Deterioration of sexual function in men including problems with premature ejaculation, erectile dysfunction, low sexual desire, and sexual pain is very common. Considering that these problems lead to low self-esteem, mood disorders (such as depression), marital problems and detrimental to quality of life, it is important to understand their causes and develop effective treatments.
Beyond the hypothesis that impaired sexual function has profoundly disturbing consequences, recent research – using both male and female samples – has suggested that impaired sexual function is not always linked to sexual distress.
In fact, the association between sexual function and a sense of personal sexual well-being seems quite variable. For example, some researchers found that older men reported more severe erectile difficulties than younger men, but nevertheless also reported greater sexual satisfaction.
In short, pleasure is not always linked to sexual performance and functioning.
So while it is clear that male sexual dysfunctions are common and potentially problematic, it remains unclear when and why impaired function is strongly related to levels of subjective suffering and sexual satisfaction. It would then be very useful to understand the processes through which the alteration of sexual function can cause distress and diminish satisfaction, and then to approach comprehensive sexological treatments in a more personalized way.
To delve deeper into this issue, we turn to an article published in the Journal of Sexual Medicine in 2018, entitled Why is impaired sexual function distressing for men? Consequences of Impaired Male Sexual Function and its Associations with Sexual Well-Being.
Analyzing the relationship between sexual dysfunction and its negative consequences, the authors argue that a priori men would be expected to report that impaired sexual function may result in interruption of sex, decreased physical pleasure for themselves or for the partner, and negative emotional responses from the partner. And it was precisely the aim of the study to test these predictions by exploring the role of the sexual consequences of the deterioration of male sexual function.
Participants were recruited through online publications and newspaper advertisements in the United States of America. These were the inclusion criteria: men over the age of 18, currently in a monogamous heterosexual relationship, sexually active in the past month and having experienced impaired sexual function in the past month. The final sample consisted of 166 men with an average age of 37 years. The instruments used to measure the results were the Sexual Satisfaction Scale, the International Erectile Function Index and the Sexual Consequence Measurement.
Three broad categories of consequences were measured: interruption of sex and pleasure, negative emotional responses of the partner, and deterioration of the partner’s sexual function.
Overall, the findings suggest that the sexual consequences assessed are commonly experienced in the study sample, produce distress, and may explain at least in part why impaired sexual function is distressing to men. Seventeen specific negative consequences were reported with at least moderate frequency, and rated at least somewhat distressing.
Let us now look at the most specific conclusions:
-Some consequences can be particularly distressing, such as people not being able to continue sexual activity, physical pleasure being reduced, the couple being upset, and making negative judgments about the nature of the relationship.
-Men with sexual dysfunction tend to process information during sexual activity as spectators rather than participants, rather than focusing on sexual stimuli. This mechanism blocks sexual function and in fact psychosexual therapy aims to deactivate it.
-It is remarkable that the current findings are very similar to previous results from a sample of women with sexual difficulties, suggesting that the basic processes that maintain sexual problems may be similar for men and women.
-If these consequences explain why impairment of sexual function generates stress, eliminating those consequences would significantly reduce anguish related to sexual problems. In fact, the attempt to eliminate these negative consequences of impaired sexual function is a central component of sexual therapy approaches, such as cognitive-behavioral therapy. In fact, most of the interventions in this therapy model include basic training in assertive sexual communication as well as promoting flexibility in sexual scripts, thereby reducing levels of anxiety and negative emotional response.
It is important that future studies incorporate evaluation of the experience of the partner of the man with sexual difficulties, and how that response relates to his perception and reactions.
From the clinical point of view, it is very interesting to know the specific consequences of the alteration of the sexual response since they represent possible causes for the maintenance of male sexual dysfunction and can therefore be the focus of psychosexual therapies. It is therefore essential to include the evaluation of these factors in the diagnostic interview and in the treatment plan.
Brain Aspects of Pedophilia
Pedophilia is a subject that generates controversy, curiosity and a high level of repulsion in our society. The International Classification of Diseases (ICD 10) defines pedophilia as sexual preference for pre-pubertal or early pubertal children.
Those of us who work in the field of sexology and sexual medicine continue to study the subject, trying to find its causes and also treatment alternatives, a task that so far has not achieved the best results. One of the psychological hypotheses of its aetiology is that this paraphilia is the consequence of suffering sexual abuse in childhood, giving rise to a mechanism of identification with the aggressor. But this explanation, although it could support a behavior of child sexual abuse as a way of expressing unprocessed violence psychologically, may not be enough to understand sexual attraction by prepubescent. That is to say that if what we want to understand is the sexual tendency and not only the behavior, we must look for more solid and deep theories.
In this way we find an article published by the Journal of Sexual Medicine in 2018 entitled Towards an understanding of the neurodevelopment of paedophilia, which provides quite interesting information for us to broaden the panorama.
This work shows us how the current scientific tendency is to move towards an explanation based on alterations in the neurological and potentially epigenetic development of pedophilic sexual preference. There is growing evidence that the propensity to pedophile sexual preference begins before birth, with early neurodevelopmental abnormalities as a result of different prenatal events, which can then be shaped by certain childhood developmental experiences. Ongoing studies on the biological origin of pedophilia range from neuroimage-based research to examination of the season of the year of birth to clarify other possible neurodevelopmental stressors.
Below are some recent neurological research findings about people with a pedophile preference:
-Very mild features, often considered inconsequential, associated with atypical neurodevelopment. An extreme example of this would be the stereotyped facial features of a developmental disorder such as fetal alcohol syndrome or a genetic disorder such as Down syndrome.
-These atypical neurodevelopmental characteristics were extensively studied at the Center for Addiction and Mental Health (Toronto, Ontario, Canada). These early publications showed that pedophiles had a lower IQ, higher prevalence of childhood traumatic brain injury, and atypical neuropsychological functioning compared to non-pedophiles.
-Research from the same center suggested that pedophiles are shorter in stature than individuals with typical sexual preferences. In the same vein, another recent study demonstrated shorter leg lengths in pedophiles, which is considered a marker of prenatal stress.
-Neuroimaging data regarding pedophilia continue to evolve. Initial studies analyzing MRI data indicated a decrease in overall white matter in the pedophiles’ brains.
We must recognize that it is difficult to investigate pedophilia, since very few individuals openly admit this sexual preference due to social stigma and also the possible negative consequences of their actions.
And if the research is complex, so is the therapeutics of these cases, starting with the resistance of the psychotherapists themselves to establish a relationship of help and empathy with pedophile patients. In addition, we do not have a really effective protocol of action.
That is why it seems important to us to continue advancing neurological hypotheses, since understanding pedophilia as the consequence of a spectrum of neurodevelopmental abnormalities will help to facilitate preventive efforts in early prenatal care, providing adequate social services for children and mothers and also the respective treatment efforts for adults struggling with this paraphilic attraction.
Finally, we mention the Dunkelfeld Prevention Project initiated in Berlin in 2005, which is truly unique in that it is a national effort to prevent child sexual abuse by targeting individuals with paedophile sexual preferences. Its task is to provide them with anonymous therapeutic intervention including psychotherapy and – in certain cases – drugs to suppress sexual desire. More than 8,500 individuals have approached the project since its inception, although many of them have not undergone treatment. It would be interesting to replicate this model in the rest of the world.
Sex can give you a headache
From common sense we often hear the excuse – disguised as a complaint – to avoid a sexual encounter: “I can’t today, my head hurts”, something that is generally attributed to women. However, the opposite scene can also occur, and that is when sexual activity causes headaches.
The sexual headache is not a problem as frequent as others that we treat in this space, nevertheless they have consulted us for this subject and it seems pertinent to us to review the scientific evidence. That’s why we went back to the Journal of Sexual Medicine, which in 2018 published an article titled Sexual Headache.
It is a picture in which headache attacks are exclusively related to sexual activity, and is known as primary headache associated with sexual activity (PHASA). This does not include headaches that occur during sex due to phosphodiesterase type 5 inhibitors (such as sildenafil, vardenafil, tadalafil) or other medications, since it would be a side effect of a substance.
According to the third edition of the International Classification of Headache Disorders (ICHD-3) of the International Headache Society’s Headache Classification Committee, primary headache associated with sexual activity is defined by the presence of episodes of headache or neck pain that occur only during sexual activity. They may increase during sexual arousal or begin abruptly before or at the end of orgasm. This type of headache lasts from one minute to seventy-two hours with an average of half an hour, and is not explained by another diagnosis. On the other hand, the definition refers to headaches caused by any type of sexual activity: sexual intercourse, masturbation and even nocturnal pollution.
Some studies reported a prevalence of headaches associated with sexual activity of about 1%, thus no comparison with erectile dysfunction, premature ejaculation or low sexual desire that are highly prevalent. However, considering that this is not such a well-known picture in its definition and diagnostic criteria, it is possible that these figures are underestimated.
Studies show that this picture occurs more frequently in men, with a rate up to four times higher in relation to women. With respect to age, two prevalence peaks are described, the first between 20 and 24 years old and the second between 35 and 44 years old.
Logically, patients with primary headache associated with sexual activity are more likely to abstain from sex because of the intensity of the pain, leading to other problems such as sexual dissatisfaction, sexual distress, low self-esteem, and partner conflicts.
Going on to the diagnosis, it is necessary for the patient to undergo a neurological evaluation including physical examinations to rule out other types of pathologies.
We do not have consistent treatment protocols, and we must also consider that there is a high rate of spontaneous remission (about 70% over a period of three years), so it is not clear whether the interventions are effective or not. So far, treatment strategies can be grouped into acute, preventive and prophylactic.
With respect to acute treatment, it is well known that primary headache associated with sexual activity responds poorly to over-the-counter analgesics and non-steroidal anti-inflammatory drugs after the onset of pain. The most commonly used treatment options for the acute phase are indomethacin or triptans.
In terms of preventive treatment – before sexual activity begins – indomethacin continues to be the treatment that is reported to have the most positive results.
Finally, for those cases of more chronic course or with unpredictable sexual activity, a daily prophylactic treatment with beta blockers (propranolol or metoprolol) can be tried. The recommended duration of this type of treatment is six months.
All that remains to be said, by way of conclusion, is what we often say in this space: if you have this symptom, do not stop going to the specialist. In this case it is not strictly the sexologist, but -at least in the first instanct- the neurologist.