Sexuality and sexual disorders: causes, symptoms, diagnosis, treatment

Acceptable norms of sexual behavior and relationships vary widely across cultures. Health care workers should never judge sexual behavior, even if social pressure demands it. In general, questions of normality and pathology of sexuality cannot be resolved by health care workers. Treatment is warranted when sexual behavior or difficulties are distressing or harmful to the patient or their partner.

Masturbation, once considered a perversion and a cause of mental disorders, is now considered a normal sexual activity in life; it is pathological only if it suppresses behavior directed toward a partner, is done in public, or is so compulsive as to cause distress. About 97% of men and 80% of women masturbate. Although masturbation itself is harmless, the guilt caused by disapproving and censuring attitudes from others can lead to severe distress and impairment of sexual function.

Homosexuality has not been considered a disorder by the American Psychiatric Association for over 3 decades. About 4-5% of the population identifies exclusively as homosexual throughout their lives. Like heterosexuality, homosexuality is the result of a complex of biological and environmental factors that lead to the ability to be sexually aroused by people of the same sex. Like heterosexuality, homosexuality is not a matter of choice.

Frequent sexual activity with multiple partners, often anonymous or casual, one-time relationships, suggests a decreased capacity for intimate relationships. However, promiscuity alone is not evidence of a psychosexual disorder. Casual sex is quite common, although fear of HIV infection has led to a decline in it. Most cultures frown on extramarital sex, but accept premarital sexual activity. In the United States, most people begin their sexual lives before marriage or without marriage, reflecting a trend toward greater sexual freedom in developed countries. Extramarital sex is common among married people, despite social taboos.

Acceptable norms of sexual behavior and relationships are largely influenced by parental influence. By repulsively rejecting physical sexuality, including touching, parents create guilt and shame in children and inhibit their ability to enjoy sex and develop healthy intimate relationships as adults. Relationships with parents can be damaged by excessive emotional detachment, constant punishment, or overt seduction and sexual exploitation. Children who grow up in an atmosphere of verbal or physical hostility, rejection, and cruelty often have problems developing sexual and emotional intimacy. For example, love and sexual arousal can dissociate, resulting in emotional bonds being established with people of their own social class and intellectual level, and sexual relationships being established only with those on a lower level, such as prostitutes, with whom emotional intimacy is not established.

A knowledgeable physician can provide sensitive, evidence-based advice and should not miss opportunities for helpful intervention. Behaviors that put the patient at risk for sexually transmitted infections should be addressed. The physician has the opportunity to recognize and address psychosexual issues, including sexual dysfunction, gender identity disorders, and paraphilias.

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