial management is not effective, a combined approach of pharmacological and psychosocial intervention should be considered. The adequate management of sexual dysfunction in addictive disorder can lead to a significant reduction in the stress of the individual and the couple as a whole and in turn prove to be a vital aspect in the overall management of addictive disorder.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.