LIBIDO AND AGING
HUSSEIN GHANEM M.D.
Assistant Professor of Andrology
Cairo University
Fellowship in Male Reproductive Medicine
& Surgery
University of Iowa, USA
LIBIDO CHANGES WITH AGING
THE PSYCOSEXUAL THEORIES OF DEVELOPMENT
Psychosexual development theories are based on the psychoanalytic theories introduced by Sigmund Freud. Instincts and drives are the motivating forces behind thoughts and behaviors. They arise from biosomatic processes and are experienced as urges, wishes, and fantasies. The two major categories of drives are libido and aggression. Drives press for discharge and the associated feeling of release and gratifaction. The drives and the methods available for discharge are in stages, known as psychosexual stages.
Freud introduced the concept five psychosexual stages describing the gradual, sequential emergence of the sexual drive (libido) from infancy (infantile sexuality) to adulthood (genital sexuality). These stages reflect the interaction between physical and nervous system maturation and individual experience (development).
Erik Erikson (1950), further added three more stages to Freud’s work and introduced a broader systemic framework for understanding patterns and sequences of psychological development in the context of social and cultural factors(Psychosocial theory). His basic concept describes eight stages that extend from infancy through old age. The following paragraphs will focus on the aspects related to the sex drive.
1.
Oral stage
This includes the period from birth to 18 moths. During
this period, the primary means of drive discharge and gratifaction is
through sucking (innate behavior), chewing and feeding.
2.
Anal stage
This phase spans the period from 18 months to 3 years of
age. During this stage, sphincter control is achieved and the
primary focus shifts to the anal zone and the behaviors associated with
expulsion and retention.
3.
Phallic stage
During this period from 3 to 6 years of age, the genitals
become the primary source of interest, discharge, and organization of
urges into wishes and fantasies. Characteristic behaviors include
curiosity, exhibition, and frequently masturbation. The Oedipus
complex occurs in this stage(attraction of the child to the parent of
the opposite sex).
4.
Latency stage
The latency stage extends
from the resolution of the Oedipal conflict at approximately 6 years
of age to the onset of puberty around the age of twelve. During this
period, drive interests are invested in peer relationships, socialization,
and acquisition of knowledge and skills (e.g. athletics).
5.
Adolescence
Adolescence extends from
12 to approximately 20 years of age and is marked by dramatic neuroendocrine
and physical changes that are initiated by the onset of puberty. The
drives, aims, and objectives of earlier stages are integrated as components
of libido or sexual drive and desires ideally directed to the opposite
sex. Distortion of the development of this primary sexual organization
may lead to sexual perversions.
6.
Young adulthood
This is the period from 20 to 30 years of age and is associated
with the need for sexual and social intimacy. This requires a
sense of trust, autonomy, and identity that developed during the previous
stages. Failure to form such an intimate relationship leads to a feeling
of emotional isolation.
7.
Adulthood
Adulthood, the period from 30 to 65 years of age, is typically
characterized by the establishment of a family. Libido and frequency
of sexual intercourse gradually decline. The main drive is to
maintain a sense of generativity, a continued sense of productivity
and guidance for the next generation.
8.
Maturity (later adulthood
and old age)
Maturity is the period of biologic decline, although there
is a great deal of variation. There are gradual decrements in libido,
strength, energy, tolerance to stress, and physical health. For
most people, maturity involves retirement, a change in economic
circumstances, the loss of loved ones, end the realization of mortality.
Many people have physical and emotional reserves that enables them to
adapt to change, decline, and especially loss. A sense of integrity
and pride is experienced if the person is satisfied with his past achievements.
CHANGES IN SEXUAL DRIVE
WITH AGE
The Normal Sexual
Experience (Helen Kaplan, 1983)
Modern researchers reached conclusions that are in line with these earlier views. It seems that in the healthy person, some form of sexual appetite is present throughout life (Dunn, 1988). As with any human trait, e.g., height, intelligence, etc., the intensity of sex drive varies widely, and in some cases, it may be difficult to define what is a pathologic hypoactive sexual desire and what is a normal variation (Masters and Johnson, 1970; Kaplan, 1983; Mulligan and Katz, 1988).
Sexual appetite or libido changes in intensity with age and takes a gender-specific course of development. Interestingly, even infants seem to already have some capacity for erotic feelings. They are evoked when their genitals stimulated. When the tiny penis or clitoris is touched while bathing or dressing, the infant might express pleasure by smiling and cooing (Kaplan, 1983).
Children, if they are not stopped, might masturbate and later play sexual games that may include looking at and touching each other’s genitals. We try to dismiss or repress memory of these early sexual fantasies or experiences but some memory is normally retained. If a person has no memory of prepubescent erotic feelings or fantasies, one can suspect a considerable amount of sexual inhibition or a strict upbringing (Kaplan, 1983; Greydanus et al 1985).
At puberty there is a sharp increase in sexual desire. This is most probably correlated with the maturation of the cerebral circuits governing sexual expression and sharp increase in testosterone secretion by the testicles in response to increased gonadotrophines secretion. After puberty, changes in libido take different courses in males and females. In the male desire seems to peek around 17 years and then slowly declines. The normal adolescent male is intensely interested in sex and is very easily aroused. In the absence of a sexual partner he would masturbate while immersed in erotic fantasies. The frequency of masturbation at that age period varies from several times per week to several times per day. Adolescent males may occasionally masturbate up to 20 times per week. If there is no sexual outlet, frustration is experienced. This phenomenon is so predictable that if the sexual history reveals no adolescent increase in sexual desire as reflected in masturbation, fantasy, or sexual intercourse, one may suspect a problem in psychosexual development (Kaplan, 1983; Greydanus et al 1985).
The intensity of male libido diminishes gradually after adolescence. At middle age he still desires sex, but often can go without sexual outlets for longer and longer periods of time without experiencing frustration. Throughout his life, however, his sexual desire can be aroused under exciting conditions (Kaplan, 1983; Greydanus et al 1985).
Females also experience an increase in libido at puberty. However this appears less intense than that of adolescent males. Girls seem more easily discouraged from sexual expression than boys. Thus the absence of adolescent masturbation in a female sexual history does not carry the same significance of sexual repression as it does in the male(Kaplan, 1983; Greydanus et al 1985). After adolescence, contrary to the male, the female sex drive does not decline. It slowly increases to peak around the age of forty (Kaplan, 1983).
After the age of forty, the libido in the female slowly declines as in males. In general, the female sexual desire is more variable than that of the males. Although women have a greater orgasmic potential, their sexuality is also more easily suppressed (Frank et al, 1978; Dunn, 1988).
Throughout life the normal person experiences spontaneous sexual desire, and also has the capacity to be aroused by an attractive partner. When the sex drive is high, the person will experience spontaneous desire and will be aroused by wide range of stimuli. As desire diminishes, the range of stimuli that will evoke the sexual appetite narrows, and more intense psychic and physical stimulation is needed to produce a response (Kaplan, 1983).
DISORDERS OF LIBIDO
DISORDERS OF SEXUAL DESIRE
This includes changes in desire that exceed the normal variations expected with age. Two types are identified according to the Diagnostic Manual of the American Psychiatric Association (DSM III-R).
Hypoactive sexual desire (HSD) is defined as a relative or absolute lack of desire and fantasy regarding sexual activity. It may occur in the context of a specific committed relationship, or the deficiency of desire may be global. In the later case, there is a greater likelihood of relevant organic factors, such as hormonal disturbances, side effect of medications (e.g., antihypertensives, sedatives, and major tranquilizers), and general physical illness. Depression may cause similar symptoms (DSM III-R, 1987).
Sexual aversion disorder implies extreme avoidance of sexual activity rather than a simple lack of sexual desire. It is differentiated from simple lack of desire by its association with anxiety symptoms. It is believed to be related to phobia, and may be associated with acute panic attacks. If panic disorder is present, specific treatment is essential in the overall clinical approach. The patient may have a history of sexual trauma such as rape or incest (DSM III-R, 1987).
CLINICAL VARIANTS OF HSD IN THE ELDERLY
Secondary HSD
Loss of sex drive after a history of normal sexual development is much more common than primary HSD. Secondary loss of libido in the elderly may be triggered by various psychological stresses and physical disease discussed below (Kaplan, 1983).
Widower’s Syndrome
The sexually inactive, elderly man occasionally finds that he loses much sexual competence after a protracted period of inactivity. The problem may surface when a man begins a relationship with a new sexual partner after the death of his spouse partner. A similar but less easily defined syndrome also develops in women who have not been sexually active for years and may present with dyspareunia. Although there has been much speculation about the emotional factors for this syndrome, a neurophysiologic or hormonal basis for this problem has also been suggested (Dunn, 1988).
PHYSICAL AND PSYCHOLOGICAL CONDITIONS AFFECTING LIBIDO
Several physical and psychological ailments common in the elderly may aggravate the gradually declining libido in old age. Chronic illness can decrease the patients self-esteem and adversely effects the sex drive and relationship with the partner in both men and women. The health care provider’s consideration of these effects is an important factor in the sexual adjustment of both the patient and partner (Quadri and Fonzo, 1993).
The sick role places the patient in a dependent position and may lead to regressive behavior. Malaise, anxiety, and depression associated with chronic illness can affect libido. Medications may also impair the sexual response. As a result of the illness; sexual roles are often altered with the healthier partner assuming a more nurturing role. The partners may also be physically separated as a result of illness and hospitalization (Masters and Johnson, 1970; Kaplan, 1983).
Depression is common among single elderly individuals and is probably the most common psychological cause of decreased libido with aging. Depression is marked by a variety of symptoms including sleep, eating, and libido disturbances. It has been speculated that during a depressed state the activity of the centers and circuits that serve such vital functions as eating and sex is diminished. The loss of sexual appetite may be an early symptom of depressive states and may appear even before the patient’s mood becomes perceptually sad. Characteristically, during depression, erection and orgasm are not impaired to the same extent as is libido (Kaplan, 1983).
Severe Stress, such as is experienced during a traumatic divorce, during wars, or after a job loss, or forced retirement, is often associated with a loss of sexual interest. Clinical observations suggests that crisis and stress are also associated with a physiologic depression of the sexual apparatus. For this reason it is important to assess the patient’s current life situation during the initial evaluation. Usually it is not advisable to initiate sex therapy during a crisis period. Attention should be primarily given to resolving the stressful situation (Kaplan, 1983).
Anger is a final common pathway by which sexuality can be blacked for multiple underlying factors. Masters and Johnson (1970), used the term “partner rejection” to refer to anger at the sexual partner. Hidden unresolved animosity over the years can mount to a “turn off” that can not be bypassed even with sensate focus exercises.
Hormonal changes may have adverse effects on libido in both males and females. Physical changes occurring with menopause and their psychological impact are well documented as mentioned above. On the other hand the male climacteric or andropause is a controversial issue. Although androgen production falls with age, yet some researchers suggest that this fall is not significant enough to impair libido. However, in a recent study (Swerdloff and Wang ,1993), Researchers demonstrated that androgen deficiency in elderly men may lead to asthenia, decrease in muscle mass, osteoporosis, decrease in sexual drive, and in some cases changes in mood and cognitive function. The combination of these factors may lead to impaired quality of life in elderly men (Swerdloff and Wang, 1993).
Diabetes Mellitus usually spares the libido but decreases the potency. The cause of impotence is usually organic (e.g. diabetic microangiopathy, accelerated atherosclerosis, autonomic or sensory neuropathies) but psychological factors (e.g., impaired self esteem, fear of impotence) should be also considered. Fifty to sixty percent of men with diabetes experience sexual dysfunctions of organic origin (Campbell, 1976; Whitehead and Klyde, 1990). Women with diabetes may also experience problems with arousal and vaginal lubrication. These problems may be complicated by vaginitis (Osborn et al, 1988).
Atherosclerosis and vascular disease related to hypertension, diabetes mellitus, hyperlipidemias, and cigarette smoking primarily affects erectile capacity rather than desire (Virag et al, 1985; Shabsigh et al, 1991).
Cardiovascular disease significantly impairs the sexual drive. Myocardial infarction particularly often results in decreased self-esteem, concerns about impotence, fear of death, and a decrease in the frequency of sexual intercourse caused mainly by psychological factors. Patients who participate in exercise training and education generally have a more satisfactory return to normal sexual activity. If their is no medical complications, patients may resume sexual activity within six weeks. The patient’s sex partner may have concerns that may interfere with the resumption of sexual activity. Thus, the education program should also include the patients partner. However, it should be noted that it is not unusual for patients with cardiovascular disease to experience symptoms during intercourse (Hellerstein and Friedman 1970; Shabsigh et al, 1991).
Other illnesses common in the elderly individuals such as arthritis, cancer, renal failure, liver failure, heart failure and cerebrovascular accidents may also hamper sexual desire through decreasing the patients sense of being and interfering with comfortable sexual functioning. Physicians involved in the care of such chronic disease in elderly patients should be aware of their sexual consequences and should be trained so as not to accept the altered libido as a normal consequence of aging (Quadri and Fonzo, 1993).
Medications may be responsible for decreased libido in the elderly. The fact that a patient had received a drug for many years without a decrease in libido does not rule out the deleterious effect of the drug. As people age, their metabolism of drugs changes, and previous innocuous doses may be disruptive. Medication effect of sexual function may be complex. Libido, secretions, erection, and ejaculation may be affected individually or jointly (Mulligan and Katz, 1988). About one fourth of men with decreased sexual capacity will have problems related to the use prescription drugs. The use of steroid 5 alpha reductase inhibitors in the management of prostatism has been reported to be associated with decreased libido in about 5% of users (Cunningham and Hirshkowitz, 1995).
Antihypertensives are especially common causes of sexual dysfunctions in both men and women (Smith and Talbert, 1986). Sexual dysfunctions occurs in 9% of men taking diuretics to control hypertension and in 23 to 24% of men taking combinations of several antihypertensive drugs (Morley et al, 1987). Patients with affective or cognitive problems may be diagnosed as having a low sex desire when in fact, they are suffering from the side effects of their psychotropic medications. Antiepileptic medications are also a common cause of sexual dysfunction, but in the case of epilepsy, the neurologic disorder may be playing a larger role in the dysfunction than the medication given to suppress seizures (Smith and Talbert, 1986).
Drug abuse and Alcoholism are not uncommon among single elderly individuals. The most commonly used elicit drugs that depress libido are marijuana, cocaine and heroin.
HYPERLIBIDO
It is quite rare that a patient complains of increased sexual desire. This is true even more with aging individuals. Hyperlibido presents by increased frequency of sexual fantasies, easy arousal, increased frequency of masturbation, and sexual activity. The physician should be aware about the average sexual activity at each age group. Excessive sexual desire is also known as compulsive sexual behavior, sexual addiction, or hyperactive sexual desire. It commonly presents in conjunction with obsessive-compulsive disorder, the manic phase of a bipolar disorder, or paraphilias. The affected individual uses sexual activity to decrease anxiety and tension. Sexual activity, either through masturbation or with a partner, may be the result of obsessive thoughts about sex or about other aspects of a person’s life. Management is through psychotherapy and is directed towards the primary psychiatric condition (Coleman, 1987; Levine and Troiden, 1988).
Organic brain lesions, on rare occasions, may be responsible for the hyperlibido. Increased sexual drive has been reported with temporal lobe lesions or epilepsy (Blumer and Benson, 1975), and after encephalitis or after head trauma (Siroky, 1988). Cerebral atherosclerosis in elderly individuals may present with increased libido and increased or inappropriate sexual behavior (Monga et al, 1986).
MANAGEMENT
PATIENT EVALUATION
Reliable and valid norms of human sexual behavior are not yet precisely defined. Thus, our concepts of the normal parameters of sexual drive of men and women are inferred from various statistical surveys of the frequency of intercourse and orgasm at various age groups (Kaplan, 1983). However the declining frequency of sexual intercourse with age may be a reflection of decreased erectile capacity rather than a waning libido (Macharthy, 1992).
A distinction must be made between changes in libido and changes in sexual activity. The frequency of sexual intercourse may have decreased greatly even though the libido has not changed significantly. Women with disturbances of arousal and lubrication may still have intact libido. Older women may interpret decreased vaginal lubrication and dyspareunia as decreased libido. Older men with intact sexual drive may suffer erectile difficulties and thus avoid sexual contact because of fear of failure. When poor libido is associated with erectile dysfunction, what appears to be the problem may be a mechanism for dealing with worrisome sexual dysfunction (Macharthy, 1992). A history of significant changes in libido suggests that the patient’s sex drive has become pathologically impaired and not simply low normal (Dunn, 1988).
When impaired libido is the principal complaint, it is important to establish why the patient is seeking help at this specific time. Quite often, it is his sexual partner who is anxious or trying to avoid sexual intimacy. Some patients are preoccupied with concerns regarding heath risks, malignancy, or venereal diseases (Kaplan, 1983).
A proper history taking should define if there is an associated organic or psychogenic erectile problem. The onset, course, and duration of the sexual dysfunction should be explored. The presence of morning or night erections, erections on masturbation or at any other situations should help to rule out an organic erectile problem. Risk factors for atherosclerosis (DM, smoking, hypertension, hyperlipidemias), spinal cord injury, radical pelvic surgery, drug addiction, medications, systemic diseases, marital conflicts and other etiologic factors mentioned above should all be considered (Hsieh, 1988; Kaiser et al, 1988; Macharthy, 1992). The patient should be asked specifically about alcohol, marijuana, and barbiturate use, all of which depress libido. Other drugs that may depress libido include acetazolamide, cocaine, diazepam, digoxin, heroin, imipramine, propranolol, and major tranquilizers (Greydanus et al, 1985; Smith and Talbert, 1986).
A thorough physical examination is very helpful to rule out organic factors related to the decreased libido or sexual dysfunction. General examination should include the evaluation of male secondary sex characters, gynecomastia, various pulses and sensations, scars from previous surgery or trauma, and visual field defects. Local or genital examination should evaluate the penis for size, scars, fibrosis, and pulses; and the scrotal compartments for testicular size and consistency. Rectal examination should be periodically performed on elderly men receiving androgens to exclude the presence of palpable neoplasia. Women should be also checked for visual field defects, musculanization, adnexal masses abdominal tenderness, and perineal hyposthesia (Mulligan and Katz, 1988).
INVESTIGATIONS
The role of specialized diagnostic methods to evaluate decreased sexual desire in elderly individuals should be individualized. Not all patients require these potentially invasive or expensive tests. The physician should have sufficient training and experience to determine whether the information obtained would be valuable in diagnosing and treating the patient. If the results of the tests will not alter the patient management, the tests should not be performed (Lue, 1990; Macharthy, 1992).
Nocturnal penile tumescence (NPT) monitoring may occasionally be needed to exclude organic factors if decreased libido is suspected to be secondary to erectile dysfunction. Men go through several phases of sleep among which are the rapid eye movement phases that are associated with spontaneous penile erections. These phases occur 4 -5 times per night and last 15 to 20 minutes each thus occupying about 15% - 20% of total sleep time. If one wakes up during one of these phases he notices a night or morning erection. Monitoring NPT is helpful to differentiate organic from psychogenic sexual dysfunctions (Karakan et al, 1975; Wein et al, 1983).
Changes in Nocturnal penile tumescence are noted with age. Both the number of erectile episodes and the number of maximal tumescence episodes decrease, from 6.8 and 4 per night, respectively, at puberty to 3.5 and 1.7 per night, respectively at age 70 years. These are expected normal age changes and should not be interpreted as organic erectile dysfunction (Karakan et al, 1975).
Endocrinal evaluation should be performed if an edocrinal factor is suspected for the decreased libido. For testosterone to exert an effect on the brain it must be at least partly converted to estrogen. Serum free testosterone and bioavailable testosterone should be checked in both men and women. Bioavailable testosterone includes that which is free in the plasma and that which is weakly bound to albumin. Hyperprolatcinemia may suppress sexual interest in males and females. Estradiol and follicle stimulating hormone levels help evaluate ovarian function (Morely et al, 1987; Mulligan and Katz 1988).
Vascular evaluation is not indicated to evaluate frank cases of inhibited sexual desire. However, on occasions when the decreased libido is suspected to be secondary to organic erectile dysfunction, the vascular component of the erectile response might need to be evaluated (Lue, 1990; Macharthy,1992).
The intracorporal injection test is performed through injection of a vasoactive vasodilating substance like papaverine, phentolamine or PGE1 into the corpora cavernosa leading to dilatation of the cavernosal arteries, sinusoidal relaxation resulting in passive venous occlusion and a full erection in most normal subjects (Lue et al, 1992).
The Doppler ultrasound machine was introduced to evaluate the penile arteries. Currently, Duplex ultrasonography with pulsed Doppler analysis after papaverine injection and coloured Doppler are the methods of choice for a more specific evaluation of the penile cavernosal arteries. Selective internal pudendal angiography is a very invasive procedure and should be performed only in a young patient being prepared for arterial surgery (Lue, 1990; Lue et al, 1992).
Tests to evaluate penile veins & corpora cavernosa are moderately invasive. Cavernosometry and cavernosography should be performed only if a corporal veno-occlusive dysfunction is suspected by a normal arterial response on duplex evaluation in the absence of a rigid erection with papaverine injection (Lewis, 1991).
Neurologic evaluation is carried on if a neurologic organic lesion is suspected to be related to the low libido or if the decreased sex desire is suspected to be secondary to an erectile dysfunction of neurogenic etiology. Afferent Pathways may be evaluated by biothesiometry dorsal nerve somatosensory evoked potential testing. A biothesiometer is a vibration apparatus having a fixed frequency & a variable amplitude. It is used to measure the vibration sense at the sides of the penile shaft & glans. It is a good screening procedure for sensory deficit impotence. The dorsal nerve somatosensory evoked potential test is a neurophysiologic test involving electrical stimulation of the dorsal nerve of the penis. Evoked EEG waveforms are recorded over the sacral cord & cerebral cortex, and analyzed using computer signal averaging and complex electronic equipment. Obtaining the peripheral conduction time to the sacral cord & the central conduction time to the brain from one or more points on the penis aids in diagnosing sacral or suprasacral sensory lesions as well as calculating the dorsal nerve conduction velocity (Padma-Nathan, 1988).
Efferent Pathway integrity may be evaluated though cystometry with betanechol supersensitivity testing. A rise in intravesical pressure of < 20 cm water after a subcutaneous. injection of 5 mg betanechol indicates a normal vesical parasympathetic outflow but is not specific regarding the cavernosal parasympathetic nerves. Supersensitivity with a rigid erection, to a small dose of papaverine has been suggested but not widely accepted as an indicator of a lesion hindering the autonomic supply to the penis. Normal nocturnal penile tumescence (NPT) testing signifies integrity of the efferent pathways to the penis during sleep. However an abnormal NPT test could be due to a variety of neurologic and vascular conditions (Padma-Nathan, 1988).
Both afferent & efferent pathways can be evaluated through the bulbocavernosus (sacral) evoked response. A stimulating electrodes placed on the penile shaft, a recording electrode is placed in the bulbocavernous muscle to record reflex EMG responses. The reflex latency is the time from the stimulus to the first reflex EMG response. Normally it is less than 40 msec. This test is the neurophysiologic representation of the bulbocavernosus reflex (S2,3,4) (Chiappa, 1983).
TREATMENT
It must be remembered that age alone is not a contraindication to treatment. Eighty percent of patients over the age of 80 are relatively independent and function well in the community and should not be considered helpless, untreatable, or hopeless (Cohen, 1981; Eisdorfer, 1981; Kaplan, 1983).
Based on the information gathered from the interview, physical examination, and investigations done when indicated, the physician can now make a prognostic decision about which type of treatment will suit the individual patient or couple (Lue, 1990; Macharthy, 1992).
In many elderly couples or individuals the problem may simply be lack of knowledge about age related-changes in sexual functioning. Patients need to be informed that as early as the age of forty, there is a gradual slowing down of the sexual response. A longer time is needed for obtaining a full erection and vaginal lubrication. Their is greater need for direct physical stimulation to the genitals for full excitement to occur. The longer refractory period and the inability to ejaculate on each sexual encounter are normal aging changes that the patient need not to be worried about. Overreaction to these changes leads to anxiety, distress, and sexual failure. Simple education about these aging changes in sexuality can help the patient and partner feel comfortable at sexual occasions and could be sufficient to restore libido with or without the help of sensate focus exercises (Dunn, 1988; Renshaw, 1988).
General care for elderly patients is advisable. Social support is important through planning for a structured schedule of activities, familiar surroundings, continued achievement, and avoidance of loneliness. Proper medical attention to any existing illness as well as treating any reversible components of an organic brain syndrome. Behavioral therapy and positive reinforcement of desirable behavior may help elderly patients with impaired cognitive abilities. Psychologic support may be required to help in adjusting to changing roles and commitments and finding new goals and viewpoints (Cohen, 1981; Eisdorfer, 1981).
Sex therapy and sensate focus exercises are indicated to resolve disorders of sexual desire and excitement of phychogenic basis (Masters and Johnson, 1970).
Goals of sex therapy.
· Establishing a mutual responsibility for satisfaction. Each partner has something to gain in resolving the hypoactive sexual desire problem. Sex therapists consider sexually related disorders shared problems. To avoid assigning blame to either partner fosters a spirit of cooperation.
· Correcting myths and misinformation and providing education, for both partners regarding normal libidinal changes at different age stages is essential for the success of any form of therapy, and may occasionally be sufficient to resolve the problem.
· Ensuring a high level of physical and psychological stimulation is important to build up the sexual drive particularly in elderly individuals. The sensate focus exercises devised by Masters and Johnson encourage couples to explore sensual sharing and communication in a gradual relaxed manner without concerns regarding performance.
· Eliminating cognitive interference (performance demand, anxiety, or negative self evaluation) can greatly improve the sex drive. Again, sex education and sensate focus exercises can help resolve these difficulties.
· Eliminating relationship problems and marital tensions. The couple may need help to reevaluate their communication skills and conflict resolution abilities. Techniques of initiating and refusing sexual contact with offending or stressing the partner are common sense but must be stressed and explained to the patient.
Strategies for sex therapy (Masters and Johnson, 1970)
· Sensate focus (relaxed sensual massage): This was the term used by Masters and Johnson for relaxed sensual massage. A couple in the treatment is instructed to taking turns at giving and receiving stimulation in a relaxed setting, fully disrobed, while forbidding genital touching, vaginal penetration and orgasm. Pleasure replaces orgasm as the goal of sexual activity. The couple are advised to give positive and negative verbal feedback to each other about what feels good and what doesn’t. The sensate focus is utilized as a re-educative tool for reducing performance concerns, as well as a diagnostic tool for uncovering hidden problems in the relationship.
· Non-demand genital touching: The next step is to allow mutual genital & breast touching but still intercourse and orgasm are not allowed. Again the couple is asked to take turns in giving and receiving stimulation The inclusion of genital caress tends to generate high levels of arousal.
· Vaginal containment (quite vagina): Vaginal penetration is allowed but both partners remain still (no pelvic thrusting). The aim is still to build up desire and excitement while eliminating the performance anxiety.
· Female superior coitus: The woman mounts facing the supine man, guides the penis in with her hand, and moves up and down on the erect penis. The aim again is to assist resolving the performance anxiety.
· Fantasy: Imagining sexually stimulating situations may help increase libido. Most men use fantasy while engaged in masturbation, with no difficulty in developing erections and achieving orgasm. Many men inhibit their fantasies during sexual activity with a partner. Frequently, sexual desire and performance may be enhanced if the patient is given “permission” to fantasize about sex.
Other forms of therapy are also indicated if decreased libido is diagnosed to be related to a physical ailment or secondary to a physical sexual dysfunction. Preventive therapy through avoiding risk factors (e.g. smoking, alcohol and drugs) is advisable at all age groups (Morley, 1987; Shabsigh, 1991).
Medical therapy may help resolve several conditions of depressed libido. Treatment of the cause of decreased libido should be attempted if a causative factor is identified. Endocrine disorders may be managed through hormonal replacement therapy. Bromocryptine may be used for hyperprolactinemia (Pirke and Kockett, 1982).
Androgen therapy in elderly men with decreasing androgen production may be of some benefit. Androgen replacement may increase bone and muscle mass, and improve sexual desire and general well being. However, these potential benefits of androgen should be weighed against the potential hazards on the prostate, cardiovascular, and liver function. Adverse effects of androgen therapy should be taken into account. These include: Hepatotoxic effects and cholestatic Jaundice with the esterified compounds; increased erythropoiten production and polycythemia that is however usually not clinically significant; gynaecomastia - which is more prominent in patients with hepatic cirrhosis - due to peripheral aromatization to estradiol; prostate growth and carcinoma are usually androgen dependent and thus androgen therapy is contraindicated in patients with prostate cancer or senile enlargement of the prostate; suppression of spermatogenesis and gonadotropin production; weight gain secondary to sodium retention may be a significant problem in elderly men with congestive heart failure or renal failure; hyperlipidemia; and increased oiliness of the skin and acneform eruptions (Swerdloff and Wang,1993).
Hormonal replacement therapy is less controversial in the treatment of postmenopausal women. Its benefits include relief of vaginal atrophy and dyspareunia, decreasing the woman’s risk of fatal heart attacks, probably by decreasing low density lipoproteins, and increasing high density lipoprotein levels. Estrogen also helps to prevent osteoporosis, hot flushes, and improve libido and mood. The risks of estrogen also include a probable increase in breast cancer risk, especially in women with a close family history of the disease. Endometrial cancer risk increases unless adequate progestin is used. Uterine myomas that shrink after menopause may continue to grow with estrogen therapy Gall bladder disease requiring cholecystectomy increases with estrogen. Currently estrogen/progestins preparations are generally the treatment of choice for the postmenopausal syndrome including decreased libido and dyspareunia (Osborn, 1988).
If the decreased sexual drive is due to prescription drugs, switching to safe medications may resolve the problem (e.g. Captopril & calcium channel blockers are antihypertensives that do not cause impotence; Trazodone is a safe antidepressant that does not depress libido) (Smith and Talbert 1986).
Aphrodisiacs are drugs that are said to improve sexual performance nonspecifically. The most popular of these drugs is yohimbine (presynaptic alpha 2 blocker); & Isoxsupine (beta adrenergic stimulant). However, there is insufficient evidence that its popularity is justified through repeated placebo controlled prospective double blind studies (Morales, 1986).
Certain instrumental techniques that are used to treat impotence have been suggested to be used transiently if the decreased sexual desire is judged to be secondary to performance anxiety as in some cases of widower’s syndrome. Such methods may include the use of External vacuum & constriction devices or Intracorporal injections of vasoactive substances for limited periods. For women, gradual vaginal dilatation may be required to overcome dyspareunia for elderly women with widowers syndrome (Lue, 1990; Macharthy, 1992).
Surgical options are reserved for the treatment of irreversible organic impotence, and do not have a role so far in the management of desire disorders.
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